NF FCP Forms FY11 by 94HxgAtc

VIEWS: 1 PAGES: 17

									schedules revised 7/20/11                                          NURSING FACILITY (NF)
                                                             FACILITY COST PROFILE (FCP) INDEX
                                                                 FISCAL YEAR ENDED 6/30/11




       (1)                                                                            (2)
Sheet Tab Name                                                             Purpose of the Sheet Tab




         Index              Briefly states the purpose of each sheet tab


    Instructions            Instructions on how to prepare and submit the Excel spreadsheet schedules. PLEASE READ CAREFULLY


        Sch A               Schedule A, pages 1-3: Certification and General Information


        Sch B               Schedule B: Revenue and Provider Adjustments


       Sch B-1              Schedule B-1: Revenue Adjustment Details


        Sch C               Schedule C, pages 1-4: Expenses and Provider Adjustments


       Sch C-1              Schedule C-1: Expense Adjustment Details


       Sch C-2              Schedule C-2: Key and Related Employee Compensation and Related-Party Disclosures


        Sch D               Schedule D: Patient Days and Occupancy

      Summary               Summary of Schedules A thru D




              rprice
              10/3/2012
              C:\Docstoc\Working\pdf\d1031c4f-0acb-4f79-b7d9-8f76099295d0.xls
schedules revised 7/20/11                                                 NF - FACILITY COST PROFILE (FCP) INSTRUCTIONS




PLEASE READ CAREFULLY BEFORE INPUTTING DATA INTO THE FCP SCHEDULES

1. Cells shaded light yellow are to be filled in by the preparer. Cells shaded light blue contain formulas and are protected.

2. Use "miscellaneous" lines to report data that does not fit into existing line descriptions.

3. Complete each FCP schedule. If a schedule is not applicable, type N/A on it and submit with the other schedules.

4. After entering data into the FCP schedules, save the completed Excel file under a new file name.

5. Print an original set of schedules along with the supporting documents.

6. Make sure the Owner/Officer and FCP preparer sign the certification on page 1 of Schedule A.

7. Make two complete photocopies of the schedules and supporting documents.

8. Keep one photocopy on file at your facility for five years.

9. Send the original and one photocopy so they arrive in our offices no later than Wednesday, August 31, 2011, 6:00 p.m.:

   via UPS or FedEx:
                                                    Roger Price
                                            Utah Department of Health
                                         Office of Internal Audit, 4th Floor
                                               288 North 1460 West
                                                   SLC UT 84116
   via U.S. Post Office:
                                                    Roger Price
                                            Utah Department of Health
                                         Office of Internal Audit, 4th Floor
                                                  PO Box 143104
                                               SLC UT 84114-3104

10. E-mail the electronic Excel file to rogerprice@utah.gov no later than Wednesday, August 31, 2011, 6:00 p.m.

11. Reuse this Excel file to complete an FCP for each NF nursing home for which you are responsible.

If you have any questions or comments, please contact Roger Price at rogerprice@utah.gov or (801) 538-6468.




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schedules revised 7/20/11                                                                  NF - CERTIFICATION AND GENERAL INFORMATION
                                                                                                                                    SCHEDULE A
                                                                                                                                      Page 1 of 3




     I,                                                                          Mailing address if different than facility address.
                            (Name of Owner/Officer)

     of
                 (Legal Name of Long Term Care Facility)


                  (DBA Name of Long Term Care Facility)                                  (DBA Name of Long Term Care Facility)


                                 (Street Address)                                                       (Street Address)


                        (City)          (State)     (Zip)                                     (City)           (State)      (Zip)

HEREBY CERTIFY that by signing and submitting this report, which is required by the Department for the purpose of
documenting expenses with respect to the operation of the facility and its continuing eligibility, that the information provided
in this report, and any supporting information submitted with it, is true, accurate, and complete and prepared from the books
and records of the nursing home facility in accordance with all applicable rules, regulations, instructions, and requirements.
I further certify and represent that I have personally reviewed this report and that all items of expense indicated in this report
were actually incurred as represented and were necessary and reasonable and related to patient care. I hereby agree to
keep such records as are necessary to disclose fully the information contained herein for a period of no less than five (5) years
from the date hereof and further agree to make all said records and information available as original documentation or as
copies as designated by the request of authorized state personnel, including, but not limited to, agents of the Department
of Health and Social Services and the Bureau of Medicaid Fraud.
I UNDERSTAND AND INTEND THAT THE DEPARTMENT WILL RELY UPON MY STATEMENTS HEREIN TO DETERMINE
THE RATES OF REIMBURSEMENT FOR MEDICAL BENEFITS PAID AND PAYABLE TO THE FACILITY FROM FEDERAL
AND STATE FUNDS AND THAT ANY MISREPRESENTATION, FALSIFICATION, CONCEALMENT, OR OMISSION OF
MATERIAL FACTS CONSTITUTES FRAUD AND I MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAW.

