3590 (Cont.)
FORM CMS 2540-96
5-06
SKILLED NURSING FACILITY
PROVIDER NO.: PERIOD
WORKSHEET
AND SKILLED NURSING FACILITY
FROM_____________
S - 2
COMPLEX IDENTIFICATION DATA _______________ ____________________ TO_______________
Skilled Nursing Facility and Skilled Nursing Facility Complex Address:
1 Street: X
P.O Box: X
1
2 City: X
State: X Zip Code:
X
2
3 County: X MSA Code:
CBSA Code: X Urban / Rural:
X
3
3.1 Facility Specific Rate:
Transition Period - enter 1, 2, 3 or 100
X
3.1
3.2 Wage Index Adjustment Factor: Before October 1 X After Sept 30
X
3.2
SNF and SNF-Based Component Identification:
 
Payment System
Component Provider No.
NPI\ Number Date (P, O, or N)
Component Name  
Certified V XVIII XIX
0 1 2
2.01 3 4 5 6
4 S N F X X
X
X X 4
5
5
6 Nursing Facility X
X
X 6
6.1 I C F / M R
X
X
X 6.1
7 SNF-Based O.L.T.C.  
7
8 SNF-Based H.H.A. X
X
X X 8
9
9
10 SNF-Based Outpatient
10
Rehabilitation Providers X
X
X X
11 SNF-Based R.H.C. X
X
X X 11
12 SNF-Based HOSPICE X
X
12
13 Cost Reporting Period (mm/dd/yyyy) From:
To:
13
14 Type of Control (See Instructions)
X
14
12-00
FORM CMS 2540-96
3590 (Cont.)
PROVIDER NO.: PERIOD:
RECLASSIFICATION AND ADJUSTMENT
FROM ___________ WORKSHEET A
OF TRIAL BALANCE OF EXPENSES ________ TO _______
   
RECLASSI- RECLASSIFIED ADJUSTMENTS NET EXPENSES
FICATIONS TRIAL TO EXPENSES FOR COST
COST CENTER SALARIES OTHER TOTAL Increase/Decrease BALANCE Increase/Decrease ALLOCATION
(Omit Cents)
( Col 1 + Col 2 ) ( Fr Wkst A-6 ) ( Col 3 +/- Col 4 ) ( Fr Wkst A-8 ) ( Col 5 +/- Col 6 )
A B C D 1 2 3 4 5 6 7
GENERAL SERVICE COST CENTERS
1 0100 x Captial-Related Costs - Building & Fixture
X
X
X
1
2 0200 x Capital-Related Costs - Movable Equipment
X
X
X
2
3 0300 x Employee Benefits X X
X
X
3
4 0400 x Administrative and General X X
X
X
4
5 0500 x Plant Operation, Maintenance and Repairs X X
X
X
5
6 0600 x Laundry and Linen Service X X
X
X
6
7 0700 x Housekeeping X X
X
X
7
8 0800 x Dietary X X
X
X
8
9 0900 x Nursing Administration X X
X
X
9
10 1000
Central Services and Supply X X
X
X
10
11 1100
Pharmacy X X
X
X
11
12 1200
Medical Records and Library X X
X
X
12
13 1300
Social Service X X
X
X
13
14 1400
Intern & Residents (Apprvd Tchng Prog.) X X
X
X
14
15
Other General Service Cost X X
X
X
15
INPATIENT ROUTINE SERVICE COST CENTERS
16 1600 x Skilled Nursing Facility X X
X
X
16
17
17
18 1800 x Nursing Facility X X
X
X
18
18.1 1810
Intermediate Care Facility - Mentally Retarded X X
X
X
18.1
19 1900 x Other Long Term Care X X
X
X
19
20
Other Inpatient Routine Cost
20
ANCILLARY SERVICE COST CENTERS
21 2100 x Radiology X X
X
X
21
22 2200 x Laboratory X X
X
X
22
23 2300 x Intravenous Therapy X X
X
X
23
24 2400 x Oxygen (Inhalation) Therapy X X
X
X
24
25 2500 x Physical Therapy X X
X
X
25
26 2600 x Occupational Therapy X X
X
X
26
27 2700 x Speech Pathology X X
X
X
27
28 2800 x Electrocardiology X X
X
X
28
29 2900 x Medical Supplies Charged to Patients X X
X
X
29
30 3000 x Drugs Charged to Patients X X
X
X
30
31 3100 x Dental Care - Title XIX only X X
X
X
31
32 3200 x Support Surfaces X X
X
X
32
33
x Other Ancillary Service Cost Center X X
X
33
x Indicates the lines to be used under the Simplified Method
OUTPATIENT SERVICE COST CENTERS
34 3400
Clinic X X
X
X
34
35 3500
Rural Health Clinic (RHC) X X
X
X
35
36
Other Outpatient Service Cost X X
X
X
36
OTHER REIMBURSABLE COST CENTERS
37 3700
Administrative and General - HHA X X
X
X
37
38 3800
Skilled Nursing Care - HHA X X
X
X
38
39 3900
Physical Therapy - HHA X X
X
X
39
40 4000
Occupational Therapy - HHA X X
X
X
40
41 4100
Speech Pathology - HHA X X
X
X
41
42 4200
Medical Social Services - HHA X X
X
X
42
43 4300
