Free WI Medicaid Program Nursing Home Cost Report - Wisconsin


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Pages: 54
Date: September 22, 2008
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State: Wisconsin
Category: Health Care
Author: DHS
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http://dhs.wisconsin.gov/forms/F0/F01812.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-01812 (09/2008)

STATE OF WISCONSIN

WISCONSIN MEDICAID PROGRAM 2008 NURSING HOME COST REPORT
Completion of this form is required by Section 1.171 of the Methods of Implementation for Wisconsin Medicaid Nursing Home Payment Rates (Methods). Failure to complete and submit this form by the due date may result in a reduction or forfeiture of the payment rate, as provided in Section 49.45(13), Wis. Stats.

SCHEDULE 1 ­ FACILITY AND PREPARER INFORMATION AND CERTIFICATION
SECTION A ­ FACILITY INFORMATION
Facility Name Facility Street Address Contact Person Cost Report Period Start Date Administrator Cost Report Period End Date Main Telephone Number City Contact Telephone Number Medicaid Provider Number State Contact E-Mail Address National Provider Identifier (NPI) Main E-Mail Address Zip Code Corporate Facility Number POP ID Number

Chief Financial Officer

Where are the financial records of the nursing home located?

SECTION B ­ PREPARER OF THE REPORT IF NOT AN EMPLOYEE OF THE PROVIDER
Name and Title Address SIGNATURE ­ Original Signature of Preparer City Telephone Number State Date Signed Zip Code

SECTION C ­ CERTIFICATION BY AN OFFICER OR ADMINISTRATOR OF THE NURSING HOME
This certification must be signed and submitted before the information included in the cost report can be used to calculate Medicaid payment rates. Misrepresentation or falsification of any information contained in this report may be punishable by fine and/or imprisonment under state or federal law. I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying report and any supporting schedules. I HEREBY CERTIFY that to the best of my knowledge and belief, it is a true, correct, and complete report prepared from the books and records of the provider in accordance with applicable instructions, except as noted in the report. SIGNATURE ­ Original Signature of Officer or Administrator of Nursing Home Title Medicaid District Auditor Date Signed

SECTION D ­ For Department Use

Date Received

NURSING HOME COST REPORT SCHEDULE 1

F-01812 Page 2

Medicaid Provider Number

SCHEDULE 2 - PROVIDER'S NOTES, COMMENTS AND QUALIFICATIONS REGARDING THE MEDICAID NURSING HOME COST REPORT
INSTRUCTIONS: This schedule may be used by the nursing home administrator, owners, officers and cost report preparers to provide notes, comments or qualifications regarding the financial and statistical data reported in the accompanying cost report. Attach additional sheets if necessary.

Commentator's Name

Title

Date

NURSING HOME COST REPORT SCHEDULE 2

F-01812 Page 3

Medicaid Provider Number

SCHEDULE 3 ­ GENERAL INFORMATION
1. Type of Medicaid certification (check all that apply) 2. Type of license (check all that apply) 3. Type of ownership (check one) 4. County of facility 6. Does the facility provide laundry services to residents for personal clothing? 7. Are any employees of the facility covered by a union contract? 8. Is the facility Medicare (Title XVIII) certified? 9. Fiscal Year Beginning Month 10. Fiscal Year Ending Month DATE BEDS List the number of licensed beds at the beginning and end of your cost reporting period. Do not include restricted use beds. Beds at Beginning of Cost Reporting Period Beds at End of Cost Reporting Period If there has been a change in the number of licensed beds, list the date(s) of the change(s), the number of beds and briefly explain. 11. Has a certified audit been conducted for the cost reporting period? If yes, submit complete report copy including notes to the financial statements. 12. Check all related party transaction types for which expenses are reported. (1) Related party lease of building (3) Interest expense on related party loans (1) Yes (2) No (01) Nursing Facility (01) Skilled Nursing (10) Intermediate Care (1) Proprietary (10) ICF-MR (20) Developmentally Disabled (40) IMD (2) Voluntary Non-Profit (3) Governmental For Department Use ­ County Code (1) Yes (1) Yes (1) Yes (1) Yes For Department Use ­ End For Department Use ­ Average Beds (2) No (2) No (2) No (2) No For Department Use - Total For Department Use - Total

5. Does the facility self-fund any of the fringe benefits reported on schedule 28? If yes, provide documentation to support the amount claimed.

(2) Compensation to owners/ family relation (4) Other related party transactions Yes Yes No No

13 A. A final adjusted trial balance for the cost reporting period, including a reconciliation of the trial balance to the cost report must be submitted with this cost report. Have copies been made and included with this cost report? 13 B. Asset depreciation schedules detailing amounts reported on Schedule 34 ­ Depreciation Expenses must be submitted. Have copies been made and included with this cost report?

14. Single occupancy rooms: On the right side of the license effective on the last day of the cost report period, you will find the capacity of 1 BED, 2 BED, 3 BED, and 4 BED rooms. Add the number of beds labeled 1 BED and enter it in column C (Single-Bed Rooms). Add the number of beds on all other lines and enter it in column D (Beds in MultipleBed Rooms). Add the number of beds in single rooms (column C) to the number of beds in multiple-bed rooms (column D) and enter the total in column E (Total Licensed Beds). This total must agree with the maximum capacity shown on your license. If your facility has more than one license, list each license on a separate line and total for each column. A. Name 1. 2. 3. 4. TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NURSING HOME COST REPORT SCHEDULE 3

B. License Number

C. Single-Bed Rooms

D. Beds in Multiple-Bed Rooms

E. Total Licensed Beds

F-01812 Page 4

Medicaid Provider Number

SCHEDULE 4 ­ MAJOR REVENUE GENERATING ACTIVITIES
Identify all major revenue generating activities with which the Medicaid nursing home provider is associated. 1. Another Medicaid NH provider, Name of provider: 2. Hospital, Name of hospital: Beds at end of cost report period: 3. Non-Medicaid NH unit or structure, Beds at end of cost report period: 4. Non-Medicaid CBRF, Beds at end of cost report period: 5. Room and board unit or structure, Beds at end of cost report period: 6. Apartment units, Units at end of cost report period: 7. School, Describe: Does school serve students under 21? 8. Outpatient mental health clinic 9. Contract with county mental health/disability board for special services to NH patients, Describe: 10. Therapy services, Describe: 11. Pharmacy 12. Laboratory or radiology services 13. Rental of building space 14. Elderly or other day care 15. Elderly home care 16. Fund raising activities 17. Farm 18. Food catering services (meals on wheels, etc.) 19. Child care 20. Clinic 21. Other, Describe:
NURSING HOME COST REPORT SCHEDULE 4

Check services shared with the nursing home Nursing Sp. Care Dietary Maint. Hskg. Laundry A&G Util.

Yes

No

F-01812 Page 5

Medicaid Provider Number

SCHEDULE 5 ­ BUILDING SQUARE FOOTAGE
SECTION A ­ GENERAL INFORMATION Name or description of building or wing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Year construction was functionally completed on building or wing . . . . . . . . . . . . . Total Square footage of building or wing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION B ­ NURSING HOME SERVICE AREAS 1. Nuns or other employees' housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Employees' unique fringe benefit areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Dietary (kitchen, food preparation & storage, dish washing, kitchen cleanup) . 4. Plant equipment (furnace/boiler room, electrical, water, similar plant equip.) . . 5. Laundry (washing/drying rooms, sorting/folding rooms, central linen storage) . 6. Administration (general/accounting offices, reception areas, meeting rooms) . 7. Laboratory and radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Occupational therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Other therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Beauty and barber shops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Gift shop, canteen, snack shop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. Patient areas (rooms, bathrooms, halls, nurse desk/office, dayrooms, rec.) . . SECTION C ­ RENTED AND OTHER MAJOR REVENUE ACTIVITY AREAS (SEE SCHEDULE 4). IDENTIFY EACH ACTIVITY. 15. Hospital direct patient service areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16. 17. 18. SECTION D ­OTHER AREAS 19. Major idle or closed areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. Residual unidentified square footage (Total area less lines 1 through 19) . . . . Describe general purpose or use of line 20 square footage: FOR DEPT. USE ­ NET SQ. FT.
NURSING HOME COST REPORT SCHEDULE 5

Wing A

Wing B

Wing C

Wing D

sq.ft.

sq.ft.

sq.ft.

sq.ft.

F-01812 Page 6

Medicaid Provider Number

SCHEDULE 6 ­ TOTAL PATIENT DAYS
SECTION A ­ INHOUSE PATIENT DAYS
NON DD 1a. Medicaid (T-19) . . . . . . . . . . . . . . . . . 1b. FDD Medicaid (T-19) . . . . . . . . . . . . . . 1c. Family Care (T-19) . . . . . . . . . . . . . . . 1d. Other Partnership Programs (T-19) . . 1e. Hospice (T-19). . . . . . . . . . . . . . . . . . . 1f. Ventilator (T-19). . . . . . . . . . . . . . . . . . 2. Medicare (T-18) . . . . . . . . . . . . . . . . . . 3. Private pay & Insurance . . . . . . . . . . . 4. Other - Specify. . . . . . . . . . . . . . . . . . . 5. TOTAL INHOUSE PATIENT DAYS. . . . DD 3 DD 2

LEVEL OF CARE (LOC)
DD 1B DD 1A TOTAL

SECTION B ­ BEDHOLD DAYS
6a. Medicaid (T-19) . . . . . . . . . . . . . . . . . 6b. FDD Medicaid (T-19) . . . . . . . . . . . . . 6c. Family Care & Partnership (T-19) . . . . 7. All Other . . . . . . . . . . . . . . . . . . . . . . . . 8. TOTAL BEDHOLD DAYS . . . . . . . . . . .

NON DD

DD 3

DD 2

DD 1B

DD 1A

TOTAL

SECTION C ­ TOTAL PATIENT DAYS
NON DD 9. TOTAL DAYS (lines 5 + 8) . . . . . . . . . 13. Is your facility a distinct part ICF-MR (certified as both a NF and ICF-MR)? If yes, complete schedule 7 . . . . . . . . . . . . . . No
NURSING HOME COST REPORT SCHEDULE 6

DD 3

DD 2

DD 1B

DD 1A

TOTAL

F-01812 Page 7

Medicaid Provider Number

SCHEDULE 7 ­ NO LONGER USED
Information is now on Schedule 6

SCHEDULE 8 ­ TOTAL PATIENT DAYS BY MONTH
1. MONTH . . . . . . . . . 2. Days in Month. . . . 3. Licensed Beds for Bedhold Testing. . . . 4. Occupancy Test - Enter Lower of: Row 2 X Row 3 X .94 Row 2 X (Row 3 ­ 9) 5. Inhouse patient days. . . . . . . . . . . . . . 6. Bedhold days . . . . 7. TOTAL DAYS . . . . TOTAL

Explanation for why Licensed Beds for Bedhold Testing are less than Licensed Beds _________________________________________________________ NOTE: If "Occupancy Test" on line 4 is greater than the "Total Days" on Line 7, bedhold should not be billed in the following month.

