Worksheet S-7

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NORTH CANYON CARE CENTER
BOUNTIFUL, UT  84010

Medicare Provider Number: 465163
Cost report status: Settled Without Audit
[Record Code 1347821 - 2010]
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PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA Provider CCN: 465163
PERIOD:
FROM 07/01/2020
TO 06/30/2021
 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