Home Health Aide - HHA X X
X
X
43
44 4400
Durable Medical Equipment - Rented - HHA X X
X
X
44
45 4500
Durable Medical Equipment - Sold - HHA X X
X
X
45
46 4600
Home Delivered Meals - HHA X X
X
X
46
47 4700
Other Home Health Services - HHA X X
X
X
47
48 4800
Ambulance X X
X
X
48
49 4900
Intern and Resident (Not Apprvd Tchng Prog) X X
X
X
49
50 5000
Outpatient Rehabilitation Provider X X
X
X
50
51
Other Reimbursable Cost X X
X
X
51
SPECIAL PURPOSE COST CENTERS
52 5200
Malpractice Premiums & Paid Losses X X
X
X
52
53 5300
Interest Expense
X
X
X - 0 - 53
54 5400 x Utilization Review -- SNF X X
X
X - 0 - 54
55 5500
Hospice X X
X
X - 0 - 55
56
x Other Special Purpose Cost X X
X
X
56
57 5700
Subtotals X X
X
X
57
NON REIMBURSABLE COST CENTERS
58 5800
Gift, Flower, Coffee Shops and Canteen X X
X
X
58
59 5900 x Barber and Beauty Shop X X
X
X
59
60 6000
Physicians' Private Offices X X
X
X
60
61 6100
Nonpaid Workers X X
X
X
61
62 6200
Patients Laundry X X
X
X
62
63
x Other Non Reimbursable Cost X X
X
X
63
75
x TOTAL X X
X
75
04-06
FORM CMS 2540-96
3590 ( Cont.)
PROVIDER NO.: PERIOD:  
CALCULATION OF   FROM __________ WORKSHEET E
REIMBURSEMENT SETTLEMENT _____________ TO ___________ PART III  
PART III - SNF REIMBURSEMENT UNDER PPS
Check one: [ ] Title V [ ] Title XVIII [ ] Title XIX
PART A - INPATIENT SERVICE PPS PROVIDER COMPUTATION OF REIMBURSEMENT LESSER OF COST OR CHARGES
1 Inpatient ancillary services - Part A - ( See Instructions ) X 1
2 Interns & Residents and Medical Education cost for Title XVIII ( See Instructions ) X 2
3 Total cost ( Sum of lines 1 and 2) X 3
4 Medicare inpatient ancillary charges (see instructions) X 4
5 Intern and Resident Charges ( From Provider Records) X 5
6 Cost of covered services (lesser of line 3, or the sum of lines 4 and 5) X 6
7 Inpatient PPS amount (see instructions) X 7
3590 ( Cont.)
FORM CMS 2540-96 07-99
 
PROVIDER NO.: PERIOD:
BALANCE SHEET
FROM ______ WORKSHEET G
(If you are nonproprietary and do not maintain fund-type _______ TO _______
accounting records, complete the "General Fund" column only)
Specific
Assets General Purpose Endowment Plant
(Omit cents) Fund Fund Fund Fund
1 2 3 4
CURRENT ASSETS
1 Cash on hand and in banks X X X X 1
2 Temporary investments X X X X 2
3 Notes receivable X X X X 3
4 Accounts receivable X X X X 4
5 Other receivables X X X X 5
6 Less: allowances for uncollectible notes ( X ) ( X ) ( X ) ( X ) 6
and accounts receivable
7 Inventory X X X X 7
8 Prepaid expenses X X X X 8
9 Other current assets X X X X 9
10 Due from other funds X X X X 10
11 TOTAL CURRENT ASSETS
11
(Sum of lines 1 - 10) X X X X
FIXED ASSETS
12 Land X X X X 12
13 Land improvements X X X X 13
14 Less: Accumulated depreciation ( X ) ( X ) ( X ) ( X ) 14
15 Buildings X X X X 15
16 Less Accumulated depreciation ( X ) ( X ) ( X ) ( X ) 16
17 Leasehold improvements X X X X 17
18 Less: Accumulated Amortization ( X ) ( X ) ( X ) ( X ) 18
19 Fixed equipment X X X X 19
20 Less: Accumulated depreciation ( X ) ( X ) ( X ) ( X ) 20
21 Automobiles and trucks X X X X 21
22 Less: Accumulated depreciation ( X ) ( X ) ( X ) ( X ) 22
23 Major movable equipment X X X X 23
24 Less: Accumulated depreciation ( X ) ( X ) ( X ) ( X ) 24
25 Minor equipment nondepreciable X X X X 25
26 Other fixed assets X X X X 26
27 TOTAL FIXED ASSETS
27
(Sum of lines 12 - 26) X X X X
OTHER ASSETS
28 Investments X X X X 28
29 Deposits on leases X X X X 29
30 Due from owners/officers X X X X 30
31 Other assets X X X X 31
32 TOTAL OTHER ASSETS
32
(Sum of lines 28 - 31) X X X X
33 TOTAL ASSETS
33
(Sum of lines 11, 27 and 32) X X X X
( ) = contra amount
11-98
FORM CMS 2540-96 3590 ( Cont.)