SCHEDULE 9A ­ HOSPICE PATIENT DAYS ­ NO LONGER USED
Information is now on Schedule 6

SCHEDULE 9B - VENTILATOR DEPENDENT PATIENT DAYS ­ NO LONGER USED
Information is now on Schedule 6

NURSING HOME COST REPORT SCHEDULES 7, 8, 9A, 9B

F-01812 Page 8

Medicaid Provider Number

SCHEDULE 10 ­ BALANCE SHEET
ASSETS
Cash on hand and in bank . . . . . . . . . . . . . . . . . Temporary investments . . . . . . . . . . . . . . . . . . . Resident accounts receivable . . . . . . . . . . . . . . Other accounts receivable . . . . . . . . . . . . . . . . . Due from related parties . . . . . . . . . . . . . . . . . . Notes receivable . . . . . . . . . . . . . . . . . . . . . . . . Accrued interest receivable . . . . . . . . . . . . . . . . Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prepaid expenses . . . . . . . . . . . . . . . . . . . . . . . Resident funds held in trust . . . . . . . . . . . . . . . . Other current assets, list below: Begin Date $ End Date $

LIABILITIES AND OWNERS' EQUITY
Notes and loans payable, list below:

Begin Date

End Date

$ CURRENT LIABILITIES

$

CURRENT ASSETS

Due to related parties . . . . . . . . . . . . . . . . . . Accounts payable . . . . . . . . . . . . . . . . . . . . . Accrued salaries . . . . . . . . . . . . . . . . . . . . . . Other accrued expenses . . . . . . . . . . . . . . . . Resident trust funds payable . . . . . . . . . . . . . Other current liabilities . . . . . . . . . . . . . . . . . . TOTAL CURRENT LIABILITIES . . . . . . . . . . Notes and loans payable, list below:

$

$

TOTAL CURRENT ASSETS . . . . . . . . . . . . . . . Land . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Land improvements . . . . . . . . . . . . . . . . . . . . . . Buildings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leasehold improvements . . . . . . . . . . . . . . . . . Fixed equipment . . . . . . . . . . . . . . . . . . . . . . . . Moveable equipment . . . . . . . . . . . . . . . . . . . . . Transportation equipment . . . . . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Less: accumulated depreciation . . . . . . . . . . . . TOTAL PROPERTY, PLANT, EQUIPMENT Long term investments . . . . . . . . . . . . . . . . . . . OTHER Other Assets, list below:

$ $

$ $

LONG TERM LIAB.

$

$

PROPERTY, PLANT, EQUIP.

Other long term liabilities . . . . . . . . . . . . . . . . TOTAL LONG TERM LIABILITIES . . . . . . . . OWNERS' EQUITY, list below:

$

$

OWNER EQUITY

$

$

( $ $

)

( $ $

)

TOTAL OWNER'S EQUITY . . . . . . . . . . . . . .

$

$

TOTAL OTHER ASSETS . . . . . . . . . . . . . . . . .

$

$

TOTAL ASSETS . . . . . . . . . . . . . . . . . . . .

$

$

TOTAL LIABILITIES AND EQUITY . . .

$

$

NURSING HOME COST REPORT SCHEDULE 10

F-01812 Page 9

Medicaid Provider Number

SCHEDULE 10A ­ SUMMARY OF CHANGES IN OWNERS' EQUITY
1. Beginning Owners' Equity (from schedule 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Add Net income (from schedule 11, line 21) . . . . . . . . . . . . . . . . . . Owners' capital contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . County appropriation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Net decrease in accrued vacation, holiday and sick time. . Other, Specify: Other, Specify: Total additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $

3. Deduct

Net loss (from schedule 11, line 21) . . . . . . . . . . . . . . . . . . . . Dividends and withdrawals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Net increase in accrued vacation, holiday and sick time. . . Other, Specify: Other, Specify:

$( ( ( ( (

) ) ) ) ) ( )

Total deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. ENDING OWNERS' EQUITY (schedule 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$

NURSING HOME COST REPORT SCHEDULE 10A

F-01812 Page 10

Medicaid Provider Number

SCHEDULE 11 ­ SUMMARY OF REVENUES AND EXPENSES
SECTION A ­ SUMMARY OF REVENUE
1. Daily patient service revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Service fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Rent from outside medical providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Dietary revenues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Miscellaneous services and materials revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Rental revenues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Revenues from other major activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Sales to related organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Investment revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Gains (Losses) on disposal of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Grants for government-subsidized employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Grants, contributions, donations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. Other revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15. Subtract: deductions from revenues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . schedule 14, line 12 schedule 15, line 14A schedule 15, line 14B schedule 15, line 14C schedule 16, line 5A schedule 16, line 17 schedule 17, line 21A schedule 17, line 37 schedule 18, line 41 schedule 18, line 45 schedule 18, line 53 schedule 18, line 57 schedule 18, line 62 schedule 18, line 69 schedule 19, line 9 $ ( ) $

16. NET REVENUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SECTION B ­ SUMMARY OF NET INCOME OR LOSS
17. Subtract: total expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18. Add or subtract the amount to adjust related party transactions to cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . schedule 12, line 39 schedule 42, line 15 $ ( $ ) $( )

19. NET INCOME OR LOSS BEFORE INCOME TAXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. Subtract income taxes ­ optional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . schedule 38, line 6

21. NET INCOME OR LOSS AFTER INCOME TAXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NURSING HOME COST REPORT SCHEDULE 11

F-01812 Page 11

Medicaid Provider Number

SCHEDULE 12 ­ SUMMARY OF TOTAL EXPENSES
Cost Center 1. Daily patient service expense . . . . . . . . . . . 2. Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Physical Therapy . . . . . . . . . . . . . . . . . . . . . 6. Occupational Therapy . . . . . . . . . . . . . . . . . 7. Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Social Services . . . . . . . . . . . . . . . . . . . . . . 9. Recreational Activities . . . . . . . . . . . . . . . . . 10. Religious Services . . . . . . . . . . . . . . . . . . . 11. Speech . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Psychotherapy . . . . . . . . . . . . . . . . . . . . . . 14. Respiratory Care . . . . . . . . . . . . . . . . . . . . . 15. Volunteer coordinator, ward clerks, other . . 16. Dietary . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17. Plant operation and maintenance . . . . . . . . 18. Housekeeping . . . . . . . . . . . . . . . . . . . . . . . 19. Laundry and linen . . . . . . . . . . . . . . . . . . . . 20. Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reference S20, L16 S21, L15 S21, L15 S21, L15 S22, L15 S22, L15 S22, L15 S23, L15 S23, L15 S23, L15 S24, L15 S24, L15 S24, L15 S24, L15 S24A, L15 S25, L19 S25, L19 S25, L19 S25, L19 S25, L19 $ Expense Cost Center 21. Transportation . . . . . . . . . . . . . . . . . . . . . 22. Administrative service expense . . . . . . . . Other cost centers, Specify: 23. 24. 25. 26. 27. UNASSIGNED EXPENSES 28. Employee fringe benefit expense . . . . . . . 29. Heating fuel and utility expense . . . . . . . . . 30. Interest on operating working capital loans 31. Insurance expense . . . . . . . . . . . . . . . . . . 32. Amortization expense . . . . . . . . . . . . . . . . . 33. Interest on plant asset loans . . . . . . . . . . . 34. Depreciation expense . . . . . . . . . . . . . . . . . 35. Expense on operating and non-cap. leases 36. Expense on capitalized leases . . . . . . . . . 37. Property tax expense . . . . . . . . . . . . . . . . 38. Other non-salary expense . . . . . . . . . . . . S28, L17 S29, L10 S30. L6 S31, L9 S32, L5 S33, L8 S34, L20 S35, L9 S36, L3 S37, L8 S39, L4 $ S27, L15 S27, L15 S27, L15 S27, L15 S27, L15 Reference S25, L19 S26, L12 Expense

. 39. TOTAL EXPENSES FOR REPORT PERIOD (Sum 1-38)
(To schedule 11, line 17)

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SCHEDULE 13 ­ SUMMARY OF SALARY AND WAGE EXPENSES
Cost Center and Schedule Daily patient service . . . . . . . . . . Laboratory . . . . . . . . . . . . . . . . . . Radiology . . . . . . . . . . . . . . . . . . Pharmacy . . . . . . . . . . . . . . . . . . Physical therapy . . . . . . . . . . . . . Occupational therapy . . . . . . . . . Physician . . . . . . . . . . . . . . . . . . . Social services . . . . . . . . . . . . . . Recreational activities . . . . . . . . . Religious services . . . . . . . . . . . . Speech . . . . . . . . . . . . . . . . . . . . Dental . . . . . . . . . . . . . . . . . . . . . Psychotherapy . . . . . . . . . . . . . . Respiratory care . . . . . . . . . . . . . Volunteer coordinator . . . . . . . . . Ward clerks . . . . . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . . . . . . . Dietary . . . . . . . . . . . . . . . . . . . . . 20 21 21 21 22 22 22 23 23 23 24 24 24 24 24A 24A 24A 25
NURSING HOME COST REPORT SCHEDULE 13 TOTAL SALARY AND WAGE EXPENSE

Total Salary and Wage Expense (Line 1 or 5) $

Cost Center and Schedule Plant operation / maintenance . Housekeeping . . . . . . . . . . . . . . Laundry and linen . . . . . . . . . . . Security . . . . . . . . . . . . . . . . . . Transportation . . . . . . . . . . . . . Administrative service . . . . . . . Nurse aide training . . . . . . . . . . Beauty and barber . . . . . . . . . . Other, Specify:
25 25 25 25 25 26 27 27 27

Total Salary and Wage Expense (Line 1 or 5)

$

For Department Use

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SCHEDULE 14 ­ DAILY PATIENT SERVICE REVENUES
INSTRUCTIONS: If a facility has received its retroactive Medicaid rate adjustment, the adjusted revenues should be included in line 2 for the months of service in the cost reporting period. Some facilities may have not received the retroactive Medicaid rate adjustments due to them for services provided during the months of the cost reporting period. SECTION A ­ DAILY RATE CHARGES 1. Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Private Pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION B ­ BEDHOLD CHARGES 5. Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Private Pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION C ­ MEDICAL SUPPLIES 8. Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Other, Specify: 11. OTC drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION D ­ TOTAL 12. TOTAL DAILY PATIENT SERVICE REVENUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do Medicaid revenues on Line 2 include retroactive Medicaid rate adjustments? (Check one)
$ $