 From:                              07/01/10                                     To:                          06/30/11
                                    (MM/DD/YY)                                                               (MM/DD/YY)



                    (Name of Owner or Officer) & (Title)                                         (Name of Preparer) & (Title)


                       (Signature of Owner or Officer)                                                 (Signature of Preparer)


                                  (Date Mailed)                                                           (Date Prepared)


                   (Telephone Number of Owner/Officer)                                         (Telephone Number of Preparer)


                      (E-mail address of Owner/Officer)                                          (E-mail address of Preparer)




A.        Please mark X to indicate that the following documents are attached:

                      Copy of Trial Balance (must include all balance sheet and income statement accounts; must provide legend
                      'that cross-references to FCP accounts).
                      If management fees and/or home office costs are reported on the FCP, a copy of the
                      Medicare cost report for the home office and/or management company must be filed
                      with the FCP.
                                                                Medicare Cost Report Period
                                        From:                                             To:
                                                     (MM/DD/YY)                                         (MM/DD/YY)
0                                                                                                             NF - CERTIFICATION AND GENERAL INFORMATION
07/01/10                             06/30/11                                                                                                 SCHEDULE A
schedules revised 7/20/11                                                                                                                       Page 2 of 3

B.          Owner/Licensee Information

            Owner/licensee Name
            Address
            City, State ZIP
            Contact Person
            Phone Number
            Fax Number
            E-mail address

C.          Is the facility under common ownership with other Utah facilities?

                                         Yes                                              No

            If yes, list the names of the other Utah facilities and the parent company information below.

            Names of Other Utah Facilities                                                Parent Company Information

                                                                                          Parent Company Name
                                                                                          Address
                                                                                          City, State ZIP
                                                                                          Contact Person
                                                                                          Phone Number
                                                                                          Fax Number
                                                                                          E-Mail Address




D.          Does a management company manage your facility?                                Yes                      No
            Did you change management companies this year?                                 Yes                      No
            If the management company changed, indicate date of change
                                                                                                     (MM/DD/YY)
            Management Company Information

            Management Company Name
            Address
            City, State ZIP
            Contact Person
            Phone Number
            Fax number
            E-Mail Address

E.          Is this a final or first time FCP due to a change in ownership?

                                         Yes                                               No

            If yes, please complete below:
            Date of Change:
            New Owner and Address:
            Old Owner and Address:
            Reason for Change:

F.          Did the facility change its name during the reporting period?

                                         Yes                                               No

            If Yes, what date?
                                                 (MM/DD/YY)
            If Yes, list new name,
            and old name




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0                                                                                                                   NF - CERTIFICATION AND GENERAL INFORMATION
07/01/10      06/30/11                                                                                                                              SCHEDULE A
schedules revised 7/20/11                                                                                                                             Page 3 of 3

G.            Current 12-Digit Medicaid Provider Number

              Previous 12-Digit Medicaid Provider
              Number (if changed during the reporting
              period)

H.            Medicare Intermediary Information

              Name
              Address
              Contact Person
              Telephone Number
              Fax Number
              E-mail Address
              Intermediary General Telephone Number

I.            Medicare 6-Digit Provider Number:

J.            Facility's Capitalization Dollar Threshold*
              (Must be the same as on the
              FRV Data Report forms,
              Schedule 2)

              * Amount at which the facility capitalizes and lists items on their fixed asset schedule (ex. $500)




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0                                                                                                                                                         NF - REVENUE
07/01/10        06/30/11                                                                                                                                   SCHEDULE B
      (1)             (2)                         (3)                                     (4)                             (5)                            (6)
     REV            ACCT                        TITLE                           REVENUES PER G/L                 PROVIDER'S ADJ (DEBIT)        FCP REPORTED REVENUE
     CAT             NO                                                    Positive Contractual Adjustments             CREDIT                      (COL 4/COL 5)
                                                                          (Negative Contractual Adjustments)
     01                     MEDICAID REVENUE - UTAH
                     01     Gross Medicaid Revenue-Utah                                                                                                            $0
                     02     Contractual Adjustments                                                                                                                $0
                            NET MEDICAID REVENUE - UTAH                                                   $0                              $0                       $0

     02                     MEDICAID REVENUE - NON UTAH
                     01     Gross Medicaid Revenue-Non Utah                                                                                                        $0
                     02     Contractual Adjustments                                                                                                                $0
                            NET MEDICAID REVENUE - NON UTAH                                               $0                              $0                       $0

     03                     MEDICARE REVENUE
                     01A    Gross Medicare Part A Revenue                                                                                                          $0
                     01B    Gross Medicare Part B Revenue                                                                                                          $0
                     02     Contractual Adjustment                                                                                                                 $0
                            NET MEDICARE REVENUE                                                          $0                              $0                       $0

     04                     MEDICARE HMO REVENUE
                     01A    Gross Medicare Part A Revenue                                                                                                          $0
                     01B    Gross Medicare Part B Revenue                                                                                                          $0
                     02     Contractual Adjustment                                                                                                                 $0
                            NET MEDICARE HMO REVENUE                                                      $0                              $0                       $0

     05                     VETERANS REVENUE
                     01     Gross Veterans Revenue                                                                                                                 $0
                     02     Contractual Adjustments                                                                                                                $0
                            NET VETERANS REVENUE                                                          $0                              $0                       $0

     06                     PRIVATE REVENUE (Complete Table Below)
                     01     Gross Private Revenue                                                                                                                  $0
                     02     Contractual Adjustments                                                                                                                $0
                            NET PRIVATE REVENUE                                                           $0                              $0                       $0


     07                     HOSPICE REVENUE - MEDICAID
                     01     Gross Hospice Revenue-Medicaid                                                                                                         $0
                     02     Contractual Adjustments                                                                                                                $0
                            NET HOSPICE REVENUE - MEDICAID                                                $0                              $0                       $0


     08                     HOSPICE REVENUE - NON MEDICAID
                     01     Gross Hospice Revenue-Non Medicaid                                                                                                     $0
                     02     Contractual Adjustments                                                                                                                $0
                            NET HOSPICE REVENUE - NON MEDICAID                                            $0                              $0                       $0


     09                     OTHER REVENUE
                     01     Other Revenue                                                                                                                          $0
                     02     Contractual Adjustments                                                                                                                $0
                            NET OTHER REVENUE                                                             $0                              $0                       $0


