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PRINTED: 08/20/2020 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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A complaint filed without prior notice and conducted on the premises.
Any individual who has concerns regarding a particular situation on a premises.
The complaint form must be completed with detailed information about the situation and submitted to the appropriate authority.
To address and investigate potential issues or violations that are occurring on a premises.
Details about the situation, location, individuals involved, and any supporting evidence.
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