Revenue

Yes, all significant retroactive Medicaid rate adjustments are included. No, substantial retroactive Medicaid rate adjustments are NOT included. Estimate, an estimate of retroactive Medicaid rate adjustments IS included Other, Specify
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SCHEDULE 15 ­ SPECIAL SERVICE REVENUES
INSTRUCTIONS: Refer to schedules 25A, 25B, 26B, 29, and 40 and their instructions regarding the allocation of general services and property expenses to those building areas which are used for providing the revenue generating services or which are rented out for those services. If applicable, administrative service expenses must be allocated to the revenue generating service. For Column B (Rent Revenue), describe the rental fee basis (example: rent per month, percent of charges) and the services, equipment, and square feet of space furnished to the outside provider. Add additional sheets if necessary. SECTION A ­ SERVICE REVENUES A. Service Fee Charges 1. Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . 2. Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Physical therapy . . . . . . . . . . . . . . . . . . . . . 5. Speech/hearing therapy . . . . . . . . . . . . . . . 6. Occupational therapy . . . . . . . . . . . . . . . . . 7. Physician care . . . . . . . . . . . . . . . . . . . . . . 8. Psychotherapy . . . . . . . . . . . . . . . . . . . . . . 9. Respiratory therapy . . . . . . . . . . . . . . . . . . 10. Social services . . . . . . . . . . . . . . . . . . . . . 11. Recreational activities . . . . . . . . . . . . . . . . 12. Special duty nursing . . . . . . . . . . . . . . . . . 13. Other, Specify: 14. TOTAL SPECIAL SERVICE REVENUE . . If totals exceed $4,000, see instructions above. SECTION B ­ THERAPY REVENUES 15. Are physical, occupational, or speech therapy services provided by staff, assistants, contractors, or consultants IN SPACE AT YOUR FACILITY? 16. Total gross revenues for physical, occupational, and speech therapy services provided at your facility during the cost report period . . . . . . . . . . . . Provide the total regardless of who provides the services, who bills for the services, or who receives the services (residents vs. non-residents). 17. From section A, total the amounts in columns A, B and C on lines 4, 5 and 6 (sum 4A , 4B, 4C, 5A, 5B, 5C, 6A, 6B, 6C) . . . . . . . . . . . . . . . . . . . . . . . . . 18. If there is any variance between the totals reported on lines 16 and 17, explain. 19. Are therapy services provided to individuals in addition to your nursing home residents? 20. Does your facility or related organization bill Medicare Part B for therapy services at your facility? 21. Did you charge rent to a rehabilitation agency or independent contractor? Yes Yes Yes No No No If yes, amount of revenue If yes, amount of revenue If yes, amount of revenue $ $ $ $ $ Yes No $ $ $ $ $ B. Rent from Outside Medical Providers $ C. From Other Sources Describe Other

NURSING HOME COST REPORT SCHEDULE 15

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SCHEDULE 16 ­ OTHER REVENUES
SECTION A ­ CAFETERIA AND DIETARY REVENUE 1. Donated and surplus food commodities . . . . . . . . . . . . . . . . 2. Dietary supplies sold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Meals sold to employees (transfer to sched. 25A, line 10) . 4. Meals on wheels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Other meals sold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a.TOTAL DIETARY REVENUE . . . . . . . . . . . . . . . . . . . . . . . . SECTION B ­ MISCELLANEOUS SERVICES AND MATERIALS Revenue 6a.Personal laundry services for private pay residents . . . . . . . 6b.Other laundry serv., Specify: 7. Dry cleaning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Sale of personal hygiene items . . . . . . . . . . . . . . . . . . . . . . . 9. Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Beauty and barber shops . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Gift shop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Canteen and snack counter . . . . . . . . . . . . . . . . . . . . . . . . . 13. Vending machines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. Sale of clothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15. Television and radio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16. Telephone and telegraph . . . . . . . . . . . . . . . . . . . . . . . . . . . 17. TOTAL MISCELLANEOUS SERVICES AND MATERIALS $
NURSING HOME COST REPORT SCHEDULE 16

$

Included in food supply expense for donated/surplus . . . . Cost of dietary supplies sold (if known) . . . . . . . . . . . . . . .

$ Expenses Directly Ascribable To Or Identifiable With Revenue A. Related Direct B. Cost Center where C. Schedule D. Line Expense (if known) expense included Number Number $ $ $ $ $ $ $ $ $ $ $ $

$

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SCHEDULE 17 ­ OTHER REVENUES
INSTRUCTIONS: For Section C, refer to schedules 25A, 25B, 29, and 40 and their instructions regarding the allocation of expenses to rented equipment or building space. For section D, only report revenues if the direct expenses and the shared and indirect expenses associated with the revenue activity are reported in this cost report. See schedule 4 or Section 700 of the instructions for more details on the reporting of expenses. SECTION C ­ RENTAL REVENUE 18. Equipment rental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. Rental of nursing home space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. Rental of non-nursing home space . . . . . . . . . . . . . . . . . . . . . . . . . . 21. Parking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21a.TOTAL RENTAL REVENUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $ Revenue Property Rented Square Feet Rented Services Provided

SECTION D ­ REVENUE FROM MAJOR ACTIVITIES 22. Another Medicaid nursing home provider . . . . . . . . . . . . . . . . . . . . . 23. Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24. A non-Medicaid nursing home unit . . . . . . . . . . . . . . . . . . . . . . . . . . . 25. A non-Medicaid residential facility (CBRF, RCAC) . . . . . . . . . . . . . . . 26. Room and board unit or structure . . . . . . . . . . . . . . . . . . . . . . . . . . . 27. Apartment units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28. Child care institution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29. School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30. Outpatient mental health clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31. Elderly or other day care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32. Elderly home care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33. Farm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34. 35. 36. 37. TOTAL REVENUE FROM OTHER MAJOR ACTIVITIES . . . . . . . . . $ $

Revenue

Total Billable Patient Days if revenue generated from activities 24,25,26

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SCHEDULE 18 ­ OTHER REVENUES
SECTION E ­ SALES TO RELATED ORGANIZATIONS 38. 39. 40. 41. TOTAL SALES TO RELATED ORGANIZATIONS . . . . . . . $ $ Revenue SECTION H ­ GRANTS FOR GOVT. SUBSIDIZED EMP. 54. 55. 56. 57. TOTAL GRANTS FOR GOVT. SUBS. EMPLOYEES . . $ $ Revenue

SECTION F ­ INTEREST AND INVESTMENT REVENUE 42. Revenue from invested gift/grant funds not commingled with other funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43. Revenue from invested funds used for current cash needs 44. Other revenue from invested funds . . . . . . . . . . . . . . . . . . . 45. TOTAL INVESTMENT REVENUE . . . . . . . . . . . . . . . . . . . . $ $

Revenue

SECTION I ­ GRANTS, CONTRIBUTIONS, DONATIONS 58. Donated services (see 64 below) . . . . . . . . . . . . . . . . . 59. Donated supplies and materials (see 64 below) . . . . . 60. General donations and contributions . . . . . . . . . . . . . . 61. Donor restricted funds used for current operations (see 64 below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62. TOTAL GRANTS, CONTRIBUTIONS, DONATIONS . . 63. Donor restricted funds for plant asset purchase or debt retirement (do not transfer to schedule 11) . . . . . . . $ $ $

Revenue

46. If total investment revenue exceeds $6,000, describe major investments (type, invested amount, purpose if any)

64. For lines 58, 59 and 61, attach a sheet describing the items, amount of related expense reported in this cost report, and where the expense is reported.

SECTION G ­ GAINS (LOSSES) DISPOSAL OF ASSETS 47. Land . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48. Land improvements, buildings, fixed equipment . . . . . . . . . 49. Moveable equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50. Transportation vehicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51. Investment securities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52. Other assets, Specify: 53. TOTAL GAINS (LOSSES) ON DISPOSAL OF ASSETS . . . $ $

Gain (Loss)

SECTION J ­ OTHER REVENUES 65. 66. 67. 68. 69. TOTAL OTHER REVENUES . . . . . . . . . . . . . . . . . . . . $ $

Revenue

NURSING HOME COST REPORT SCHEDULE 18

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SCHEDULE 19 ­ DEDUCTIONS FROM REVENUES
INSTRUCTIONS: This schedule outlines deductions from revenue for amounts reported on schedules 14 and 15. Deductions from revenue are amounts which should be subtracted from revenues to determine net realized revenues. Such deductions are not expenses. SECTION A ­ MISCELLANEOUS 1. Bad debts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Charity Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Revenue Deductions $

SECTION B ­ DAILY SERVICE AND SPECIAL SERVICE CONTRACTUAL ADJUSTMENTS 3. Medicare Physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Speech therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Medicaid Physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Speech therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Other Physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Speech therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occupational therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . All other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

SECTION C ­ OTHER DEDUCTIONS FROM REVENUE 6. 7. 8. $

SECTION D ­ TOTAL 9. TOTAL DEDUCTIONS FROM REVENUE (Sum 1-9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

NURSING HOME COST REPORT SCHEDULE 19

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SCHEDULE 20 ­ DAILY PATIENT SERVICE EXPENSES
SALARIES, WAGES, PURCHASED SERV. 1. TOTAL SALARY AND WAGE EXPENSE 2 TOTAL SALARY AND WAGE HOURS $ hrs. A. Registered Nurses $ hrs. B. Licensed Practical Nurses C. Nurse Aides and Assistants $ hrs. D. Resident Living Staff $ hrs. E. Total Expense/Hrs. (sum A ­ D) $ hrs.

3.EXPENSE FOR PURCHASED SERVICES Lines 4 ­ 7 are no longer used NURSING AND INCONTINENCY SUPPLIES

$

$

$

$

$

8. Purchased laundry service for diapers/underpads, Specify vendor:

____________________________________________________________

$

9. Diapers, underpads, and other paper and cloth incontinency supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Catheter and bladder irrigation supplies and other incontinency apparatuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OXYGEN 11. Oxygen, or daily rental of oxygen concentrators, all other oxygen supplies and cylinder rental . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . OTHER 12. Other medical supplies, personal comfort supplies, and minor medical equipment . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Nonbillable over the counter (OTC) drugs for all residents (report OTC drugs that are billable on schedule 21, line 11) . . . . . . . . . . . . . . . . . . . . . . . 14. 15. 16. TOTAL DAILY PATIENT SERVICE EXPENSE (Sum 1,3, 8-15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

NURSING HOME COST REPORT SCHEDULE 20

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SCHEDULE 21 ­ SPECIAL SERVICE EXPENSES
TYPE OF SERVICE SECTION A ­ SALARY AND WAGES 1. Expense for hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . 2. Number of hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Expense for hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . 4. Number of hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . . . 5. TOTAL SALARY AND WAGE EXPENSE . . . . . . . . . . . . . . . . . . . . . $ $ -0-0hrs. $ $ hrs, $ -0-0hrs. $ A. Laboratory $ hrs. $ hrs. B. Radiology $ hrs. C. Pharmacy

SECTION B ­ PURCHASED SERVICES 6. Expense for purchased service ­ Billable . . . . . . . . . . . . . . . . . . . . . 7. Number of hours of purchased service ­ Billable (optional) . . . . . . . . 8. Expense for purchased service ­ Non-billable . . . . . . . . . . . . . . . . . . 9. Number of hours of purchased service ­ Non-billable (optional) . . . . $ -0-0hrs. $ hrs. $ -0-0hrs. $ hrs. $ hrs. $ hrs.

