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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15G80511/17/2021FORM

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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 business owner or manager is required to file this visit.

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You can fill out this visit by providing all necessary information requested on the form.

What is the purpose of this visit was for?

The purpose of this visit is to ensure compliance with regulations and standards.

What information must be reported on this visit was for?

The information that must be reported includes date of visit, findings, corrective actions taken, and any recommendations.

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