     10                     MISCELLANEOUS INCOME*

                     01     Telephone                                                                                                                              $0

                     02     Employee / Guest Meals                                                                                                                 $0

                     03     Laundry / Linen Services                                                                                                               $0

                     04     Rental of Space                                                                                                                        $0

                     05     Employee Sales                                                                                                                         $0

                     06     Equipment Rentals                                                                                                                      $0

                     07     Contributions/Donations                                                                                                                $0

                     08     Interest Income                                                                                                                        $0

                     09     Vending Machines/Commissions                                                                                                           $0

                     10     Gift Shop/Snack Bar                                                                                                                    $0

                     11     Barber/Beauty Shop                                                                                                                     $0

                     12     Other (Attach Detail if Greater Than $100)                                                                                             $0

                            TOTAL MISC INCOME                                                             $0                              $0                       $0

                            TOTAL NET REVENUE PER FCP                                                     $0                              $0                       $0

                            TOTAL NET REVENUE PER G/L

                            FCP less G/L must = $0                                                        $0




               (1)                                (2)                                    (3)                                (4)                          (5)              (6)              (7)            (8)
                                                                                                 PRIVATE REVENUE TABLE
                                                                                       Average Private Revenue Per Day By Quarter
                                              1st Quarter                            2nd Quarter                        3rd Quarter                  4th Quarter         Total                         Difference
PRIVATE REVENUE
Gross Private Revenue
                                                                                                                                                                                      Net Private
                                                                                                                                                                                    Revenue (Sch B,
Contractual Adjustments                                                                                                                                                                cell K38)
NET PRIVATE REVENUE                                                  $0                                   $0                              $0                        $0           $0              $0             $0
                                                                                                                                                                                     Private Days
                                                                                                                                                                                        (Sch D)
Private Days                                                                                                                                                                      0                0            0
Revenue Per Day (Net
Private Revenue/Private
Days)
0                                                                                          NF - REVENUE ADJUSTMENT SUMMARY
07/01/10         06/30/11                                                                                      SCHEDULE B-1
schedules revised 7/20/11



This schedule gives the detail of the Provider's Revenue adjustments posted on Schedule B, Col 5.
Give totals where appropriate.

     (1)                                    (2)                                         (3)     (4)        (5)        (6)
 Adjustment         Purpose of Adjustment (provide detailed explanation)             Revenue Account      Title     (Debit)
  Number                                                                             Category Number                Credit
                                                                                                  From Schedule B
       1
       2
       3




TOTAL                                                                                                                         $0

                 Total adjustments Schedule B, Col 5                                                                          $0
                 Variance                                                                                                      $0




NOTE:            If this sheet is not large enough to list all provider adjustments, add additional
                 sheets in the same format as necessary.
                      0                                                                                                                                                              NF - EXPENSES
                      07/01/10      06/30/11                                                                                                                                           SCHEDULE C
                     schedules revised 7/20/11                                                                                                                                            Page 1 of 4

                          (1)           (2)                                  (3)                                     (4)            (5)              (6)                   (7)          (8)
                        COST           ACCT                                                                    EXPENSES PER     PROVIDER'S      FCP REPORTED          HOURS WORKED   HOURS PAID
                         CAT            NO                                 TITLE                                GEN. LEDGER    ADJUSTMENTS    EXPENSE (Col 4+Col 5)

                         010                                     GENERAL ADMINISTRATIVE
                                        010      Administrator Salary                                                                                          $0
                                        011      Asst Admin Salary                                                                                             $0
                                        012      Office Salaries & Wages                                                                                       $0
                                        040      Payroll Taxes & Emp Benefits                                                                                  $0
                                        050      Director Fees                                                                                                 $0
                                        060      Management Services                                                                                           $0
                                        070      Home Office Charges(attach detail schedule)                                                                   $0
                                        080      Advertising                                                                                                   $0
                                        090      Telephone                                                                                                     $0
                                        100      Dues, Subscriptions & Licenses                                                                                $0
                                        110      Off Supplies, Printing & Postage                                                                              $0
                                        120      Legal and Accounting                                                                                          $0
                                        130      Utilization Review                                                                                            $0
                                        140      Travel, Seminars & Admin Training                                                                             $0
                                        150      Data Processing                                                                                               $0
                                        160      Amortization-Organization and Start-up Costs                                                                  $0
                                        170      Patient Day Assessment                                                                                        $0
                                        180      Interest - Operating Loans                                                                                    $0
                                        190      Income Taxes                                                                           $0                     $0
                                        200      Bad Debts                                                                              $0                     $0
                                        210      Contributions                                                                          $0                     $0
                                        220      Worker's compensation                                                                                         $0
                                        230      Professional/General Liability Insurance                                                                      $0
                                        240      Civil Money Penalties (Medicare and Medicaid)                                          $0                     $0
                                        250      Other Taxes (attach schedule)                                                                                 $0
                                        270      Other Penalties/fines                                                                  $0                     $0
                                        280      Transportation salaries & wages                                                                               $0
                                        290      Transportation Payroll Taxes & Emp Benefits                                                                    $0
                                        300      Gifts                                                                                                          $0
                                        310      Bank/Service Charges                                                                                           $0
                                        320      Public Relations                                                                                               $0
                                        330      Purchased services                                                                                             $0
                                        340      Recruiting expense                                                                                             $0
                                        350      TV/Cable/Satellite expense                                                                                     $0
                                        360      Beauty & Barber expense                                                                                        $0
                                        490      Miscellaneous (Attach Detail Schedule if greater than $100)                                                    $0
                                                 TOTAL GENERAL ADMINISTRATIVE                                             $0             $0                     $0