SECTION C ­ SUPPLY AND OTHER EXPENSE 10. Pharmacy ­ legend drugs - Billable . . . . . . . . . . . . . . . . . . . . . . . . . 11. Pharmacy ­ over the counter drugs - Billable . . . . . . . . . . . . . . . . . . 12. Supply and Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. $ -0-0$ -0-0$

SECTION D ­ TOTAL 15. TOTAL EXPENSES (Sum 5,6,8,10-14) . . . . . . . . . . . . . . . . . . . . . . 16. TOTAL HOURS (Sum 2,4,7,9) . . . . . . . . . . . . . . . . . . . . . . . . . . $ hrs. $ hrs. $ hrs.

NURSING HOME COST REPORT SCHEDULE 21

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SCHEDULE 22 ­ SPECIAL SERVICE EXPENSES
TYPE OF SERVICE SECTION A ­ SALARY AND WAGES 1. Expense for hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . 2. Number of hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Expense for hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . 4. Number of hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . . 5. TOTAL SALARY AND WAGE EXPENSE . . . . . . . . . . . . . . . . . . . . . $ $ hrs. $ $ hrs. $ hrs. $ A. Physical Therapy $ hrs. $ hrs. B. Occupational Therapy $ hrs. C. Physician

SECTION B ­ PURCHASED SERVICES 6. Expense for purchased service ­ Billable . . . . . . . . . . . . . . . . . . . . . 7. Number of hours of purchased service ­ Billable (optional) . . . . . . . . 8. Expense for purchased service ­ Non-billable . . . . . . . . . . . . . . . . . . 9. Number of hours of purchased service ­ Non-billable (optional) . . . . $ hrs. $ hrs. $ hrs. $ hrs. $ hrs. $ hrs.

SECTION C ­ SUPPLY AND OTHER EXPENSE 10. 11. 12. 13. 14. $ $ $

SECTION D ­ TOTAL 15. TOTAL EXPENSES (Sum 5, 6, 8, 10-14) . . . . . . . . . . . . . . . . . . . . . 16. TOTAL HOURS (Sum 2, 4, 7, 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ hrs. $ hrs. $ hrs.

NURSING HOME COST REPORT SCHEDULE 22

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SCHEDULE 23 ­ SPECIAL SERVICE EXPENSES
TYPE OF SERVICE SECTION A ­ SALARY AND WAGES 1. Expense for hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . 2. Number of hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Expense for hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . 4. Number of hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . . 5. TOTAL SALARY AND WAGE EXPENSE . . . . . . . . . . . . . . . . . . . . . $ $ hrs. $ $ A. Social Services -0-0hrs. $ hrs. $ $ B. Recreational Activities -0-0hrs. $ hrs. $ C. Religious Services -0-0hrs.

SECTION B ­ PURCHASED SERVICES 6. Expense for purchased service ­ Billable . . . . . . . . . . . . . . . . . . . . . 7. Number of hours of purchased service ­ Billable (optional) . . . . . . . . 8. Expense for purchased service ­ Non-billable . . . . . . . . . . . . . . . . . . 9. Number of hours of purchased service ­ Non-billable (optional) . . . . $ hrs. $ -0-0hrs. $ hrs. $ -0-0hrs. $ hrs. $ -0-0hrs.

SECTION C ­ SUPPLY AND OTHER EXPENSE 10. 11. 12. 13. 14. $ $ $

SECTION D - TOTAL 15. TOTAL EXPENSES (Sum 5, 6, 8, 10-14) . . . . . . . . . . . . . . . . . . . . . 16. TOTAL HOURS (Sum 2, 4, 7, 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ hrs. $ hrs. $ hrs.

NURSING HOME COST REPORT SCHEDULE 23

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SCHEDULE 24 ­ OTHER TYPES OF SPECIAL SERVICE EXPENSES
TYPE OF SERVICE SECTION A ­ SALARY AND WAGES 1. Expense for hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . 2. Number of hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Expense for hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . 4. Number of hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . . 5. TOTAL SALARY AND WAGE EXPENSE . . . . . . . . . . . . . . . . . . . . . $ $ hrs. $ $ hrs. $ hrs. $ A. Speech $ hrs. $ hrs. $ B. Dental $ hrs. $ hrs. C. Psychotherapy D. Respiratory Care $ hrs.

SECTION B ­ PURCHASED SERVICE 6. Expense for purchased service ­ Billable . . . . . . . . . . . . . . . . . . . . . 7. Number of hours of purchased service ­ Billable (optional) . . . . . . . . 8. Expense for purchased service ­ Non-billable . . . . . . . . . . . . . . . . . . 9. Number of hours of purchased service ­ Non-billable (optional) . . . . $ hrs. $ hrs. $ hrs. $ hrs. $ hrs. $ hrs. $ hrs. $ hrs.

SECTION C ­ SUPPLY AND OTHER EXPENSE 10. 11. 12. 13. 14. $ $ $ $

SECTION D - TOTAL 15. TOTAL EXPENSES (Sum 5, 6, 8, 10-14) . . . . . . . . . . . . . . . . . . . . . 16. TOTAL HOURS (Sum 2, 4, 7, 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ hrs. $ hrs. $ hrs. $ hrs.

NURSING HOME COST REPORT SCHEDULE 24

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SCHEDULE 24A ­ OTHER TYPES OF SPECIAL SERVICE EXPENSES
TYPE OF SERVICE SECTION A ­ SALARY AND WAGES 1. Expense for hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . 2. Number of hours worked ­ Billable . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Expense for hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . 4. Number of hours worked ­ Non-billable . . . . . . . . . . . . . . . . . . . . . . 5. TOTAL SALARY AND WAGE EXPENSE . . . . . . . . . . . . . . . . . . . . . $ $ hrs. $ $ A. Volunteer Coord. -0-0hrs. $ hrs. $ $ C. B. Ward Clerks -0-0hrs. $ hrs. $ $ hrs. $ hrs. $ hrs. D.

SECTION B ­ PURCHASED SERVICE 6. Expense for purchased service ­ Billable . . . . . . . . . . . . . . . . . . . . . 7. Number of hours of purchased service ­ Billable (optional) . . . . . . . . 8. Expense for purchased service ­ Non-billable . . . . . . . . . . . . . . . . . . 9. Number of hours of purchased service ­ Non-billable (optional) . . . . $ hrs. $ -0-0hrs. $ hrs. $ -0-0hrs. $ hrs. $ hrs. $ hrs. $ hrs.

SECTION C ­ SUPPLY AND OTHER EXPENSE 10. 11. 12. 13. 14. $ $ $ $

SECTION D - TOTAL 15. TOTAL EXPENSES (Sum 5, 6, 8, 10-14) . . . . . . . . . . . . . . . . . . . . . 16. TOTAL HOURS (Sum 2, 4, 7, 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . $ hrs. $ hrs. $ hrs. $ hrs.

NURSING HOME COST REPORT SCHEDULE 24A

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SCHEDULE 25 ­ GENERAL SERVICE EXPENSES
SECTION A ­ SALARIES AND WAGES 1. TOTAL SALARY AND WAGE EXPENSE 2. NUMBER OF HOURS WORKED Lines 3-5 are no longer used SECTION B ­ DIETICIAN CONSULTANT 6. Dietician consultant expense Line 7 is no longer used SECTION C ­ OUTSIDE SERVICE 8. 9. 10. 11. SECTION D ­ FOR DEPARTMENT USE 12. $ hrs. A. Dietary B.Plant Op./Maint. C. Housekeeping D. Laundry / Linen E. Security F. Transportation

$ hrs.

$ hrs.

$ hrs.

$ hrs.

$ hrs.

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

SECTION E ­ SUPPLY AND OTHER EXPENSE 13. $ 14. 15. 16. 17. SECTION F ­ FOR DEPARTMENT USE 18. SECTION G ­ TOTAL 19. TOTAL EXPENSES (Sum 1, 6, 8-11, 13-17)

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

NURSING HOME COST REPORT SCHEDULE 25

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Medicaid Provider Number

SCHEDULE 25A ­ ALLOCATION OF DIETARY AND PLANT OPERATION AND MAINTENANCE EXPENSES
SECTION A ­ ALLOCAITON OF DIETARY EXPENSES 1. Total dietary expenses (from schedule 25, line 19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Deduct expense for food products provided to employees without charge (to line 9 below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Deduct amount for donated and surplus food commodities included in dietary expense (from schedule 16, line 1) . . . . . . . . . . . . . . . . . . . . . . . 4. Deduct revenue (related expense) for food products sold (from schedule 16, line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. NET DIETARY EXPENSES TO ALLOCATE (to line 8 A below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Residents' Meals C. Employees' Meals D. Meals on Wheels $ ($ ($ ($ $ ) ) )

A. Total 6. Meals served . . . . . . . . . . . . . . . . . . . . . . 7. Ratio to total meals served to 4 decimals 8. DIETARY EXPENSE ALLOCATION . . . . (see instructions below line to complete) $ From line 5 1.0000 $

E. Other

F. Other

$ 8A X 7B $ ( ) 8A X 7C

$ 8A X 7D

$ 8A X 7E

$ 8A X 7F

9. Food products provided to employees without charge (from line 2) . . . . . . . . . . . . . . . . 10.Deduct revenue from meals sold to employees (from schedule 16, line 3) . . . . . . . . . . . 11.NET EXPENSE (PROFIT) FOR MEALS AND FOOD PROVIDED TO EMPLOYEES (line 8C + line 9C ­ line 10C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION B ­ ALLOCATION OF PLANT OPERATION AND MAINTENANCE EXPENSES A. Total 12. Total square feet for areas . . . . . . . . . . . 13. Ratio to total square feet to 4 decimals . . 14. TOTAL PLANT OP/MAINT EXP. ALLOC. 1.0000 $ From S25, L19 $ 14A X 13B B. Nursing Home Area

$ Non-Nursing Home Areas w/ Plant Operation and Maint. D. E. F.

