Medicare Provider Number: -E
[Record Code 1322370 - 2010]

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SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTH CARE COMPLEX STATISTICAL DATA Provider CCN:
PERIOD:
FROM 12/31/1969
TO 12/31/1969
WORKSHEET S-3 PART I
PART I - STATISTICAL DATA
Component Number of Beds Bed Days Available Inpatient Days / Visits Discharges Average Length of Stay Admissions Full Time Equivalent  
Title V Title XVIII Title XIX Other Total Title V Title XVIII Title XIX Other Total Title V Title XVIII Title XIX Total Title V Title XVIII Title XIX Other Total Employees on Payroll Nonpaid Workers
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1 Skilled Nursing Facility 1
2 Nursing Facility         2
3 ICF/IID                 3
4 Home Health Agency                                 4
5 Other Long Term Care                         5
6 SNF-Based CMHC                                           6
7 Hospice 7
8 Total (sum of lines 1-7) 8
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105)
Rev. 7   41-307