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PRINTED: 08/03/2020 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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What is this visit was for?

This visit was for a routine inspection.

Who is required to file this visit was for?

The facility manager is required to file this visit.

How to fill out this visit was for?

The visit should be documented in the inspection report form provided by the regulatory agency.

What is the purpose of this visit was for?

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

What information must be reported on this visit was for?

The information that must be reported includes observations, findings, corrective actions taken, and any recommendations for improvement.

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