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                      0                                                                                                                                                           EXPENSES
                      07/01/10   06/30/11                                                                                                                                       SCHEDULE C
                                                                                                                                                                                  Page 2 of 4
                          (1)       (2)                                 (3)                                     (4)            (5)             (6)                   (7)           (8)
                        COST       ACCT                                                                   EXPENSES PER     PROVIDER'S     FCP REPORTED          HOURS WORKED   HOURS PAID
                         CAT        NO                                TITLE                                GEN. LEDGER    ADJUSTMENTS   EXPENSE (Col 4+Col 5)

                         020                          PROPERTY AND RELATED EXPENSES
                                     230    Building Rent                                                                                                $0
                                     240    Building Depreciation                                                                                        $0
                                     250    Building Interest Expense                                                                                    $0
                                     260    "RealProperty" Property Tax*                                                                                 $0
                                     270    "Real Property" Property Insurance*                                                                          $0
                                     280    Vehicle Depreciation                                                                                         $0
                                     290    Vehicle Interest Expense                                                                                     $0
                                     300    Vehicle Property Tax                                                                                         $0
                                     310    Vehicle Insurance                                                                                            $0
                                     320    Equipment Leases (Operating Leases Only)                                                                     $0
                                     330    Equipment Depreciation                                                                                       $0
                                     340    Equipment Interest Expense                                                                                   $0
                                     350    Personal Property Tax                                                                                        $0
                                     360    Gain/loss on asset disposition                                                                               $0
                                     490    Miscellaneous (Attach Detail Schedule if greater than $100)                                                  $0
                                            TOTAL PROPERTY & RELATED                                                 $0            $0                    $0

                         030                          PLANT OPERATION & MAINTENANCE
                                     012    Salaries and Wages                                                                                           $0
                                     040    Payroll Taxes & Emp Benefits                                                                                 $0
                                     110    Supplies                                                                                                     $0
                                     230    Equipment Rental-Short Term                                                                                  $0
                                     240    Furniture & Equipment Less Than Capitalization $ Threshold                                                   $0
                                     310    Purchased Services/Consultants                                                                               $0
                                     320    Repair & Maintenance - Building & Grounds                                                                    $0
                                     330    Repair & Maintenance - Equipment                                                                             $0
                                     340    Repair & Maintenance - Vehicles (include vehicle fuel)                                                       $0
                                     350    Utilities                                                                                                    $0
                                     490    Miscellaneous (Attach Detail Schedule if greater than $100)                                                  $0
                                            TOTAL PLANT OPERATION & MAINTENANCE                                      $0            $0                    $0

                         040                                        DIETARY
                                     012    Salaries and Wages                                                                                           $0
                                     040    Payroll Taxes & Emp Benefits                                                                                 $0
                                     310    Purchased Services/Consultants                                                                               $0
                                     380    Food                                                                                                         $0
                                     390    Food Supplies                                                                                                $0
                                     490    Miscellaneous (Attach Detail Schedule if greater than $100)                                                  $0
                                            TOTAL DIETARY                                                            $0            $0                    $0

                         050                                  LAUNDRY AND LINEN
                                     012    Salaries and Wages                                                                                           $0
                                     040    Payroll Taxes and Benefits                                                                                   $0
                                     110    Supplies                                                                                                     $0
                                     310    Purchased Services/Consultants                                                                               $0
                                     410    Linen and Bedding                                                                                            $0
                                     490    Miscellaneous (Attach Detail Schedule if greater than $100)                                                  $0
                                            TOTAL LAUNDRY AND LINEN                                                  $0            $0                    $0




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                      0                                                                                                                                                            EXPENSES
                      07/01/10   06/30/11                                                                                                                                        SCHEDULE C
                                                                                                                                                                                   Page 3 of 4
                          (1)       (2)                                 (3)                                      (4)            (5)             (6)                   (7)           (8)
                        COST       ACCT                                                                    EXPENSES PER     PROVIDER'S     FCP REPORTED          HOURS WORKED   HOURS PAID
                         CAT        NO                                 TITLE                                GEN. LEDGER    ADJUSTMENTS   EXPENSE (Col 4+Col 5)

                         060                                    HOUSEKEEPING
                                     012    Salaries and Wages                                                                                            $0
                                     040    Payroll Taxes and Benefits                                                                                    $0
                                     110    Supplies                                                                                                      $0
                                     310    Purchased Services/Consultants                                                                                $0
                                     490    Miscellaneous (Attach Detail Schedule if greater than $100)                                                   $0
                                            TOTAL HOUSEKEEPING                                                        $0            $0                    $0

                         070                                      NURSING
                                     012    Nurse Admin Salaries-Med Rec, In Ser:
                                                                                       Medical Director                                                   $0
                                                                                    Registered Nurses                                                     $0
                                                                            Licensed Practical Nurses                                                     $0
                                                                               Certified Nursing Aides                                                    $0
                                                                                                Others                                                    $0
                                     013    Nurse Admin Payroll Tax and Benefits:
                                                                                       Medical Director                                                   $0
                                                                                    Registered Nurses                                                     $0
                                                                            Licensed Practical Nurses                                                     $0
                                                                               Certified Nursing Aides                                                    $0
                                                                                                Others                                                    $0
                                     040    Nursing Dir Care Salaries & Wages:
                                                                                    Registered Nurses                                                     $0
                                                                            Licensed Practical Nurses                                                     $0
                                                                               Certified Nursing Aides                                                    $0
                                                                                                Others                                                    $0
                                     041    Nursing Dir Care Payroll Tax & Benefit:
                                                                                    Registered Nurses                                                     $0
                                                                            Licensed Practical Nurses                                                     $0
                                                                               Certified Nursing Aides                                                    $0
                                                                                                Others                                                    $0
                                     050    Purchased Nursing Services:
                                                                                       Medical Director                                                   $0
                                                                                    Registered Nurses                                                     $0
                                                                            Licensed Practical Nurses                                                     $0
                                                                               Certified Nursing Aides                                                    $0
                                                                                                 Others                                                   $0
                                     110    Medical Supplies                                                                                              $0
                                     111    Non Medical Supplies (Charts & Forms)                                                                         $0
                                     230    Oxygen Equipment & Rental                                                                                     $0
                                     430    Respiratory/Inhalation Therapy                                                                                $0
                                            Nurses Aide Training Costs
                                    440.1                                              Evaluation Costs                                                   $0
                                    440.2                                               Instructor Costs                                                  $0
                                    440.3                                                 Testing Costs                                                   $0
                                    440.4                                                 Material Costs                                                  $0
                                    440.5                                                    Misc. Costs                                                  $0
                                     490    Miscellaneous (Attach Detail Schedule if greater than $100)                                                   $0
                                            TOTAL                                                                     $0            $0                    $0




