SNFData - 155811 - 12/2020 - Worksheet S-3 Part I

WELLBROOKE OF AVON
INDIANAPOLIS, IN 46234-1250

Medicare Provider Number: 155811

Cost report status: Settled Without Audit

[Record Code 1291511 - 2010]

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SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTH CARE COMPLEX STATISTICAL DATA															Provider CCN: 155811			PERIOD: FROM 01/01/2020 TO 12/31/2020				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
		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	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