SNFData - 455509 - 12/2011

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Form S700
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV

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NOLAN NURSING & REHABILITATION L.P.
SWEETWATER, TX 79556-1369

Medicare Provider Number: 455509

Cost report status: Settled Without Audit

[Record Code 1014295 - 2010]

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PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA		Provider CCN: 455509	PERIOD: FROM 01/01/2011 TO 12/31/2011	WORKSHEET S-7
	RUGS GROUPS (Through September 30, 2019)			Days
	1			2
1	RUX				1
2	RUL				2
3	RVX				3
4	RVL			###	4
5	RHX			###	5
6	RHL				6
7	RMX				7
8	RML				8
9	RLX				9
10	RUC			###	10
11	RUB			###	11
12	RUA			###	12
13	RVC			###	13
14	RVB			###	14
15	RVA			###	15
16	RHC			###	16
17	RHB			###	17
18	RHA			###	18
19	RMC			###	19
20	RMB			###	20
21	RMA			###	21
22	RLB				22
23	RLA			###	23
24	ES3				24
25	ES2				25
26	ES1				26
27	HE2				27
28	HE1				28
29	HD2			###	29
30	HD1				30
31	HC2				31
32	HC1				32
33	HB2				33
34	HB1			###	34
35	LE2			###	35
36	LE1			###	36
37	LD2			###	37
38	LD1				38
39	LC2			###	39
40	LC1				40
41	LB2				41
42	LB1			###	42
43	CE2			###	43
44	CE1			###	44
45	CD2			###	45
46	CD1				46
47	CC2				47
48	CC1				48
49	CB2				49
50	CB1				50
51	CA2				51
52	CA1			###	52
53	SE3				53
54	SE2				54
55	SE1				55
56	SSC				56
57	SSB				57
58	SSA				58
59	IB2			###	59
60	IB1				60
61	IA2			###	61
62	IA1			###	62
63	BB2				63
64	BB1			###	64
65	BA2				65
66	BA1				66
67	PE2				67
68	PE1			###	68
69	PD2				69
70	PD1			###	70
71	PC2				71
72	PC1			###	72
73	PB2				73
74	PB1			###	74
75	PA2				75
76	PA1			###	76
99	AAA			###	99
100	Total			###	100
A notice published in the "Federal Register" Vol. 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003 Congress expected this increase to be used for direct patient care and related expenses. For lines 101 through 106: Enter in column 1 the amount of expense for each category. Enter in column 2 the percentage of total expenses for each category to total SNF revenue from Worksheet G-2, Part I line 1 column 3. Indicate in column 3 "Y" for yes or "N" for no if the spending reflects increases associated with direct patient care and related expenses for each category. (If column 2 is zero, enter N/A in column 3) (see instructions)
		Expenses	Percentage	Y/N
		1	2	3
101	Staffing	###	###	###	101
102	Recruitment	###	###	###	102
103	Retention of employees	###		###	103
104	Training			###	104
105	Other (Specify)			###	105
106	Total SNF revenue (Wkst. G-2, Pt. I, line 1, col. 3)		###		106

FORM CMS-2540-10 (11/2019) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4109 - 4109.1)
41-314				Rev. 9

Worksheet S-7