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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:15562101/06/2016FORM

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What is this visit was for?

This visit was for a regular inspection of the facility.

Who is required to file this visit was for?

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

How to fill out this visit was for?

The visit must be documented in the facility logbook with details of date, time, purpose, and findings.

What is the purpose of this visit was for?

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

What information must be reported on this visit was for?

Details of any issues identified during the inspection, corrective actions taken, and follow-up procedures must be reported.

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