 
PROVIDER NO.: PERIOD:  
BALANCE SHEET   FROM _______ WORKSHEET G
(If you are nonproprietary and do not maintain fund-type
TO __________ (Cont.)
accounting records, complete the "General Fund" column only)
Liabilities and Fund
Specific
Balances General Purpose Endowment Plant
(Omit cents) Fund Fund Fund Fund
1 2 3 4
  CURRENT LIABILITIES          
34 Accounts payable X X X X 34
35 Salaries, wages & fees payable X X X X 35
36 Payroll taxes payable X X X X 36
37 Notes & loans payable (Short term) X X X X 37
38 Deferred income X X X X 38
39 Accelerated payments X
39
40 Due to other funds X X X X 40
41 Other current liabilities X X X X 41
42 TOTAL CURRENT LIABILITIES
42
(Sum of lines 34 - 41) X X X X
  LONG TERM LIABILITIES          
43 Mortgage payable X X X X 43
44 Notes payable X X X X 44
45 Unsecured loans X X X X 45
46 Loans from owners: a. Prior to 7/1/66
46
b. On or after 7/1/66 X X X X
47 Other long term liabilities X X X X 47
48
48
49 TOTAL LONG TERM LIABILITIES
49
(Sum of lines 43 - 48) X X X X
50 TOTAL LIABILITIES
50
(Sum of lines 42 and 49) X X X X
  CAPITAL ACCOUNTS          
51 General fund balance X
51
52 Specific purpose fund
X
52
53 Donor created - endowment fund
53
balance - restricted
X
54 Donor created - endowment fund
54
balance - unrestricted
X
55 Governing body created - endowment
55
fund balance
X
56 Plant fund balance - invested in plant
X 56
57 Plant fund balance - reserve for
57
plant improvement, replacement and
expansion
X
58 TOTAL FUND BALANCES
58
(Sum of lines 51 thru 57) X X X X
59 TOTAL LIABILITIES AND
59
FUND BALANCES
(Sum of lines 50 and 58) X X X X
( ) = contra amount
11-98 FORM CMS 2540-96 3590 ( Cont.)
  PROVIDER NO: PERIOD:
STATEMENT OF PATIENT REVENUES ______________ FROM _________ WORKSHEET G - 2
AND OPERATING EXPENSES
TO ___________ PARTS I & II
PART I - PATIENT REVENUES
Revenue Center INPATIENT OUTPATIENT TOTAL
1 2 3
GENERAL INPATIENT ROUTINE CARE SERVICES
1 Skilled Nursing Facility X
1
2
2
3 Nursing facility X
3
4 Other long term care X
4
5 Total general inpatient care services
5
(Sum of lines 1 - 4) X
All Other Care Service
6 Ancillary services X X
6
7 Clinic X X
7
8 Home health agency
X
8
9
9
10 Ambulance X X
10
11 Hospice X X
11
12 Outpatient Rehabilitation Provider X X
12
13
X X
13
14 Total Patient Revenues ( Sum of lines 5 - 13 )
14
( Transfer column 3 to Worksheet G-3, Line 1 ) X X X
PART II - OPERATING EXPENSES
1 Operating Expenses ( Per Worksheet A, Col. 3, Line 75 )
1
X
2 Add ( Specify )
2
3
3
4
4
5
5
6
6
7
7
8 Total Additions ( Sum of lines 2 - 7 )
8
X
9 Deduct ( Specify )
9
10
10
11
11
12
12
13
13
14 Total Deductions ( Sum of lines 9 - 13 )
14
X
15 Total Operating Expenses ( Sum of lines 1 and 8, minus line 14 )
15
( Transfer to Worksheet G-3, Line 4 )
X
3590 ( Cont.) FORM CMS 2540-96 11-98
STATEMENT OF REVENUES PROVIDER NO: PERIOD:
AND EXPENSES ______________ FROM _________ WORKSHEET G - 3
TO ___________
1 Total patient revenues (From Wkst. G - 2, Part I, col. 3, line 14)
1
2 Less: contractual allowances and discounts on patients accounts
2
3 Net patient revenues (Line 1 minus line 2)
X 3
4 Less: total operating expenses (From Worksheet G-2, Part II, line 15)
4
5 Net income from service to patients (Line 3 minus 4) X 5
6 Other income:
6
7 Contributions, donations, bequests, etc
X 7
8 Income from investments
X 8
9 Revenues from telephone and telegraph service
9
10 Revenue from television and radio service
10
11 Purchase discounts
11
12 Rebates and refunds of expenses
12
13 Parking lot receipts
13
14 Revenue from laundry and linen service
14
15 Revenue from meals sold to employees and guests
15
16 Revenue from rental of living quarters
16
17 Revenue from sale of medical and surgical supplies to other than patients
17
18 Revenue from sale of drugs to other than patients
18
19 Revenue from sale of medical records and abstracts
19
20 Tuition (fees, sale of textbooks, uniforms, etc.)
20
21 Revenue from gifts, flower, coffee shops, canteen
21
22 Rental of vending machines
22
23 Rental of skilled nursing space
23
24 Governmental appropriations
X 24
25 Other (specify)
25
26 Total other income (Sum of lines 7 - 25)
X 26
27 Total (Line 5 plus line 26)
27
28 Other expenses (specify)
28
29  
29
30  
30
31 Total other expenses (Sum of lines 28 - 30)
X 31
32 Net income (or loss) for the period (Line 27 minus line 31)
X 32
3590 (Cont.)
FORM HCFA 2540-96
10-03
SKILLED NURSING FACILITY AND PROVIDER NO.: PERIOD WORKSHEET S-3
SKILLED NURSING FACILITY HEALTH CARE COMPLEX
FROM____________________ PART I
STATISTICAL DATA                  
Number Bed I n p a t i e n t D a y s D i s c h a r g e s
of Days Title Title Title
Total Title Title Title
Total
Component Beds Available V XVIII XIX Other
V XVIII XIX Other
1 2 3 4 5 6 7 8 9 10 11 12
1 Skilled Nursing Facility X X X X X X X X X X X X 1
2
2
3 Nursing Facility X X X
X X X X
X X X 3
3.1 ICF/MR X X
X X X
X X X 3.1
4 Other Long Term Care X X
X X
X X 4
5 Home Health Agency
5
6
6
7 SNF-Based Outpatient
7
Rehabilitation Providers
8 Hospice X X X X X X X X X X X X 8
9 Total (Sum of lines 1-8) X X X X X X X X X X X X 9
10 Ambulance Trips
X
10
       
Full Time
Average Length of Stay A d m i s s i o n s Equivalent
Title Title Title Total Title Title Title
Total Employees Nonpaid
V XVIII XIX
V XVIII XIX Other
on Payroll Workers
13 14 15 16 17 18 19 20 21 22 23
1 Skilled Nursing Facility X X X X
X X X X X X 1
2
2
3 Nursing Facility
X
X X X
X X X X X 3
3.1 ICF/MR
X X
X X X X X 3.1
4 Other Long Term Care Facility
X
X X X X 4
5 Home Health Agency
X X 5
6
6
7 SNF-Based Outpatient
7
Rehabilitation Providers
X X
8 Hospice
X X X X X X X X X X X 8
9 Total (Sum of lines 1-8) X X X X X X X X X X X 9
10 Ambulance trips
10
08-01   FORM CMS 2540-96
3590(Cont.)
PROVIDER NO.: PERIOD: WORKSHEET S-3
SNF WAGE INDEX INFORMATION
FROM __________ PARTS II & III
 
______________ TO _____________
Reclass. Adjusted Paid Hours Average
of Salaries Salaries Related Hourly Wage
PART II DIRECT SALARIES Amount from Wkst. (col. 1 ± to Salary (col. 3 ÷ Data
Reported A-6 col. 2) in col. 3 col. 4) Source
1 2 3 4 5 6
1 Total salary (See Instructions) X
X X X
1
2 Physician salaries-Part A X X X X X
2
3 Physician salaries-Part B X X X X X
3
4 Interns & Residents (approved) X X X X X
4
5 Home office personnel X X X X X
5
6 Sum of lines 2 thru 5 X X X X X
6
7 Revised wages (line 1 minus line 6) X
X X X
7
8 Other Long Term Care X X X X X
8
9 Other Inpatient Routine Service
9
10 Interns & Residents
10
(Not In Approved Program) X X X X X
11 HHA X X X X X
11
12 Outpatient Rehabilitation Providers X X X X X
12
13 Hospice X X X X X
13
14 Non-reimbursable X X X X X
14
15 Total Excluded salary
15
(Sum of lines 8 through 14) X X X X X
16 Subtotal (line 7 minus line 15) X X X X X
16
17 Contract Labor: Patient Related & Mgmt X X X X X CMS 339 17
18 Home office salaries & wage related costs X X X X X
18
19 Wage related costs (core) X X X
CMS 339 19
20 Wage related costs (other) X X X
CMS 339 20
21 Wage related costs (excluded units) X X X
CMS 339 21
22 Subtotal (see instructions) X
X
X
22
23 Total (see instructions) X
X X X
23
24 Contract Labor: Physician services-Part A X X X X X
24
PART III - OVERHEAD COST - DIRECT SALARIES
Reclass. Adjusted Paid Hours Average
of Salaries Salaries Related Hourly Wage
Amount from (col. 1 ± to Salary (col. 3 ÷
Reported Wkst. A-6 col. 2) in col. 3 col. 4)
1 2 3 4 5
1 Employee Benefits X X X X X
1
2 Administrative & General X X X X X
2
3 Plant Operation, Maintenance & Repairs X X X X X
3
4 Laundry & Linen Service X X X X X
4
5 Housekeeping X X X X X
5
6 Dietary X X X X X
6
7 Nursing Administration X X X X X
7
8 Central Services and Supply X X X X X
8
9 Pharmacy X X X X X
9
10 Medical Records &
10
Medical Records Library X X X X X
11 Social Service X X X X X
11
12 Interns & Records (Apprvd Tching Prog) X X X X X
12
13 Other General Service (specify) X X X X X
13
14 Total (sum lines 1 thru 13) X X X X X
14
04-06
FORM CMS 2540-96
3590 (Cont.)