C. Emp. Unique Fringe Benefit Area

$ 14A X 13C

$ 14A X 13D

$ 14A X 13E

$ 14A X 13F

NURSING HOME COST REPORT SCHEDULE 25A

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SCHEDULE 25B ­ ALLOCATION OF HOUSEKEEPING, LAUNDRY, SECURITY AND TRANSPORTATION
SECTION A ­ ALLOCATION OF HOUSEKEEPING EXPENSES A. Total 15. Square feet or hours of service provided 16. Ratio to total sq. ft./ hours to 4 decimals 17. TOTAL HOUSEKEEPING EXP. ALLOC. $ From S25, L19 SECTION B ­ ALLOCATION OF LAUNDRY AND LINEN EXPENSES A. Total 18. Pounds of laundry processed . . . . . . . . . 19. Ratio to total pounds to 4 decimals . . . . . 20. TOTAL LAUNDRY/LINEN EXP. ALLOC. $ From S25, L19 SECTION C ­ ALLOCATION OF SECURITY EXPENSES A. Total 21. Total square feet of area . . . . . . . . . . . . . 22. Ratio to total square feet to 4 decimals . . 23. TOTAL SECURITY EXPENSE ALLOC. $ From S25, L19 SECTION D ­ ALLOCATION OF TRANSPORTATION EXPENSES A. Total 24. Alloc. basis, Specify: 25. Ratio to total alloc. basis to 4 decimals 26. TOTAL TRANS. EXPENSE ALLOC. $ From S25, L19 1.0000 $ 26A X 25B $ 26A X 25C $ 26A X 25D $ 26A X 25E B. Nursing Home Area C. 1.0000 $ 23A X 22B $ 23A X 22C $ 23A X 22D $ 23A X 22E B. Nursing Home Area C. 1.0000 $ 20A X 19B $ 20A X 19C $ 20A X 19D $ 20A X 19E B. Nursing Home Area C. 1.0000 $ 17A X 16B $ 17A X 16C $ 17A X 16D $ 17A X 16E B. Nursing Home Area C. Non-Nursing Home Areas Receiving Housekeeping Services D. E.

Non-Nursing Home Areas Receiving Laundry/Linen Services D. E.

Non-Nursing Home Areas Receiving Security Services D. E.

Non-Nursing Home Areas Receiving Transportation Services D. E.

NURSING HOME COST REPORT SCHEDULE 25B

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SCHEDULE 26 ­ ADMINISTRATIVE SERVICE EXPENSES
INSTRUCTIONS: For facilities managed by an outside, contracted management firm, the amount of management fee expense for the cost reporting period must be separately identified and reported on line 10 of this schedule. Enclose a copy of the management contract that was in effect during the cost reporting period. SECTION A ­ SALARIES AND WAGES A. General Admin. Serv. B. Medical Records C. Central Supply D. Accounting/Other Serv. E. TOTAL (sum A-D)

1. TOTAL SALARY AND WAGE EXPENSE.

$

$

$

$

$

2. NUMBER OF HOURS WORKED. . . . . . Lines 3-5 are no longer used

hrs.

hrs.

hrs.

hrs.

hrs.

SECTION B ­ RELATED ORGANIZATION CENTRAL SERVICE COSTS 6. Home office costs allocated to facility (from schedule 26A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. County costs allocated to facility (from schedule 26A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

SECTION C ­ NON-SALARY EXPENSES 8. Purchased services - legal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Licensed bed assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Contractual management fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Total other non-salary (from schedule 26 attachment) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

SECTION D ­ TOTAL 12. TOTAL ADMINISTRATIVE SERVICE EXPENSES (Sum 1, 6 -11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

NURSING HOME COST REPORT SCHEDULE 26

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SCHEDULE 26 ATTACHMENT ­ OTHER NON-SALARY ADMINISTRATIVE SERVICE EXPENSES
INSTRUCTIONS: Itemize the expenses for other non-salary administrative service expenses which are reported on schedule 26, line 11. Use account descriptions from the facility general ledger with as much detail as possible. Add additional sheets if necessary. Description of Other Non-Salary Administrative Service Expenses 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. TOTAL OTHER NON-SALARY ADMINISTRATIVE SERVICE EXPENSES (should equal schedule 26, line 11) . . . . . . . . . . . . . . . . . . . . $ $ Expense Amount

NURSING HOME COST REPORT SCHEDULE 26 Attachment

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SCHEDULE 26A ­ HOME OFFICE AND COUNTY CENTRAL SERVICE EXPENSES
INSTRUCTIONS: This schedule should be completed by any facility which is related by common ownership or control to a parent organization which provides centralized services to the nursing home or any county-operated nursing home which receives administrative services from centralized county services. Expenses which are indirectly allocated to this facility for home office or county centralized administrative services should be reported on schedule 26. The allocated costs must be reported from the organization's fiscal year which ended during the nursing home's cost report period. SECTION A ­ GENERAL INFORMATION 1. Name and address of home office or county courthouse 2. Name and telephone number of contact at home office SECTION B ­ HOME OFFICE COST ALLOCATION REPORT Parent or chain organizations must submit a Home Office Cost Allocation Report or a Medicare Home Office Cost Statement (or other home office report form acceptable to Medicare). A copy of the completed report should be sent to DHS at the Bureau of Nursing Home Services, DLTC, P.O. Box 7851, Madison, WI 53707-7851. A county facility can base the county centralized service costs allocated to the facility on the countywide cost allocation plan prepared in accordance with the policies and procedures contained in OMB Circular A-87. A separate Home Office Cost Allocation Report does not need to be completed. SECTION C ­ AFFILIATED NURSING HOMES Wisconsin Nursing Homes Operated by the Parent Organization or County (add additional sheets if necessary) 1. 2. 3. 4. SECTION D ­ COSTS ALLOCATED TO THIS FACILITY 1. Amount of home office or county centralized costs allocated to this facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Deduct the amount of return on owner's equity included in the line 1 amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Deduct expenses included in line 1 which are directly ascribable to this facility. Reclassify these expenses to their appropriate cost center and specify:

City

$ ( ( ( ( ( ) ) ) ) )

4. NET HOME OFFICE OR COUNTY COSTS ALLOCATED TO THIS FACILITY (to schedule 26, line 6 or 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Amount on line 4 is from (date) 6. Amount on line 4 is from (check one) Home Office Cost Allocation Report through (date) Medicare Home Office Cost Statement

$

Countywide Cost Allocation Plan

NURSING HOME COST REPORT SCHEDULE 26A

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SCHEDULE 26B ­ ALLOCATION OF ADMINISTRATIVE SERVICE EXPENSES
INSTRUCTIONS: On line 17, enter the quantitative amounts for the allocation basis used by the facility. Describe the type of basis used and how it was determined. 1. Total Admin. Service Expense (S26, L12) SECTION A ­ DIRECT EXPENSES Exp. Directly Ascribable To Each Activity 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. TOTAL DIRECT EXP. (sum 2-14) . . . . . . 16. NET UNASSIGNED EXP. (line 1-line 15) SECTION B ­ ALLOC. OF INDIRECT EXP. 17. Allocation basis amounts . . . . . . . . . . . . 18. Ratio to total basis to 4 decimals . . . . . . 19. UNASSIGNED ADMIN. EXP. ALLOC . . . 20. TOTAL ADMINISTRATIVE EXPENSE . . $ net from line 16 $ (line 15A + 19A) $ B15 + B19 1.0000 $ 19A X 18B $ C15 + C19 $ 19A X 18C $ D15 + D19 $ 19A X 18D $ E15 + E19 $ 19A X 18E $( ( ( ( ( ( ( ( ( ( ( ( ( $( $ A. Total B. NH Provider C. D. E. A. Total ) ) ) ) ) ) ) ) ) ) ) ) ) ) $ $ $ $ $ B. NH Provider C. $ $ Non-Nursing Home Activities Receiving Administrative Services D. $ E. $

NURSING HOME COST REPORT SCHEDULE 26B

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SCHEDULE 27 ­ OTHER COST CENTERS

SECTION A ­ SALARIES AND WAGES 1. TOTAL SALARY AND WAGE EXPENSE. 2. NUMBER OF HOURS WORKED. . . . . . .

A. Nurse Aide Training $ hrs.

B. Beauty/Barber Shop $ hrs.

C. $ hrs.

D. $ hrs.

E. $ hrs.

SECTION B ­ NON-SALARY EXPENSES 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. SECTION C - TOTAL

A. Nurse Aide Training $

B. Beauty/Barber Shop $

C. $

D. $

E. $

A. Nurse Aide Training

B. Beauty/Barber Shop

C.

D.

E.

15. TOTAL EXPENSES (sum 1,3-14) . . . . . .

$

$

$

$

$
NURSING HOME COST REPORT SCHEDULE 27

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Medicaid Provider Number

SCHEDULE 28 ­ EMPLOYEE FRINGE BENEFIT EXPENSES
SECTION A ­ FRINGE BENEFITS PAID ON BEHALF OF EMPLOYEES INSTRUCTIONS: Under the column labeled "Self-Funded", indicate yes or no. If yes, attach documentation to support the amount claimed for each self-funded benefit. Fringe Benefits Paid on Behalf of Employees 1. Employer's share of F.I.C.A. . . . . . . . . . . . . . . 2. State unemployment compensation . . . . . . . . 3. Federal unemployment compensation . . . . . . 4. Worker's compensation insurance . . . . . . . . . 5. Health insurance . . . . . . . . . . . . . . . . . . . . . . . 6. Life and disability insurance . . . . . . . . . . . . . . 7. Wage continuation insurance . . . . . . . . . . . . . 8. Pension and deferred comp. plans (section C) 9. Employee physicals . . . . . . . . . . . . . . . . . . . . . SECTION B ­ SELF-EMPLOYMENT TAXES INSTRUCTIONS: If a nursing home is a sole proprietorship or partnership, complete the following for self-employment taxes as reported for the year ending during the cost reporting period. Do not include self-employment taxes in line 1. Owner's Name Salary or Net Income $ $ SECTION C ­ PENSION AND DEFERRED COMPENSATION PLANS INSTRUCTIONS: For the purpose of benefits, some pension plans recognize years of service built up by employees before the plan was established. Briefly explain how the pension expense for service from prior years is amortized to or recognized in this cost reporting period. List the amount of expense for prior year service included in line 8. Self-Emp. Tax Paid $ $ Owner's Name Salary or Net Income $ $ Self-Emp. Tax Paid $ $ Self-Funded? Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No $ Expense Fringe Benefits Paid on Behalf of Employees 10. Uniforms . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 12. 13. 14. Self-Funded? Yes Yes Yes Yes Yes No No No No No $ Expense

