Nursing Facility Census Data Collection Form

When completed, please e-mail this form to this address: NFcensus@state.ma.us

Indicate census date:	   
January 1st	  April 1st	  July 1st	  October 1st

Nursing facility name:

MassHealth provider number:

City or town:	Zip code:

Total number of nursing facility licensed beds:	

Total number of Medicare licensed beds:	

Number of Medicaid fee-for-service (FFS) residents:	

Number of Medicaid Senior Care Organization (SCO) residents:	

Number of Medicaid Program for All-inclusive Care of the Elderly
(PACE) residents:	

Number of residents on medical leave of absence (MLOA):	

Medicare census data:	

Medicare HMO data:	

Hospice Medicaid data:	

Hospice Medicare data:	

Hospice private data:	

Total empty beds:	

Other census data:	

Number of out-of-state residents:	

Indicate state of primary residence:	

Explanation of nursing facility empty beds:
(Please code this row if appropriate as follows.)
1 = Beds out of service
2 = Low census
3 = Construction
4 = Staffing issues	

Total rest home licensed beds:	

Total rest home census:	

Total rest home empty beds:	

NF-CDCF (03-10)