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PRINTED: 08/04/2017 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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Autumn Lake Healthcare is a skilled nursing facility located at 123 Main Street in Anytown.

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The purpose of Autumn Lake Healthcare is to maintain comprehensive records of the healthcare services offered at the facility for regulatory and patient care purposes.

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Information such as patient demographics, medical history, treatment plans, medication administration, and progress notes must be reported on Autumn Lake Healthcare.

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