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                      0                                                                                                                                                                                             EXPENSES
                      07/01/10   06/30/11                                                                                                                                                                         SCHEDULE C
                                                                                                                                                                                                                    Page 4 of 4
                          (1)        (2)                                    (3)                                       (4)                  (5)                     (6)                        (7)                    (8)
                         COST       ACCT                                                                        EXPENSES PER           PROVIDER'S             FCP REPORTED               HOURS WORKED            HOURS PAID
                         CAT         NO                                    TITLE                                 GEN. LEDGER          ADJUSTMENTS           EXPENSE (Col 4+Col 5)


                         080                ANCILLARIES NOT IN MEDICAID DAILY RATE
                                     013    Physician & Psychiatrist-Staff Salaries                                                                                              $0
                                     014    Physician & Psychiatrist Payroll tax & Benefit                                                                                       $0
                                     017    Physical Therapy - Staff Salaries                                                                                                    $0
                                     018    Physical Therapy Payroll tax & Benefit                                                                                               $0
                                     019    Speech Therapy-Staff Salaries                                                                                                        $0
                                     040    Speech Therapy Payroll tax & Benefit                                                                                                 $0
                                     041    Audiology Therapy-Staff Salaries                                                                                                     $0
                                     042    Audiology Therapy Payroll tax & Benefit                                                                                              $0
                                     043    Occupational Therapy-Staff Salaries                                                                                                  $0
                                     044    Occupational Therapy Payroll tax & Benefits                                                                                          $0
                                     045    Laboratory & Radiology-Staff Salaries                                                                                                $0
                                     046    Laboratory & Radiology Payroll tax & Benefits                                                                                        $0
                                     112    Physician & Psychiatrist-Supplies/Other                                                                                              $0
                                     113    Physical Therapy -Supplies/Other                                                                                                     $0
                                     114    Speech Therapy-Supplies/Other                                                                                                        $0
                                     115    Audiology Therapy-Supplies/Other                                                                                                     $0
                                     116    Occupational Therapy-Supplies/Other                                                                                                  $0
                                     117    Laboratory & Radiology-Supplies/Other                                                                                                $0
                                     311    Purchased Physician & Psychiatrist(non-emp)                                                                                          $0
                                     312    Purchased Physical Therapy (non-employee)                                                                                            $0
                                     313    Purch. Serv.-Speech Therapy (non-employee)                                                                                           $0
                                     314    Purch. Serv.-Aud.Therapy(non-employee)                                                                                               $0
                                     315    Purch. Serv.-Occup.Therapy(non-employee)                                                                                             $0
                                     316    Laboratory & Radiology Service                                                                                                       $0
                                     350    Other Direct Care (i.e. psychologists, podiatrists, optometrists)                                                                    $0
                                     360    Dental Services                                                                                                                      $0
                                     370    Emergency Ambulance                                                                                                                  $0
                                     380    Eye Glasses, Dentures, Hearing Aids                                                                                                  $0
                                     390    Special Equipment Approved by Medicaid**                                                                                             $0
                                     400    Prosthetic Devices***                                                                                                                $0
                                     450    Prescription Drugs****                                                                                                               $0
                                     460    Oxygen Gas                                                                                                                           $0
                                     490    Miscellaneous (Attach Detail Schedule if greater than $100)                                                                          $0
                                            TOTAL ANCILLARIES NOT IN MEDICAID RATE                                            $0                     $0                          $0

                         090                RECREATIONAL ACTIVITY & SOCIAL SERVICES
                                     012    Salaries and Wages                                                                                                                   $0
                                     040    Payroll Taxes and Emp Benefits                                                                                                       $0
                                     310    Purchased Services/Consultants                                                                                                       $0
                                     470    Recreational Therapy                                                                                                                 $0
                                     480    Sheltered Workshops                                                                                                                  $0
                                     490    Miscellaneous (Attach Detail Schedule if greater than $100)                                                                          $0
                                            TOTAL REC ACT & SOCIAL SERVICES                                                   $0                     $0                          $0

                                            TOTAL EXPENSES PER FCP                                                            $0                     $0                          $0               0                     0

                                            TOTAL EXPENSES PER G/L
                                            FCP less G/L must = $0 *****                                                       $0




                                            * Real Property - Land and improvements, including buildings and Personal Property, that is permanently attached to the land or customarily transferred with the land.
                                            ** Limited to air flotation beds and water flotation beds that are self-contained, thermal regulated, and alarm regulated, and mattresses and overlays specific for decubitus
                                            care, and customized (Medicaid definition) and motorized wheelchairs.
                                            *** Medicaid defines prosthetic devices to include (1) articfical legs, arms, and eyes; (2) special braces for the leg, arm, back, and neck; and (3) internal body organs. Specifically
                                            excluded are urinary collection and other retention systems. This definition requires catheters and other related devices to be covered by the per diem payment rate.
                                            ****Prescription drugs (legend drugs) plus antacids, insulin and total nutrition, parental or enteral diet given through gastrostomy, jejunostomy, IV or stomach tube.
                                            In addition, antilipemic agents and hepatic agents or high nitrogen agents are billed by pharmacies directly to Medicaid.
                                            ***** Total expenses reported on the FCP must agree to total expenses per the General Ledger therefore, total expenses per the
                                            FCP less total expenses per the G/L must equal $0.