15. TOTAL PAID ON BEHALF OF EMPLOYEES (sum 1-14) . . . . 16. Expense for special salary or wage payments to employees not included elsewhere (see section D) . . . . . . . . . . . . . . . . . . 17. TOTAL FRINGE BENEFIT EXPENSE (sum 15+16) . . . . . . . . $

SECTION D ­ SPECIAL SALARY AND WAGE PAYMENTS TO EMPLOYEES INSTRUCTIONS: Check the types of special salary and wage payments to employees which are included in section A, line 16. Christmas bonus Longevity bonus Productivity bonus Other, Specify:

Bonuses to owners and immediate family relations, Specify:
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SCHEDULE 29 ­ HEATING FUEL AND UTILITY EXPENSES
INSTRUCTIONS: Report the accrued expense incurred during the cost reporting period for each type of heating fuel and utility service. Accounts payable: The expense should be adjusted to excluded beginning accounts payable and to include ending accounts payable for the reporting period. Make sure to include exactly 12 months of expense for a full-year cost report and exactly six months of expense for a six-month cost report. Inventories: The expense for heating fuels such as heating oil, L.P. gas and coal should be adjusted for changes in inventories between the beginning and ending dates of the cost reporting period. Cost allocation: In section B, allocate the fuel and utility expense between the Medicaid nursing home area and other major revenue-generating areas or non-nursing home areas. Describe the allocation technique if an allocation basis other than square footage is used. The allocation basis used is similar to the maintenance allocation on schedule 25A. SECTION A ­ ACCRUED EXPENSE BY TYPE 1. Fuel oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Natural gas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. L.P. gas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Coal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Electricity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Accrued Expense Expense by Type 6. Water and sewer utility charges . . . . . . . . . . 7. Purchased steam . . . . . . . . . . . . . . . . . . . . . 8. 9. 10. TOTAL FUEL AND UTILITY EXPENSE . . . $ $ Accrued Expense

SECTION B ­ ALLOCATION OF FUEL AND UTILITY EXPENSE C. Emp. Unique Fringe Ben. Area

Non-NH Areas, Other Rev. Areas Receiving Fuel/Util. Serv.

A. Total 11. Total square feet for areas . . . . . . . . . . . 12. Ratio to total square feet to 4 decimals . 13. TOTAL ALLOC. FUEL/UTIL. EXPENSE $ From line 10 1.0000 $

B. NH Area

D.

E.

F.

$ 13A X 12B 13A X 12C

$ 13A X 12D

$ 13A X 12E

$ 13A X 12F

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SCHEDULE 30 ­ INTEREST EXPENSES ON OPERATING WORKING CAPITAL LOANS
Name of Lender 1a. 2a. 3a. 4a. 5a. 6. Is Lender a Related Party? b. b. b. b. b. Yes Yes Yes Yes Yes No No No No No $ $ Interest Expense

TOTAL EXPENSES ON OPERATING WORKING CAPITAL LOANS (sum 1-5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SCHEDULE 31 ­ INSURANCE EXPENSES
Type of Insurance Coverage 1. Property insurance on building and contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Automobile insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Liability insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Business interruption insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Life insurance on owners and employees with facility as the beneficiary . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Mortgage insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 8. Self-funded? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No $ $ Insurance Expense

9. TOTAL INSURANCE EXPENSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SCHEDULE 32 ­ AMORTIZATION OF DEFERRED EXPENSES
A. Deferred Expense or Asset Being Amortized (give detailed description) 1. 2. 3. 4. 5. TOTAL AMORTIZATION EXPENSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $ B. Original Cost C. Year Cost Incurred D. Number of Years Amortized E. Unamortized Beginning Balance $ F. Unamortized Ending Balance $ $ G. Amortization Expense

NURSING HOME COST REPORTS SCHEDULES 30, 31, 32

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SCHEDULE 33 ­ INTEREST EXPENSES ON PLANT ASSET LOANS
Remaining Balance of Loan Principal D. Begin date E. 6Mo.date F. End date Lender Name and Purpose of Loan 1a.Name 1b. Related party? 1c.Purpose 2a.Name 2b. Related party? 2c.Purpose 3a.Name 3b. Related party? 3c.Purpose 4a.Name 4b. Related party? 4c.Purpose 5a.Name 5b. Related party? 5c.Purpose 6a.Name 6b. Related party? 6c.Purpose 7a.Name 7b. Related party? 7c.Purpose 8. TOTAL LOAN PRINCIPAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $ $ TOTAL EXP. $ Yes No $ $ $ $ % $ Yes No $ $ $ $ % $ Yes No $ $ $ $ % $ Yes No $ $ $ $ % $ Yes No $ $ $ $ % $ Yes No $ $ $ $ % $ Yes No $ $ $ $ % $ A. Original Month, Year of Loan B. Maturing Month, Year of Loan C. Original Amount of Loan Begin Bal. 6 Mo. Bal. End Bal. G. Interest Rate H. Interest Expense

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SCHEDULE 34 ­ DEPRECIATION EXPENSES
SECTION A ­ CAPITALIZED HISTORICAL COST Begin Date B. Beginning Balance 1. Land . . . . . . . . . . . . . . . . . . . . . . 2. Land improvements . . . . . . . . . . 3. Buildings . . . . . . . . . . . . . . . . . . 4. Leasehold improvements . . . . . . 5. Fixed equipment . . . . . . . . . . . . 6. Moveable equipment . . . . . . . . . 7. Transportation vehicles . . . . . . . 8. ________________________ 9. 10. TOTAL CAPITALIZED COST . . $ $ ( $( ) ) $ $ $ C. Additions During Report Period D. Disposals During Report Period $( ( ( ( ( ( ( ) ) ) ) ) ) ) End Date E. Ending Balance $

SECTION B ­ DEPRECIATION EXPENSE AND ACCUMULATION DEPRECIATION A. Depreciation Method, Lives Used 11. Land improvements . . . . . . . . . . . . . . . . . 12. Buildings . . . . . . . . . . . . . . . . . . . . . . . . . 13. Leasehold improvements . . . . . . . . . . . . 14. Fixed equipment . . . . . . . . . . . . . . . . . . . 15. Moveable equipment . . . . . . . . . . . . . . . . 16. Transportation vehicles . . . . . . . . . . . . . . 17 ______________________________ 18. 19. TOTAL ACCUMULATED DEPRECIATION . . . . . . . . . . . . . . . . . $ $ ( $( ) ) $ Begin Date B. Beginning Balance $ C. Depreciation Exp. During Report Period $ D. Removal of Accum. Deprec. on Disposals. $( ( ( ( ( ( ) ) ) ) ) ) End Date E. Ending Balance $

20. TOTAL DEPRECIATION EXPENSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21. Cost of Bariatric Equipment included with Additions reported above purchased during this cost report period $____________________________ Include copies of invoices to support the cost of any Bariatric Equipment (see sec. 2.750 of Methods of Implementation for definition) purchases reported on Line 21 Include a copy of your plant ledger that supports the amounts reported on this Schedule 34 ­ See Schedule 3 Line 13B
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SCHEDULE 35 ­ LEASE EXPENSES ON OPERATING LEASES AND NON-CAPITALIZED LEASES
INSTRUCTIONS: For any lessor that is a related party to the provider, report the lessor's ownership cost of the property and complete and attach copies of schedules 31, 32, 33, 34, 37 and 39. Label the schedule copies, "Related Party Leased Property". For any lease contract expense which totals above $5,000, submit a copy of the lease. Identify any of the leased property listed below which was formerly owned by the leasing provider. SECTION A ­ LEASE EXPENSE FOR LAND, BUILDING AND FIXED EQUIPMENT A. Name of Lessor 1. 2. 3. B. Related Party? Yes Yes Yes No No No C. Lease Purchase Agreement? Yes Yes Yes No No No D. Lessor Acquisition Cost (if known) $ $ $ E. Month, Year acquired use F. Describe Property $ G. Lease Exp.

SECTION B ­ LEASE EXPENSE FOR MOVEABLE EQUIPMENT AND OTHER LEASES A. Name of Lessor 4. 5. 6. 7. 8. B. Related Party? Yes Yes Yes Yes Yes No No No No No C. Lease Purchase Agreement? Yes Yes Yes Yes Yes No No No No No D. Lessor Acquisition Cost (if known) $ $ $ $ $ E. Month, Year acquired use F. Describe Property $ G. Lease Exp.

SECTION C ­ TOTAL 9. TOTAL LEASE EXPENSE ON OPERATING LEASES AND NON-CAPITALIZED LEASES (sum 1-8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

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SCHEDULE 36 ­ LEASE EXPENSES ON CAPITALIZED LEASES
INSTRUCTIONS: For any lessor that is a related party to the provider, report the lessor's ownership cost of the property and complete and attach copies of schedules 31, 32, 33, 34, 37 and 39. Label the schedule copies "Related Party Leased Property". For any lease contract expense which totals above $5,000, submit a copy of the lease. Identify any of the leased property listed below which was formerly owned by the leasing provider. SECTION A ­ CAPITALIZED LEASE INFORMATION 1. Name of lessor . . . . . . . . . . . . . . . . . Is lessor a related party? . . . . . . . . . Date use of property was acquired . Ensuring date of lease . . . . . . . . . . . Is this a lease purchase agreement? Description of leased property . . . . . 2. Name of lessor . . . . . . . . . . . . . . . . . Is lessor a related party? . . . . . . . . . Date use of property was acquired . Ensuring date of lease . . . . . . . . . . . Is this a lease purchase agreement? Description of leased property . . . . . 3. TOTAL CAPITALIZED LEASE EXPENSE FOR REPORTING PERIOD ­ transfer to schedule 12 (sum 1d+2d) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SECTION B ­ ACTUAL LEASE PAYMENTS RELATED TO CAPITALIZED LEASES A1. Name of lessor . . . . . . . . . . . . A3. Are any capitalized costs reported on other schedules? . . . . . . Yes No A2. Actual payments required by lease in report period . . . A4. If yes, (schedule) (line) (amount) $ $ $ Yes No Yes No 2a. Amortization of capitalized lease value . . . . . . . . . . . . 2b. Interest expense on capital lease obligation . . . . . . . . 2c. Accrued contingent lease payments for period . . . . . . 2d. SUBTOTAL LEASE EXPENSE (sum 2a-2c) . . . . . . . . $ $ $ $ Yes No Yes No 1a. Amortization of capitalized lease value . . . . . . . . . . . . 1b. Interest expense on capital lease obligation . . . . . . . . 1c. Accrued contingent lease payments for period . . . . . . 1d. SUBTOTAL LEASE EXPENSE (sum 1a-1c) . . . . . . . . $ Lease Expense $

B1. Name of lessor . . . . . . . . . . . . B3. Are any capitalized costs reported on other schedules? . . . . . . Yes No

B2. Actual payments required by lease in report period . . . B4. If yes, (schedule) (line) (amount)

