Worksheet S-3 Part I

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FORM CMS-2552-10
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1

CARSON TAHOE CONTINUING CARE HOSPITA - CARSON CITY, NV
Cost report status - Settled Without Audit
[Record Code 565644 - 2010]

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HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX STATISTICAL DATA Provider CCN: 292008
PERIOD:
FROM 01/01/2013
TO 12/31/2013
 WORKSHEET S-3 PART I
PART I - STATISTICAL DATA
Component Wksht. A Line No. No. of Beds Bed Days Available CAH/REH Hours Inpatient Days / Outpatient Visits / Trips Full Time Equivalents Discharges  
Title V Title XVIII Title XIX Total All Patients Total Interns & Residents Employees On Payroll Nonpaid Workers Title V Title XVIII Title XIX Total All Patients
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 Hospital Adults & Peds. (columns 5, 6, 7 and 8 exclude Swing Bed, Observation Bed and Hospice days) (see instructions for col.2 for the portion of LDP room available beds) ### ### ### ### ### ###       ### ### ### 1
2 HMO and other (see instructions)           ###           ###   2
3 HMO IPF Subprovider                         3
4 HMO IRF Subprovider                         4
5 Hospital Adults & Peds. Swing Bed SNF                       5
6 Hospital Adults & Peds.Swing Bed NF                         6
7 Total Adults and Peds. (exclude observation beds) (see instructions)   ### ### ### ### ###               7
8 Intensive Care Unit ###               8
9 Coronary Care Unit ###               9
10 Burn Intensive Care Unit ###               10
11 Surgical Intensive Care Unit ###               11
12 Other Special Care ###               12
13 Nursery ###                       13
14 Total (see instructions)   ### ### ### ### ### ### ### ### ### 14
15 CAH visits                       15
15.10 REH hours and visits                     15.10
16 Subprovider - IPF ###   16
17 Subprovider - IRF ###   17
18 Subprovider - Other ###   18
19 Skilled Nursing Facility ###           19
20 Nursing Facility ###             20
21 Other Long Term Care ###               21
22 Home Health Agency ###               22
23 ASC (Distinct Part) ###                       23
24 Hospice (Distinct Part) ###             24
24.10 Hospice (non-distinct part)                       24.10
25 CMHC ###               25
26 RHC/FQHC (specify) ###               26
27 Total (sum of lines 14-26)   ###             ###         27
28 Observation Bed Days                         28
29 Ambulance Trips                             29
30 Employee discount days (see instructions)                             30
31 Employee discount days -IRF                             31
32 Labor & delivery (see instructions)                     32
32.01 Total ancillary labor & delivery room outpatient days (see instructions)                           32.01
33 LTCH non-covered days                           33
33.01 LTCH site neutral days and discharges                           33.01
34 Temporary Expansion COVID-19 PHE Acute Care                 34
FORM CMS-2552-10  (12-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, §4005.1)
12-22   Rev. 18