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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTIONPRINTED:11/1/2017 FORM APPROVED OMB NO. 09380391 (X3) DATE SURVEY COMPLETED(X1)
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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 responsible person is required to file this visit.
How to fill out this visit was for?
The visit report must be filled out completely and accurately with all relevant information.
What is the purpose of this visit was for?
The purpose of this visit was to ensure compliance with safety regulations and standards.
What information must be reported on this visit was for?
Information such as date and time of visit, areas inspected, findings, corrective actions taken, and signatures must be reported.
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