$ $

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SCHEDULE 37 ­ PROPERTY TAX EXPENSES
INSTRUCTIONS: Only tax exempt facilities should report the expense for municipal services which are financed through municipality property taxes. Describe the services. SECTION A ­ REAL ESTATE, PERSONAL PROPERTY, AND MUNICIPAL SERVICE EXPENSES 1. Real estate tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Personal property tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. 5. 6. 7. 8. TOTAL MUNICIPAL SERVICE EXPENSES (sum 3-6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TOTAL PROPERTY TAX AND/OR MUNICIPAL SERVICE EXPENSE (sum 1,2,7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $ Expense $ $ $ Expense

SECTION B ­ FOR ALL PROVIDERS 1. 2. 2008 real estate tax (due in 2009) relating to the nursing home operation (attach copy of bill or, if not yet received, send separately upon receipt.) 2008 personal property tax (due in 2009) relating to the nursing home operation (attach copy bill or, if not yet received, send separately upon receipt.) No, explain below Amount still outstanding Yes, explain below No Amount still outstanding

3a. Have the amounts reported on lines 1 and 2 been paid in full? Yes, go to question 3b Date(s) paid Amount(s) paid

3b. Are there any real estate or personal property tax still outstanding from prior years, eg. 2006 or 2007? Tax year Amount still outstanding Tax year SECTION C ­ FOR TAX-EXEMPT PROVIDERS ONLY

Expense $ Amount reported Date began paying fees $

4. Amount of municipal service fee expense incurred by the nursing home appropriately accrued to calendar year 2008. 5. Identify where municipal service fee expenses are reported in the cost report if not above on this schedule, section A, line 7. Cost center name Schedule number Line number 6. The facility began to pay municipal service fees (check one) Prior to January 2008 In or after January 2008 7. Describe the services provided by the municipality for the above fees. 8. Payment of the above fees was (check one) Voluntary Required by the tax authority

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SCHEDULE 38 ­ INCOME TAX EXPENSES
INSTRUCTIONS: Completion of this schedule is optional. Report estimated income tax. Type of Tax 1. State income tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Federal income tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. 4. 5. 6. TOTAL ESTIMATED INCOME TAX EXPENSES (sum 1-5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $ Tax Expense

SCHEDULE 39 ­ OTHER NON-SALARY EXPENSES
INSTRUCTIONS: Report and describe the nature and source of any non-salary expenses not included elsewhere in this cost report. Other salary expenses should be reported on schedule 27. Nature and Source of Expense 1. 2. 3. 4. TOTAL OTHER NON-SALARY EXPENSES (sum 1-3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $ Expense

NURSING HOME COST REPORT SCHEDULES 38, 39

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SCHEDULE 40 ­ ALLOCATION OF PROPERTY EXPENSES
INSTRUCTIONS: Assign expenses directly ascribable to or identifiable with each service's building area. Use column C for unique fringe benefit building areas. Areas for Non-NH Serv. or Other Major Revenue-Generating Activities SECTION A ­ DIRECT PROPERTY EXP. 1. Property insurance (s31) 2. Mortgage insurance (s31) 3. Amortization debt premium/discount (s32) 4. Plant asset interest expense (s33) 5. Depreciation land improvements (s34) 6. Depreciation buildings (s34) 7. Depreciation leasehold improve. (s34) 8. Depreciation fixed equipment (s34) 9. Depreciation moveable equip. (s34) 10. Depreciation transportation veh. (s34) 11. Depreciation other (s34) 12. Expense on operating leases (s35) 13. Expense on capitalized leases (s36) 14. Property taxes or fees (s37) 15. TOTAL EXPENSE (sum 1-14) 16. Less total directly assigned property exp. 17. NET UNASSIGNED/INDIRECT PROP. SECTION B ­ NON-SALARY EXPENSES 18. Square feet of service's building area 19. Ratio to total square feet to 4 decimals 20. Indirect property expense allocation SECTION C ­ TOTAL 21. TOTAL PROP. EXP. FOR EACH AREA $ 17A + 20 A $ (from 17A) A. Total $ 15B + 20B 1.0000 $ 20A X 19B B. NH Area C. $ 15C + 20C $ 20A X 19C D. $ 15D + 20D $ 20A X 19D E. $ 15E + 20E $ 20A X 19E $ $ $ A. Total $ (sum 15B, 15C, 15D, 15E) (15A less 16A) B. NH Area C. D. E. $ $ $ A. Total From Sched. $ B. NH Service Area $ C. $ D. $ E. $

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SCHEDULE 41 ­ ACCOUNTING AND REPORTING POLICIES
SECTION A ­ POLICIES AND PRACTICES 1. Accounting method ­ expenses are to be reported on the accrual method of accounting except for governmental facilities, which may use the cash method. Check the accounting method used in this cost report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Capitalization of plan assets ­ briefly describe the facility's policy or practice for the capitalization of plant asset purchases. Accrual Cash

3. Volunteer and unpaid employees ­ briefly explain if and how volunteer and other unpaid employee hours are reported in this cost report

4. Conformity ­ describe any accounting practices/policies in reporting revenues and expenses which are known to NOT conform to generally accepted accounting principles.

SECTION B ­ NON-PRODUCTIVE SALARY EXPENSE AND HOURS INSTRUCTIONS: Reporting on the basis of earned time-off is not permitted. Vacation, Holiday and Sick Time (VHS) salaries and hours must be reported on the basis of the timeoff actually taken by employees during the cost reporting period. For "Yes" response in column B, describe the estimation techniques used and add sheets if needed. Type of Paid Time-Off 1. Vacation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Holidays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Sick time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Break, meal time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Holiday premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. In-service training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. A. Based on Actual or Earned TimeOff? Actual Actual Actual Actual Actual Actual Actual Earned Earned Earned Earned Earned Earned Earned B. Are Reported Amounts an Estimate? Yes Yes Yes Yes Yes Yes Yes No No No No No No No

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SCHEDULE 42 ­ IDENTIFICATION OF EXPENSES FROM TRANSACTIONS WITH RELATED PARTIES AND ORGANIZATIONS
SECTION A ­ RELATED PARTY LEASES Location and Amount of Expense Included In This Cost Report A. Description of Expense Item 1. Total related party lease expense . . . . . . . . . . . . . 2. Insurance expense . . . . . . . . . . . . . . . . . . . . . . . . . 3. Amortized deferred expense . . . . . . . . . . . . . . . . . 4. Interest expense . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Depreciation expense . . . . . . . . . . . . . . . . . . . . . . . 6. Property tax expense . . . . . . . . . . . . . . . . . . . . . . . 7. 8. 9. SUBTOTAL FOR RELATED PARTY LEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Cost Ctr. C. Schedule D. Column E. Line F. Expense $( XXXXXXXXX XXXXXXXXX XXXXXXXXX XXXXXXXXX XXXXXXXXX XXXXXXXXX XXXXXXXXX $( ) $ ) G. Expense Incurred by Related Party XXXXXXXXX H. Difference (G ­ F) XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX $

SECTION B ­ OTHER RELATED PARTY TRANSACTIONS 10. 11. 12. 13. 14. 15. TOTAL AMOUNT TO ADJUST RELATED PARTY TRANSACTIONS TO COST (to schedule 11, line 18) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $( ) $ $

SECTION C ­ IDENTIFICATION OF RELATED PARTIES 16. List the names and cities of location of the related parties and organizations with whom the nursing home provider has transacted business during the cost reporting period.

NURSING HOME COST REPORT SCHEDULE 42

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SCHEDULE 43 ­ IDENTIFICATION OF EXPENSES NOT RELATED TO PATIENT CARE
INSTRUCTIONS: To the extent possible, identify significant expenses included in this cost report which were not related to patient care. See Section 600 of the Cost Report Instructions for more details on such expenses. Attach additional sheets if necessary. Location of Expense In Cost Report Expense Item 1. Promotional expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Gifts and flowers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Personal expenses of owners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Entertainment for non-residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Telephone, television, and radio in resident rooms . . . . . . . . . . . . . . . 6. Contributions and donations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Fines and penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Interest expense on non-care working capital loans . . . . . . . . . . . . . . 9. Interest expense on non-care plant asset loans . . . . . . . . . . . . . . . . . 10. Non-care related membership fees . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Training programs for non-employees . . . . . . . . . . . . . . . . . . . . . . . . 12. Special legal and professional fees (complete schedule 43A) . . . . . . 13. Owner or key person life insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 14. Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15. Fund raising expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16. Excess property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17. 18. 19.
NURSING HOME COST REPORT SCHEDULE 43

Amount $

Cost Ctr.

Schedule

Column

Line

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Medicaid Provider Number

SCHEDULE 43A ­ LEGAL FEES
INSTRUCTIONS: Identify the expenses for all legal fees included in this cost report. These expenses should have been reported on schedule 26, line 8. For the fees reported on line 2, identify any allowable amount that was specifically awarded by the administrative or judicial courts as a result of a successful appeal or prosecution. Description 1. Prosecution or defense related to Medicare or Medicaid reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Prosecution or defense pertaining to compliance with licensure or certification requirements (see instructions above) . . . . . . . . . . . . . . . . . . . . 3. Defense of an owner or employee in a personal or criminal legal matter . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Legal preparation resulting in the filing of an appeal under Chapters 50 or 227, Wisconsin Statutes, or a judicial suit . . . . . . . . . . . . . . . . . . . . 5. Collection of delinquent accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Corporate restructuring or reorganization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Potential purchase or sale of nursing home(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Purchase or sale of nursing home(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Negotiations with suppliers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Income taxes, payroll taxes, benefit plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Union related activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Guardianship for Medicaid residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Other not related to patient care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. 15. 16. TOTAL LEGAL FEES (should equal schedule 26, line 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $ Legal fees

NURSING HOME COST REPORT SCHEDULE 43A

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Medicaid Provider Number

SCHEDULE 44 ­ IDENTIFICATION OF COMPENSATION TO KEY PERSONNEL
INSTRUCTIONS: Report the compensation paid to all owners and other related parties and immediate family relationships, all workers who are members of a religious order or society that owns the nursing home, and arm's length employees who are supervisors or managers with decision making authority. See reference charts below for columns B & D. B. Title (see list below) D. Level of Education E. Years of Experience $ F. Total Comp. Expense This Facility G. Hours per Year This Facility H. Hrs. per Yr. Other Health Care Provider I. Member of Religious Order? Yes Yes Yes Yes Yes Yes Yes Yes Yes $ LEVEL OF EDUCATION (Column D) DON NURSE DIET MAINT HSK LAUND OTHER Director of Nursing Nursing Supervisor Dietary Supervisor Maintenance Supervisor Housekeeping Supervisor Laundry Supervisor Other, Specify.
NURSING HOME COST REPORT SCHEDULE 44

A. Name 1. 2. 3. 4. 5. 6. 7. 8. 9.

C. Sex Male Male Male Male Male Male Male Male Male Fem. Fem. Fem. Fem. Fem. Fem. Fem. Fem. Fem.

J. Owner or Family Relation? Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No

No No No No No No No No No

10. TOTAL COMPENSATION FOR THIS FACILITY . . . . . . . . . . . . . . . . . . . . . . . . . TITLE / RESPONSIBILITY AREA (Column B) ADM ASST ADM OTH ADM CFO BUS MGR PERSON Administrator Assistant Administrator Other Administrator, Specify. Chief Financial Officer Business Manager Personnel Manager

HS NS BS MS PHD

High School Diploma Nursing School Diploma, Associate Degree Baccalaureate Degree (BS, BA, BSN) Master's Degree (MS, MA, MSN) Doctorate Degree

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Medicaid Provider Number

SCHEDULE 45 ­ DISTRIBUTION OF COMPENSATION EXPENSES TO KEY PERSONNEL
INSTRUCTIONS: For each person listed on schedule 44, separately itemize and identify the amount of compensation expense and hours reported in each cost center of this cost report. Total compensation reported on this schedule should agree with the total reported on schedule 44, column F. Location of Expense in Cost Report A. Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. TOTAL EXPENSE (for columns E and G only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $
NURSING HOME COST REPORT SCHEDULE 45

Compensation & Hours E. Expense $ F. Hours Hrs.

