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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15515412/05/2016FORM

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What is this visit was for?

This visit is for conducting a routine inspection of the premises.

Who is required to file this visit was for?

The designated supervisor or contact person is required to file this visit.

How to fill out this visit was for?

Please ensure all relevant information is accurately documented on the form provided.

What is the purpose of this visit was for?

The purpose of this visit is to ensure compliance with safety regulations.

What information must be reported on this visit was for?

All findings, observations, and corrective actions taken must be reported.

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