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0                                                                                       NF - EXPENSE ADJUSTMENT SUMMARY
07/01/10       06/30/11                                                                                     SCHEDULE C-1
schedules revised 7/20/11



This schedule gives the detail of the Provider's expense adjustments posted on Schedule C.
Give totals where appropriate.

    (1)                                       (2)                                      (3)     (4)       (5)        (6)
Adjustment          Purpose of the Adjustment (provide detailed explanation)          Cost   Account    Title      Debit
 Number                                                                             Category Number               (Credit)
                                                                                                From Schedule C
      1
      2
      3




TOTAL                                                                                                                    $0

               Total adjustments Schedule C, Column 5*                                                                   $0
               Variance                                                                                                   $0




NOTE:          If this sheet is not large enough to list all provider adjustments, add additional
               sheets, in the same format, as is necessary.

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0                                                                                                                                                                                                                                         NF - KEY EMPLOYEE COMPENSATION AND RELATED-PARTY DISCLOSURES
07/01/10         06/30/11                                                                                                                                                                                                                                                                 SCHEDULE C-2
schedules revised 7/20/11
                                                            (1)                                                                     (2)                             (3)             (4)               (5)                  (6)                     (7)                         (8)              (9)       (10)
A.               List salary & benefit data for the owner, administrator, office manager, director of nursing,
                 officers, and other key personnel regardless of company structure or contractural agreement. Data is for this facility only.
                                                                                                                                                                                                                                                                     "Check" if related to
                                                                                                                                                               Years of      Years                                                                                   the owner,
                                                                                                                                                               education     experience                                                                              administrator, or       Hours      Hours
                                                                                                                                                               beyond high   directly related                                                                        shareholder of the      Worked     Paid
                                                                     Name                                                                   Position           school        to position            Salary               Benefits           Salary & Benefits        facility*               Annually   Annually
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0


B.               List below the compensation for all employees not listed in A above who are related
                 to the owner/administrator/shareholder or other key personnel.

                                                                                                                                                               Years of      Years
                                                                                                                                                               education     experience                                                                                                      Hours      Hours
                                                                                                                                                               beyond high   directly related                                                                                                Worked     Paid
                                                                     Name                                                                   Position           school        to position            Salary               Benefits           Salary & Benefits                                Annually   Annually
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0
                                                                                                                                                                                                                                                                $0


C.               List below goods and/or services purchased from organizations related by common ownership or control** for any of the following categories:
                 Administrator, Building Lease/Rental, Equipment Lease, Laundry, Nursing, Dietary, Management Fee, Housekeeping, Maintenance, Legal/Accounting,
                 or Other (specify). Home office costs less any markup or profit should be disclosed below.
                 SUPPORTING DOCUMENTATION, I.E. INVOICES, RECEIPTS, STATEMENTS AND SCHEDULES DETAILING EACH AMOUNT BELOW IS REQUIRED.

                                                                                                                                                                                                                  Indicate Row # on Sch
                                                                                                                                                                                                                  C-1 where adjustment
                                                                                                                                                                                                                  was made to reduce
                                                                                                                                                                                                                  expense to related-
                                                                                                                                                                                                                  party's actual cost
                                                                                                                                                                                                                  (cost must not exceed
                                                                                                                                                                                                Amount Paid for   price of comparable
                                                 Name of Related Party or Company                                                   Goods/Services Purchased                                    Goods/Services    services)***




                 * CMS PUB 15-1 902.5: "...the following persons are considered "immediate relatives": (1) husband and
                 wife, (2) natural parent, child and sibling, (3) adopted child and adoptive parent, (4) step-parent, step-child,
                 step-sister, and step-brother, (5) father-in-law, mother-in-law, sister-in-law, brother-in-law, son-in-law, and
                 daughter-in-law, (7) grandparent and grandchild.
                 ** CMS PUB 15-1 1004.3 "The term "control" includes any kind of control, whether or not it is legally
                 enforceable and however it is exercisable or exercised. It is the reality of the control which is decisive, not
                 its form or the mode of its exercise."

                 *** CMS PUB 15-1 1000 "such cost must not exceed the price of comparable services, facilities, or supplies
                 that could be purchased elsewhere. The purpose of this principle is two-fold: (1) to avoid the payment of a
                 profit factor to the provider through the related organization (whether related by common ownership or
                 control), and (2) to avoid payment of artificially inflated costs which may be generated from less than arm's-
                 length bargaining. "




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           0                                                                                                                                                                                        NF - PATIENT DAYS & OCCUPANCY
           07/01/10                     06/30/11                                                                                                                                                                        SCHEDULE D
          schedules revised 7/20/11


                                                                                                                                 FCP Patient Days
                      Column
                        (1)                    (2)                 (3)             (4)             (5)               (6)            (7)         (8)                   (9)           (10)           (11)           (12)         (13)
                                         Subject to Patient Day Assessment                                      Subject to Patient Day Assessment