PROSPECTIVE PAYMENT FOR SNF PROVIDER NO.: PERIOD:
WORKSHEET S-7
STATISTICAL DATA
FROM:
PART IV
TO:
M3PI SERVICES PRIOR TO SERVICES ON OR AFTER HIGH COST TOTAL
REVENUE October 1 October 1 RUGs (2) (see
GROUP (1) CODE RATE DAYS RATE DAYS DAYS instructions)
1 2 3 3.01 4 4.01 4.05 5
1 RUC
X X X X
X 1
2 RUB
X X X X
X 2
3 RUA
X X X X
X 3
3.01 RUX
X X X X
X 3.01
3.02 RUL
X X X X
X 3.02
4 RVC
X X X X
X 4
5 RVB
X X X X
X 5
6 RVA
X X X X
X 6
6.01 RVX
X X X X
X 6.01
6.02 RVL
X X X X
X 6.02
7 RHC
X X X X X X 7
8 RHB
X X X X
X 8
9 RHA
X X X X
X 9
9.01 RHX
X X X X
X 9.01
9.02 RHL
X X X X
X 9.02
10 RMC
X X X X X X 10
11 RMB
X X X X X X 11
12 RMA
X X X X
X 12
12.01 RMX
X X X X
X 12.01
12.02 RML
X X X X
X 12.02
13 RLB
X X X X
X 13
14 RLA
X X X X
X 14
14.01 RLX
X X X X
X 14.01
15 SE3
X X X X X X 15
16 SE2
X X X X X X 16
17 SE1
X X X X X X 17
18 SSC
X X X X X X 18
19 SSB
X X X X X X 19
20 SSA
X X X X X X 20
21 CC2
X X X X X X 21
22 CC1
X X X X X X 22
23 CB2
X X X X X X 23
24 CB1
X X X X X X 24
25 CA2
X X X X X X 25
26 CA1
X X X X X X 26
27 IB2
X X X X
X 27
28 IB1
X X X X
X 28
29 IA2
X X X X
X 29
30 IA1
X X X X
X 30
31 BB2
X X X X
X 31
32 BB1
X X X X
X 32
33 BA2
X X X X
X 33
34 BA1
X X X X
X 34
35 PE2
X X X X
X 35
36 PE1
X X X X
X 36
37 PD2
X X X X
X 37
38 PD1
X X X X
X 38
39 PC2
X X X X
X 39
40 PC1
X X X X
X 40
41 PB2
X X X X
X 41
42 PB1
X X X X
X 42
43 PA2
X X X X
X 43
44 PA1
X X X X
X 44
45 Default rate
X X X X
X 45
46 TOTAL
X
X X X 46
08-10
FORM CMS 2540-96
3590 (Cont.)
PROSPECTIVE PAYMENT FOR SNF PROVIDER NO.: PERIOD:
WORKSHEET S-7
STATISTICAL DATA
FROM:
PART IV
TO:
CONTINUED
Line
M3PI SERVICES PRIOR TO SERVICES ON OR AFTER HIGH COST TOTAL
45
REVENUE October 1 October 1 RUGs (2) (see
Sub- GROUP (1) CODE RATE DAYS RATE DAYS DAYS instructions)
script 1 2 3 3.01 4 4.01 4.05 5
45.01 ES3
45.01
45.02 ES2
45.02
45.03 ES1
45.03
45.04 HE2
45.04
45.05 HE1
45.05
45.06 HD2
45.06
45.07 HD1
45.07
45.08 HC2
45.08
45.09 HC1
45.09
45.10' HB2
45.10'
45.11 HB1
45.11
45.12 LE2
45.12
45.13 LE1
45.13
45.14 LD2
45.14
45.15 LD1
45.15
45.16 LC2
45.16
45.17 LC1
45.17
45.18 LB2
45.18
45.19 LB1
45.19
45.20' CE2
45.20'
45.21 CE1
45.21
45.22 CD2
45.22
45.23 CD1
45.23
46 TOTAL
46
               
RUG-IV groups were puiblished in the "Federal Register", Vol. 74.No. 153/August 11, 2009,
page 40288- FY 2010 SNF Final Rule. These RUGs are effective for services on and after 10/01/2010.
