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PRINTED: 04/02/2015 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:MEMORIAL HOSPITAL OF SOUTH BEND

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What is this visit was for?

This visit was for a routine inspection of the facility.

Who is required to file this visit was for?

The facility manager or designated representative is required to file this visit.

How to fill out this visit was for?

The visit report must be filled out completely and accurately, including details of any findings or observations.

What is the purpose of this visit was for?

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

What information must be reported on this visit was for?

Information such as date of visit, name of inspector, areas inspected, any violations found, and corrective actions taken must be reported.

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