                                                                                                                                                                                                  Total        Total       Total Days
                                                                                                                                                                                                 Reported    Reported       Subject to
   Row                                                        Medicaid-Non                      Medicare-                                         Hospice-       Hospice-Non
           Patient Classification         Medicaid-Utah                          Medicare                         Veterans          Private                                        Other          Days       Medicare      Patient Day
    1                                                            Utah                            HMO                                              Medicaid        Medicaid
                                                                                                                                                                                                Sum (Col 2- Days (Col 4 + Assessment
                                                                                                                                                                                                   11)           5)       (Col 12 - 13)


    2                                                                                                                                                                                                     -              -            -

    3      Net Revenue from Sch B                     $0               $0             $0              $0                $0               $0            $0                $0             $0
    4      Daily Rate (Row 9÷Row 7)                ERROR            ERROR          ERROR           ERROR             ERROR            ERROR         ERROR             ERROR          ERROR

                                                                                                                    Patient Day Assessment Days
                                         Subject to Patient Day Assessment                                      Subject to Patient Day Assessment
                                                                                                                                                                                                  Total        Total       Total Days
                                                                                                                                                                                                 Reported    Reported       Subject to
                                                              Medicaid-Non                      Medicare-                                         Hospice-       Hospice-Non
    5      Patient Classification         Medicaid-Utah                          Medicare                         Veterans          Private                                        Other          Days       Medicare      Patient Day
                                                                 Utah                            HMO                                              Medicaid        Medicaid
                                                                                                                                                                                                Sum (Col 2- Days (Col 4 + Assessment
                                                                                                                                                                                                   11)           5)       (Col 12 - 13)
           Patient Day Assessment
    6
           Days                                                                                                                                                                                           -              -            -

     7     Difference (Row 2 - Row 6)                     -                  -              -               -                -                -              -               -              -

           NOTES:                                                                                                                                  Line #                                       OCCUPANCY
     8                                                                                                                                                1          Total Licensed Beds:

                                                                                                                                                     2           Medicaid Certified Beds:

                                                                                                                                                     3           Calendar Days in Period                                              365

                                                                                                                                                     4           Total Patient Days Available (Line 1 x Line 3)                           0

                                                                                                                                                     5           Total Occupancy (Row 2, Col 11 ÷ Line 4)                                 0

                                                                                                                                                     6           Medicaid Occupancy (Row 2, Col 2 + Col 3 ÷ Line 4)                       0

                                                                                                                                                                 Medicaid Occupancy as a % of Total Occupancy (Line 6
                                                                                                                                                     7           ÷ Line 5)                                                                0




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schedules
revised
7/20/11       NF - SUMMARY
              Name of Nursing Facility                                         0
              PERIOD BEGINNING -------------->                               7/1/2010
              PERIOD ENDING ------------------>                              6/30/2011

                                                                                1                  2                3            4               5           6               7            7
                                                                           FCP AS FILED        FCP ADJ'S         ADJ FCP       AUDIT        AUDITED FCP     % OF       HOURS WORKED   HOURS PAID
                                                                                                                (COL 1 + 2)    ADJ'S         (COL 3 + 4)   TOTAL

 REV CAT                 REVENUE (INCL TPL) (SCH B)
      01      NET MEDICAID REVENUE - UTAH                                                 $0               $0             $0                          $0       0.00%
      02      NET MEDICAID - NON UTAH                                                     $0               $0             $0                          $0       0.00%
      03      NET MEDICARE REVENUE                                                        $0               $0             $0                          $0       0.00%
      04      NET MEDICARE-HMO REVENUE                                                    $0               $0             $0                          $0       0.00%
      05      NET VETERANS REVENUE                                                        $0               $0             $0                          $0       0.00%
      06      NET PRIVATE REVENUE                                                         $0               $0             $0                          $0       0.00%
      07      NET HOSPICE REVENUE - MEDICAID                                              $0               $0             $0                          $0       0.00%
      08      NET HOSPICE REVENUE - NON MEDICAID                                          $0               $0             $0                          $0       0.00%
      09      NET OTHER REVENUE                                                           $0               $0             $0                          $0       0.00%
      10      NET MISC INCOME                                                             $0               $0             $0                          $0       0.00%
              TOTAL REVENUE                                                               $0               $0             $0           $0             $0       0.00%

