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PRINTED: 03/30/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 09380391STATEMENT OF DEFICIENCIES AND(X1) PROVIDER/SUPPLIER/CHAPMAN OF CORRECTIONSIDENTIFICATION

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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 site manager is required to file this visit.

How to fill out this visit was for?

The visit can be filled out online through the designated portal.

What is the purpose of this visit was for?

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

What information must be reported on this visit was for?

Information such as maintenance records, incident reports, and safety training logs must be reported.

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