Worksheet S-2 Part I
- Return to Cost Report Summary
- Form S201
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
HERITAGE PLACE
MESQUITE, TX 75149
MESQUITE, TX 75149
Medicare Provider Number: 675119
Cost report status: Settled Without Audit
[Record Code 1117011 - 2010]
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| SKILLED NURSING FACILITY AND SKILLED NURSING FACILITY HEALTH CARE COMPLEX IDENTIFICATION DATA | Provider CCN: 675119 | PERIOD: FROM 06/01/2014 TO 05/31/2015 |
WORKSHEET S-2 PART I |
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| Skilled Nursing Facility and Skilled Nursing Facility Complex Address: | |||||||||||
| 1 | Street: ### | P.O. Box: | 1 | ||||||||
| 2 | City: ### | State: ### | ZIP Code: ### | 2 | |||||||
| 3 | County: ### | CBSA Code: ### | Urban / Rural: ### | 3 | |||||||
| SNF and SNF - Based Component Identification: | |||||||||||
| Component | Component Name | Provider CCN | Date Certified | Payment System (P, O or N) | |||||||
| V | XVIII | XIX | |||||||||
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | |||||
| 4 | SNF | ### | ### | ### | ### | ### | ### | 4 | |||
| 5 | Nursing Facility | 5 | |||||||||
| 6 | ICF/IID | 6 | |||||||||
| 7 | SNF-Based HHA | 7 | |||||||||
| 8 | SNF-Based RHC | 8 | |||||||||
| 9 | SNF-Based FQHC | 9 | |||||||||
| 10 | SNF-Based CMHC | 10 | |||||||||
| 11 | SNF-Based OLTC | 11 | |||||||||
| 12 | SNF-Based HOSPICE | 12 | |||||||||
| 13 | OTHER (specify) | 13 | |||||||||
| 14 | Cost Reporting Period (mm/dd/yyyy) | From: ### | To: ### | 14 | |||||||
| 15 | Type of Control (see instructions) | ### | ### | 15 | |||||||
| Type of Freestanding Skilled Nursing Facility | Y / N | ||||||||||
| 16 | Is this a distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5? | ### | 16 | ||||||||
| 17 | Is this a composite distinct part skilled nursing facility that meets the requirements set forth in 42 CFR section 483.5? | ### | 17 | ||||||||
| 18 | Are there any costs included in Worksheet A that resulted from transactions with related organizations as defined in CMS Pub. 15-1, chapter 10? If yes, complete Worksheet A-8-1. | ### | 18 | ||||||||
| Miscellaneous Cost Reporting Information | |||||||||||
| 19 | Is this a low Medicare utilization cost report, enter "Y" for yes or "N" for no. | ### | 19 | ||||||||
| 19.01 | If the response to line 19 is "Y", does this cost report meet your contractor's criteria for filing a low utilization cost report? (Y/N) | ### | 19.01 | ||||||||
| Depreciation - Enter the amount of depreciation reported in this SNF for the method indicated on lines 20 - 22. | |||||||||||
| 20 | Straight Line | ### | 20 | ||||||||
| 21 | Declining Balance | 21 | |||||||||
| 22 | Sum of the Year's Digits | 22 | |||||||||
| 23 | Sum of line 20 through 22 | ### | 23 | ||||||||
| 24 | If depreciation is funded, enter the balance as of the end of the period. | 24 | |||||||||
| 25 | Were there any disposal of capital assets during the cost reporting period? (Y/N) | ### | 25 | ||||||||
| 26 | Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N) | ### | 26 | ||||||||
| 27 | Did you cease to participate in the Medicare program at end of the period to which this cost report applies? (Y?N) | ### | 27 | ||||||||
| 28 | Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports? (Y/N) | ### | 28 | ||||||||
| If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of costs or charges, enter "Y" for each component and type of service that qualifies for the exemption. | Part A | Part B | Other | ||||||||
| 29 | Skilled Nursing Facility | ### | ### | 29 | |||||||
| 30 | Nursing Facility | ### | 30 | ||||||||
| 31 | ICF/MR | 31 | |||||||||
| 32 | SNF-Based HHA | ### | ### | 32 | |||||||
| 33 | SNF-Based RHC | ### | 33 | ||||||||
| 34 | SNF-Based FQHC | 34 | |||||||||
| 35 | SNF-Based CMHC | ### | 35 | ||||||||
| 36 | SNF-Based OLTC | 36 | |||||||||
| Y / N | |||||||||||
| 37 | Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless of the level of care given for Titles V & XIX patients. (Y/N) | ### | 37 | ||||||||
| 38 | Are you legally required to carry malpractice insurance? (Y/N) | ### | 38 | ||||||||
| 39 | Is the malpractice a "claims-made" or "occurrence" policy? If the policy is "claims-made," enter 1. If the policy is "occurrence", enter 2. | ### | 39 | ||||||||
| Premiums | Paid Losses | Self insurance | |||||||||
| 41 | List malpractice premiums and paid losses: | ### | ### | 41 | |||||||
| Y / N | |||||||||||
| 42 | Are malpractice premiums and paid losses reported in other than the Administrative and General cost center? Enter Y or N. If "Y", check box, and submit supporting schedule listing cost centers and amounts. | ### | 42 | ||||||||
| 43 | Are there any home office costs as defined in CMS Pub. 15-1, chapter 10? | ### | 43 | ||||||||
| 44 | If line 43 = "Y", and there are costs for the home office, enter the applicable home office chain number in column 1. | 44 | |||||||||
| If this facility is part of a chain organization, enter the name and address of the home office on the lines below. | |||||||||||
| 45 | Name: | Contractor Name: | Contractor Number: | 45 | |||||||
| 46 | Street: | P.O. Box: | 46 | ||||||||
| 47 | City: | State: | ZIP Code: | 47 | |||||||
| FORM CMS-2540-10 (06/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4104) | |||||||||||
| Rev. 10 | 06-21 | ||||||||||