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PRINTED: 06/14/2011 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

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This visit form is required for individuals who have recently visited a specific location and need to provide details about their visit. It can be used for various purposes, including documenting business visits, recording personal travel experiences, or fulfilling entry requirements for certain events or venues.

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What is this visit was for?

This visit was for a routine inspection.

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The designated department manager is required to file this visit.

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What is the purpose of this visit was for?

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

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