RUG-IV groups are added for reimbursement on Worksheet S-7, Part IV, and are displayed above.
Subscript line 45 as shown above to accommodate this addition.
NOTE: The default line code designation has been changed to "AAA".
State Average Group Average Comp #1
Facility Info
Facility Name SANTA MONICA HEALTHCARE CENTER
Street Address 1320 20TH STREET
City SANTA MONICA
State CA
Zip 90404
Provider ID 055540
Reporting Year 2010
Facility Data
Beds 108 59 59
Bed Days Available 39,318 21,535 21,535
Total Inpatient Days 34,619 18,491 18,491
Medicare Days 4,565 6,006 6,006
Non-Medicare Days 30,054 12,485 12,485
Ave. Daily Census 95.6 50.7 50.7
Occupancy Rate 88.0% 85.9% 85.9%
Payor Mix By Patient Days
Medicare 13.2% 32.5% 32.5%
Non-Medicare 86.8% 67.5% 67.5%
PPD PPD Total PPD
Revenue Mix
Net Patient Revenue $252.66 $340.83 $6,302,290 $340.83
Medicare Revenue $588.26 $607.93 $3,651,222 $607.93
Non-Medicare Revenue $201.68 $212.34 $2,651,068 $212.34
Revenue
Inpatient Revenue $219.80 $333.91 $6,174,309 $333.91
Ancillary & O/P Rev. $67.07 $118.15 $2,184,691 $118.15
Total Patient Revenue $289.79 $452.06 $8,359,000 $452.06
Less: Cont. Allow. & Disc. $37.13 $111.23 $2,056,710 $111.23
Net Patient Revenue $252.66 $340.83 $6,302,290 $340.83
Other Revenue $16.32 $0.00 $56 $0.00
Total Revenue $268.97 $340.83 $6,302,346 $340.83
Expenses
Admin. & Gen. $50.27 $78.92 $1,459,393 $78.92
Emp. Benefits $19.29 $24.77 $457,933 $24.77
Plant Operations $10.59 $7.58 $140,196 $7.58
Laundry & Linen $2.89 $2.06 $38,026 $2.06
Housekeeping $5.62 $10.37 $191,716 $10.37
Dietary $17.04 $19.70 $364,213 $19.70
Nursing Admin. $4.77 $16.91 $312,707 $16.91
Cent. Svc. & Pharm. $1.42 $3.94 $72,944 $3.94
Medical Records $1.97 $2.96 $54,718 $2.96
Social Services $4.32 $2.36 $43,710 $2.36
Nursing I/P Rout. Svc. $71.83 $75.99 $1,405,218 $75.99
Ancillary Services $29.94 $52.96 $979,347 $52.96
Other Exp. & Interns $0.37 $5.53 $102,219 $5.53
Exp. B4 Prop. Ins. & Tx. $220.33 $304.06 $5,622,340 $304.06
EBITDAR B4 Prop. Ins. & Tx $48.65 $36.77 $680,006 $36.77
The data in all VIGsnfcomps.com reports comes from the SNF Medicare Cost Report worksheets. Click on any data cell in the sample report on the left in order to see how the data is derived.
