SNFData - 525274 - 05/2003 - Worksheet S-3, Part I

MCHS FOND DU LAC
FOND DU LAC, WI 54935-

Medicare Provider Number: 525274

Cost report status: Settled Without Audit

[Record Code 198069 - 1996]

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SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTH CARE COMPLEX STATISTICAL DATA													PROVIDER NO: 525274				PERIOD: FROM 06/01/2002 TO 05/31/2003				WORKSHEET S-3 Part I
Component		Number of Beds	Bed Days Available	Inpatient Days					Discharges					Average Length of Stay				Admissions					Full Time Equivalent
		Number of Beds	Bed Days Available	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																									2
3	Nursing Facility	###	###			###	###	###			###	###	###			###	###			###	###	###	###		3
3.01	ICF/MR																								3.01
4	Other Long Term Care																								4
5	Home Health Agency																								5
6																									6
7	SNF-Based Outpatient Rehabilitation Providers																								7
8	Hospice																								8
9	Total (Sum of lines 1-8)	###	###		###	###	###	###		###	###	###	###		###	###	###		###	###	###	###	###		9
10	Ambulance Trips																								10