Purchased Services G. Expense $ H. Hours Hrs.

B. Cost Ctr.

C. Schedule

D. Column

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Medicaid Provider Number

SCHEDULE 46 ­ IDENTIFICATION OF EXPENSES FOR EMPLOYEE UNIQUE FRINGE BENEFITS
INSTRUCTIONS: Unique fringe benefits are those fringe benefit items provided to only a few select employees and the expenses for such benefits may be reported in one or more cost centers of this report. Identify the unique fringe benefits provided to any individual employee by reporting the expenses related to the benefit and where the expenses are included in this cost report. If the expense for a benefit is less than $800 per year, it does not have to be reported on this schedule. C. Describe Unique Fringe Benefit Item D. Cost Ctr. Salary Exp. Location and Amount of Benefit Expense in Cost Report I. Benefit Expense E. Cost Ctr. H. Line Amount Benefit Exp. F. Schedule G. Column $

A. Name of Employee 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

B. Title

NURSING HOME COST REPORT SCHEDULE 46

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Medicaid Provider Number

SCHEDULE 47 ­ ADMINISTRATIVE SERVICES PROVIDED TO OTHER NURSING HOMES AND ENTERPRISES
INSTRUCTIONS: On this schedule, report only the key administrative personnel identified on schedule 44 who also have responsibility for certain areas other than this nursing home. For supervisors or managers with decision making authority for another nursing home, a hospital, a community-based residential facility (CBRF), or an apartment complex, identify the employee(s) and the total number of beds/units in the appropriate column. Name 1. 2. 3. 4. 5. 6. Other Nursing Homes Number of Beds in Each Facility Hospitals CBRFs Apartments

SCHEDULE 48 ­ OUT-OF-STATE TRAVEL EXPENSES
INSTRUCTIONS: Report the amount of out-of-state travel expenses included in this cost report but do NOT include expenses for travel to and from the facility's home office, travel within 100 miles of the Wisconsin border, or travel for home office personnel when one or more associated nursing homes are located outside of Wisconsin. Types of travel expenses that should be included are meals, lodging, transportation, and training, seminar, and convention fees/expenses associated with out-of-state trips. Attach additional sheets if necessary. Employee Name, Destination, Purpose of Trip 1. 2. 3. Schedule Line $ $ $
NURSING HOME COST REPORT SCHEDULES 47, 48

Amount

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Medicaid Provider Number

SCHEDULE 49 ­ PERCENTAGE OF OWNERSHIP
INSTRUCTIONS: List all individuals or entities that own 20% or more of the nursing home operation Name of Individual or Entity 1. 2. 3. 4. 5. Percentage of Ownership

SCHEDULE 50 ­ INTEREST IN OTHER MEDICAID PROVIDERS
INSTRUCTIONS: If the nursing home organization or any of its owners, administrators, officers, or any members of their immediate families are a separate provider or had an interest in any other provider in the Wisconsin Medicaid program, list the provider and explain the nature of the interest. Report interests that existed during the cost report period and/or existed up to the date of submission of the cost report to the Department. Include any other Wisconsin nursing home providers. Attach additional sheets if necessary. Name and City of Medicaid Provider 1. 2. 3. 4. 5.
NURSING HOME COST REPORT SCHEDULES 49, 50

Type of Medical Services Provided

Nature and Extent of Interest in Provider

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Medicaid Provider Number

SCHEDULE 51 ­ MEDICAL SUPPLY REVENUES FROM MEDICARE PART B
INSTRUCTIONS: Wisconsin Medicaid policies and statutory authority on Medicare maximization include nursing homes billing Medicare for medical supplies and equipment under Medicare Part B. All Medicare-certified nursing homes should be billing Medicare Part B for services and supplies covered by the Medicare program. Nursing homes that are not Medicare certified may bill Medicare under Part B for medical supplies if they have separate Medicare certification as a durable medical equipment and supply vendor. Nursing home revenues from Medicare Part B should be included in the medical supply revenue on schedule 14 and must be identified on this schedule to property account for third party payer revenues. 1. Does the nursing home bill Medicare for covered medical supplies under Medicaid Part B for Medicare eligible residents? . . . . . . . . . . . . . . . . 2. Is the nursing home Medicare certified? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, submit a copy of worksheet D from the most recent Medicare Cost Report. 3. Does the nursing home have a separate Medicare certification to bill for equipment and supplies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Medical supplies are billed to Medicare for the following types of residents (check all that apply) . . . . . . . . Private Pay Yes Yes No No

Yes

No Other

Title XIX (Medicaid) $

5. What were the Medicare Part B revenues for medical supplies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. What were the costs related to the above medical supply revenues and where were they reported on this cost report? a. Expense b. Expense $ $ schedule schedule column column

line line
NURSING HOME COST REPORT SCHEDULE 51

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Medicaid Provider Number

SCHEDULE 52 ­ MISCELLANEOUS MEDICAID NON-RATE REVENUES
INSTRUCTIONS: Wisconsin Medicaid provides for separate reimbursement for certain items not included in the daily rate or for additional reimbursement over and above the daily rate for certain services. For the items listed below, identify the revenue accrued by your facility for the services provided during the cost reporting period and where the revenues were reported in this cost report (should be included on schedules 14 through 18). On lines 1 and 2, the amounts reported should only reflect the revenues in excess of the Medicaid daily rate for residents' levels of care and for which the related expenses are included in this cost report. For example, a resident at the ISN level of care is also authorized for a supplemental payment of $325 per day as an extensive care patient. The facility's ISN rate is $102 per day. The revenue reported on this schedule in excess of the of the level of care daily rate is $223 per day. On line 5, report the amount of reimbursement from the Medicaid program for specialized services (active treatment) for mentally ill residents who were determined to be in need of such services by a level II pre-admission screening and annual resident review. Medicaid Revenue Item 1. Extensive care patients excluding ventilator- dependent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Residents with AIDS or AIDS-related complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Exceptional supply needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Personalized durable medical equipment including Clinitron beds and motorized wheelchairs . . . . . . . . . . 5. Specialized services for the mentally ill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Level 1 screening (number of screenings) X (payment per screening) $ = $ Revenue Amount Location in Cost Report Schedule Line

7a.Nurse aide training and competency evaluations ­ revenues from training aides for other facilities . . . . . . 7b.Nurse aide training and competency evaluations ­ revenues from training aides for your own facility . . . . 7c.Nurse aide training and competency evaluations ­ revenues for performing competency evaluations . . . . 8. TOTAL MISCELLANEOUS MEDICAID NON-RATE REVENUES (sum 1-7) . . . . . . . . . . . . . . . . . . . . . . . . $
NURSING HOME COST REPORT SCHEDULE 52

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Medicaid Provider Number_________________________

SCHEDULE 53 ­ INCENTIVES ­ PRIVATE ROOM & PROPERTY
PRIVATE ROOM INCENTIVE - INSTRUCTIONS: Based on the information provided in the cost report, your facility may qualify for the Basic Private Room Incentive (BPRI) or
Replacement Private Room Incentive (RPPRI) as explained in Section 2.720 of the Methods of Implementation. A facility may receive only one of the two private room incentives. A facility will qualify for the BPRI if it has exceptional Medicaid/Medicare utilization and at least 15% of the total beds are licensed for single occupancy. A facility will qualify for the RPPRI if it has exceptional Medicaid/Medicare utilization and has replaced 100% of patient rooms after July 1, 2000.

Indicate if your facility is requesting a private room incentive
YES, my facility is requesting a private room incentive. If YES specify one: BPRI RPPRI NO, my facility is not requesting the BPRI or RPPRI. If your facility is requesting one of the incentives, you must complete the affidavit below and return it to the Department by July 1, 2009, to qualify for one of the private room incentives.

AFFIDAVIT
I HEREBY ATTEST and affirm that from July 1, 2008, to June 30, 2009, the _______________________________________________________________________ nursing home will not charge/has not charged Medicaid residents any amount for private rooms including but not limited to the surcharge as provided under Ch HFS 107.09(4)(k), Wis. Admin. Rules. I furthermore acknowledge that all payments the facility has received for the Medicaid Basic Private Room Incentive (BPRI) or Replacement Private Room Incentive (RPPRI) may be recouped retroactive to July 1, 2008, if the facility has charged Medicaid residents for private rooms during this period.
SIGNATURE ­ Original Signature of Officer or Administrator of Nursing Home Title Date

PROPERTY INCENTIVE:
Did the facility get approval for $135,000 URC on New Total Replacement Constriction? See Sec. 4.920 of Methods of Implementation Did the facility get approval for $10 per patient day for "Innovative Area"? See Sec. 3.655 of Methods of Implementation If YES to either question above ­ Complete the Following Date Approval Received: Has Construction Begun? Has construction been completed? YES YES NO NO If YES, when did it begin? If completed, when was it completed? YES YES NO NO

Number of beds in Replacement Facility or "Innovative Area" During this cost report period Number of Medicaid Fee For Service Patient days in Replacement Facility or "Innovative Area"? Number of Medicaid Family Care Patient days in Replacement Facility or "Innovative Area"? Number of Medicaid Partnership Patient days in Replacement Facility or "Innovative Area"? For Department Use
Date Received Medicaid District Auditor
NURSING HOME COST REPORT SCHEDULE 53