State Average Group Average SANTA MONICA HEALTHCARE CENTER
Number of Beds 108 59 59
Bed Days Available 39,318 21,535 21,535
Emps. on Payroll (FTE) 119.5 62.2 62.2
Direct Care FTE 83.6 34.0 34.0
Non-Direct Care FTE 35.8 28.2 28.2
Emps. Avg. Hrly Wages $21.85 $24.48 $24.48
Direct Care Avg. Hrly Wage $23.26 $25.66 $25.66
Non-Direct Care Avg. Hrly Wage $17.92 $21.57 $21.57
Occupancy Rate 88.0% 85.9% 85.9%
Medicare % 13.2% 32.5% 32.5%
Medicaid % 56.1% 49.2% 49.2%
Other % 30.7% 18.4% 18.4%
I/P Days Total 34,619 18,491 18,491
Medicare 4,565 6,006 6,006
Medicaid 19,433 9,090 9,090
Other 10,621 3,395 3,395
ALOS 103.3 71.1 71.1
Medicare 37.3 33.9 33.9
Medicaid 243.9 144.3 144.3
State Average Group Average SANTA MONICA HEALTHCARE CENTER
PPD PPD Total PPD
Revenues
Total Patient Revenues $289.79 $452.06 $8,359,000 $452.06
Total Inpatient Revenues $289.32 $452.06 $8,359,000 $452.06
Gen. Inpatient Care Services $6,174,309 $333.91
Ancillary Inpatient Services $2,184,691 $118.15
Other Inpatient Services
Total Outpatient Revenues $0.47
Ancillary Services - Outpatient
Other Outpatient Services
Net Patient Rev. after C/A $252.66 $340.83 $6,302,290 $340.83
Total Other Income $16.32 $0.00 $56 $0.00
State Average Group Average SANTA MONICA HEALTHCARE CENTER
PPD PPD Total PPD
Expenses
General Service Expenses
Cap. Exp. Bldg. & Fix. $19.79 $7.47 $138,215 $7.47
Cap. Exp. Movable Equip. $1.88 $0.40 $7,355 $0.40
Employee Benefits $19.29 $24.77 $457,933 $24.77
Salaries
Other $457,933 $24.77
Administrative & General $50.27 $78.92 $1,459,393 $78.92
Salaries $325,684 $17.61
Other $1,133,709 $61.31
Plant Ops Maint. & Rep. $10.59 $7.58 $140,196 $7.58
Salaries
Other $140,196 $7.58
Laundry & Linen Service $2.89 $2.06 $38,026 $2.06
Salaries $30,398 $1.64
Other $7,628 $0.41
Housekeeping $5.62 $10.37 $191,716 $10.37
Salaries $175,470 $9.49
Other $16,246 $0.88
Dietary $17.04 $19.70 $364,213 $19.70
Salaries $185,455 $10.03
Other $178,758 $9.67
Nursing Administration $4.77 $16.91 $312,707 $16.91
Salaries $275,581 $14.90
Other $37,126 $2.01
Central Services & Supply $1.30 $3.94 $72,944 $3.94
Salaries
Other $72,944 $3.94
Pharmacy $0.13
Salaries
Medical Records & Library $1.97 $2.96 $54,718 $2.96
Salaries $50,443 $2.73
$4,275 $0.23
Social Service $4.32 $2.36 $43,710 $2.36
Salaries $43,710 $2.36
Intern & Residents
Salaries
Other General Service Cost $0.37 $5.53 $102,219 $5.53
Non-Gen. Service Expenses
I/P Routine Serv. Cst. Ctrs. $71.83 $75.99 $1,405,218 $75.99
Salaries $1,402,726 $75.86
$2,492 $0.13
Ancillary Service Cost Centers $29.94 $52.96 $979,347 $52.96
Salaries $555,068 $30.02
Other $424,279 $22.95
Other Expenses $26.61 $26.92 $497,785 $26.92
Operating Expenses Adjustments $-0.00
Total Expenses $249.41 $317.32 $5,867,532 $317.32
NOI $16.57 $23.51 $434,814 $23.51
State Average Group Average SANTA MONICA HEALTHCARE CENTER
Total Direct Salaries
Fac. Emp. Avg. Hrly. $18.44 $22.47 $22.47
FTE 68.9
Hours Per Patient Day 7.8
Non-Phy. Cont. Labor Avg. Hrly. $47.75
FTE
Hours Per Patient Day
Home Off. Avg. Hrly. $44.45
FTE
Hours Per Patient Day
Total Facility Avg. Hrly. $23.26 $25.66 $25.66
FTE 68.9
Hours Per Patient Day 7.8
Contract Labor - Phy. Avg. Hrly. $146.33
FTE
Hours Per Patient Day
Total Overhead
Emp. Bene. Avg. Hrly. $20.08
FTE
Hours Per Patient Day
Admin. & Gen. Avg. Hrly. $29.38 $28.47 $28.47
FTE 5.5
Hours Per Patient Day 0.6
Plant Ops Avg. Hrly $17.38
FTE
Hours Per Patient Day
Laundry Avg. Hrly. $10.33 $10.14 $10.14
FTE 1.4
Hours Per Patient Day 0.2
Housekeeping Avg. Hrly. $11.18 $13.23 $13.23
FTE 6.4
Hours Per Patient Day 0.7
Dietary Avg. Hourly $12.96 $13.06 $13.06
FTE 6.8
Hours Per Patient Day 0.8
Nursing Admin. Avg. Hrly. $41.54 $42.57 $42.57
FTE 3.1
Hours Per Patient Day 0.6
Central Serv. Avg. Hrly. $0.35 $0.35
FTE
Hours Per Patient Day
Pharmacy Avg. Hrly. $31.97
FTE
Hours Per Patient Day
Med. Records Avg. Hrly $17.87 $23.42
FTE 1.0
Hours Per Patient Day 0.1
Social Serv. Avg. Hrly. $16.37 $19.02 $19.02
FTE 3.0
Hours Per Patient Day 0.3
Interns & Res. Avg. Hrly.
