SNFData - 365946 - 12/2016

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

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DIVERSICARE OF ST. THERESA
CINCINATTI, OH 45227

Medicare Provider Number: 365946

Cost report status: Settled Without Audit

[Record Code 1169384 - 2010]

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PROSPECTIVE PAYMENT FOR SNF STATISTICAL DATA		Provider CCN: 365946	PERIOD: FROM 01/01/2016 TO 12/31/2016	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