FTE
Hours Per Patient Day
Other Gen. Serv. Avg. Hrly. $17.77 $56.47 $56.47
FTE 0.9
Hours Per Patient Day 0.1
Total Ave. Hourly Wage $17.92 $21.57 $21.57
FTE 28.2
Hours Per Patient Day 3.2
SANTA MONICA HEALTHCARE CENTER
Assets
Current Assets $858,131
Cash on hand an in banks $150,827
Temporary Investments
Notes Receivable
Accounts Receivable
Other Receivables $639,882
Less: Alloc. for Uncoll.
Inventory
Prepaid Expenses $67,422
Other Current Assets
Due from Other Funds
Fixed Assets $249,068
Land
Land Improvements
Less: Land Imp. Depr.
Buildings
Less: Buildings Depr.
Leasehold Improvements $355,851
Less: Leasehld Imp. Amort. $164,821
Fixed Equipment $196,310
Less: Fixed Equip. Depr. $138,272
Automobiles and Trucks $4,000
Less: Auto & Truck Depr. $4,000
Major Movable Equipment
Less: Maj. Mov. Equip. Depr.
Minor Equip. Non-Depreciable
Other Fixed Assets
Other Assets $125,493
Investments
Deposits on Leases
Due from Owners/Officers
Other Assets $125,493
Total Assets $1,232,692
Liabilities
Current Liabilities $793,178
Accounts Payable $521,742
Salaries, wages & fees payable $233,224
Payroll taxes payable $15,086
Notes & Loans Pay (ST)
Deferred Income
Accelerated Payments
Due to other funds
Other current liabilities $23,126
Long Term Liabilities $-669,583
Mortgage payable
Notes payable
Unsecured loans
Loans from owners
Other long term liabilities $-669,583
Total Liabilities $123,595
Fund Balances $1,109,097
General Fund Balance $1,109,097
Total Liabilities & Fund Balance $1,232,692
State Average Group Average SANTA MONICA HEALTHCARE CENTER
% % Days %
Rehabilitation
RUC 12.2% 18.3% 1,099 18.3%
RUB 18.4% 20.8% 1,247 20.8%
RUA 5.3% 7.8% 471 7.8%
RUX 10.9% 24.5% 1,474 24.5%
RUL 10.1% 13.3% 798 13.3%
RVC 4.3% 1.2% 71 1.2%
RVB 8.2% 1.9% 116 1.9%
RVA 3.1% 0.9% 57 0.9%
RVX 3.2% 1.1% 64 1.1%
RVL 3.1% 0.5% 28 0.5%
RHC 2.7% 0.5% 28 0.5%
RHB 1.7% 0.3% 20 0.3%
RHA 1.1% 0.0% 3 0.0%
RHX 0.1%
RHL 0.0% 0.0% 2 0.0%
RMC 1.0% 0.6% 39 0.6%
RMB 1.0% 0.3% 18 0.3%
RMA 0.5% 0.4% 25 0.4%
RMX 3.4% 2.5% 149 2.5%
RML 1.7% 1.2% 73 1.2%
RLB 0.1%
RLA 0.0%
RLX
Extensive Services
SE3 0.7%
SE2 1.1%
SE1 0.1% 0.0% 1 0.0%
ES3 0.1%
ES2 0.1%
ES1 0.1%
Special Care
SSC 0.5% 0.7% 42 0.7%
SSB 0.5% 0.8% 46 0.8%
SSA 0.6% 0.0% 2 0.0%
Special Care High
HE2 0.0%
HE1 0.1% 0.2% 14 0.2%
HD2 0.0%
HD1 0.1%
HC2 0.1% 0.5% 31 0.5%
HC1 0.1% 0.5% 31 0.5%
HB2
HB1 0.0% 0.1% 4 0.1%
Special Care Low
LE2 0.0%
LE1 0.2%
LD2 0.0%
LD1 0.3% 0.1% 6 0.1%
LC2 0.0%
LC1 0.2% 0.3% 20 0.3%
LB2
LB1 0.1%
Clinically Complex
CE2
CE1 0.0%
CD2
CD1 0.1%
CC2 0.1%
CC1 0.4% 0.1% 8 0.1%
CB2 0.1%
CB1 0.7% 0.2% 10 0.2%
CA2 0.2%
CA1 0.5% 0.2% 14 0.2%
Impaired Cognition
IB2
IB1 0.0%
IA2
IA1 0.0%
Behavior Only
BB2
BB1 0.1%
BA2
BA1 0.1%
Physical Function Reduced
PE2 0.0%
PE1 0.1%
PD2 0.0%
PD1 0.2%
PC2 0.0%
PC1 0.1% 0.0% 3 0.0%
PB2
PB1 0.1% 0.3% 17 0.3%
PA2 0.0%
PA1 0.1% 0.1% 6 0.1%
Default 0.2%
Total 100.0% 100.0% 6,006 100.0%
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