COST CAT
  & ACCT                             EXPENSES (SCH C)
  010-000     GENERAL ADMINISTRATIVE
      010     Administrator Salary                                                        $0               $0             $0                          $0       0.00%              0            0
      011     Asst Administrator Salary                                                   $0               $0             $0                          $0       0.00%              0            0
      012     Office Salaries and Wages                                                   $0               $0             $0                          $0       0.00%              0            0
      040     Payroll Taxes & Emp Benefits                                                $0               $0             $0                          $0       0.00%
      051     Director Fees                                                               $0               $0             $0                          $0       0.00%
      060     Management Services                                                         $0               $0             $0                          $0       0.00%
      070     Home Office Charges                                                         $0               $0             $0                          $0       0.00%
      080     Advertising                                                                 $0               $0             $0                          $0       0.00%
      090     Telephone                                                                   $0               $0             $0                          $0       0.00%
      100     Dues, Subscriptions & Licenses                                              $0               $0             $0                          $0       0.00%
      110     Office Supplies, Printing & Postage                                         $0               $0             $0                          $0       0.00%
      120     Legal and Accounting                                                        $0               $0             $0                          $0       0.00%
      130     Utilization Review                                                          $0               $0             $0                          $0       0.00%
      140     Travel , Seminars, & Admin Training                                         $0               $0             $0                          $0       0.00%
      150     Data Processing                                                             $0               $0             $0                          $0       0.00%
      160     Amortization-Organization                                                   $0               $0             $0                          $0       0.00%
      170     Patient Day Assessment                                                      $0               $0             $0                          $0       0.00%
      180     Interest-Operating Loans                                                    $0               $0             $0                          $0       0.00%
      190     Income Taxes                                                                $0               $0             $0                          $0       0.00%
      200     Bad Debts                                                                   $0               $0             $0                          $0       0.00%
      210     Contributions                                                               $0               $0             $0                          $0       0.00%
      220     Worker's compensation                                                       $0               $0             $0                          $0       0.00%
      230     Professional/General Liability Insurance                                    $0               $0             $0                          $0       0.00%
      240     Civil Money Penalties (Medicare and Medicaid)                               $0               $0             $0                          $0       0.00%
      250     Other Taxes (attach schedule)                                               $0               $0             $0                          $0       0.00%
      270     Other Penalties/Fines                                                       $0               $0             $0                          $0       0.00%
      280     Transportation Salaries & Wages                                             $0               $0             $0                          $0       0.00%              0            0
      290     Transportation Payroll Taxes & Emp Benefits                                 $0               $0             $0                          $0       0.00%
      300     Gifts                                                                       $0               $0             $0                          $0       0.00%
      310     Bank/Service Charges                                                        $0               $0             $0                          $0       0.00%
      320     Public Relations                                                            $0               $0             $0                          $0       0.00%
      330     Purchased Services                                                          $0               $0             $0                          $0       0.00%
      340     Recruiting Expense                                                          $0               $0             $0                          $0       0.00%
      350     TV/Cable/Satellite Expense                                                  $0               $0             $0                          $0       0.00%
      360     Beauty & Barber Expense                                                     $0               $0             $0                          $0       0.00%
      490     Miscellaneous (Attach Schedule)                                             $0               $0             $0                          $0       0.00%
              TOTAL GENERAL ADMINISTRATIVE                                                $0               $0             $0           $0             $0       0.00%

    020-000   PROPERTY AND RELATED EXPENSES
        230   Building Rent                                                               $0               $0             $0                          $0       0.00%
        240   Building Depreciation                                                       $0               $0             $0                          $0       0.00%
        250   Building Interest Expense                                                   $0               $0             $0                          $0       0.00%
        260   "RealProperty" Property Tax*                                                $0               $0             $0                          $0       0.00%
        270   "Real Property" Property Insurance*                                         $0               $0             $0                          $0       0.00%
        280   Vehicle Depreciation                                                        $0               $0             $0                          $0       0.00%
        290   Vehicle Interest Expense                                                    $0               $0             $0                          $0       0.00%
        300   Vehicle Property Tax                                                        $0               $0             $0                          $0       0.00%
        310   Vechicle Insurance                                                          $0               $0             $0                          $0       0.00%
        320   Equipment Leases (Operating Leases Only)                                    $0               $0             $0                          $0       0.00%
        330   Equipment Depreciation                                                      $0               $0             $0                          $0       0.00%
        340   Equipment Interest Expense                                                  $0               $0             $0                          $0       0.00%
        350   Personal Property Tax                                                       $0               $0             $0                          $0       0.00%
        360   Gain/loss on asset disposition                                              $0               $0             $0                          $0       0.00%
        490   Miscellaneous (Attach Detail Schedule)                                      $0               $0             $0                          $0       0.00%
              TOTAL PROPERTY & RELATED                                                    $0               $0             $0           $0             $0       0.00%

    030-000   PLANT OPERATION & MAINTENANCE
        012   Salaries and Wages                                                          $0               $0             $0                          $0       0.00%              0            0
        040   Payroll Taxes & Emp Benefits                                                $0               $0             $0                          $0       0.00%
        110   Supplies                                                                    $0               $0             $0                          $0       0.00%
        230   Equipment Rental-Short Term                                                 $0               $0             $0                          $0       0.00%
        240   Furniture & Equipment less than Capitalization $ Threshold                  $0               $0             $0                          $0       0.00%
        310   Purchased Services/Consultants                                              $0               $0             $0                          $0       0.00%
        320   Repair & Maintenance - Building & Grounds                                   $0               $0             $0                          $0       0.00%
          Name of Nursing Facility                                                  0
          PERIOD BEGINNING -------------->                                        7/1/2010
          PERIOD ENDING ------------------>                                       6/30/2011

                                                                                     1                  2                3             4               5              6                7            7
                                                                                FCP AS FILED        FCP ADJ'S         ADJ FCP        AUDIT        AUDITED FCP        % OF        HOURS WORKED   HOURS PAID
                                                                                                                     (COL 1 + 2)     ADJ'S         (COL 3 + 4)      TOTAL
    330   Repair & Maintenance - Equipment                                                     $0               $0              $0                             $0        0.00%
    340   Repair & Maintenance - Vehicles (include vehicle fuel)                               $0               $0              $0                             $0        0.00%
    350   Utilities                                                                            $0               $0              $0                             $0        0.00%
    490   Miscellaneous (Attach Detail Schedule)                                               $0               $0              $0                             $0        0.00%
          TOTAL PLANT OPER & MAINT                                                             $0               $0              $0           $0                $0        0.00%

040-000   DIETARY
    012   Salaries and Wages                                                                   $0               $0             $0                             $0         0.00%              0            0
    040   Payroll Taxes & Emp Benefits                                                         $0               $0             $0                             $0         0.00%
    310   Purchased Services/Consultants                                                       $0               $0             $0                             $0         0.00%
    380   Food                                                                                 $0               $0             $0                             $0         0.00%
    390   Food Supplies                                                                        $0               $0             $0                             $0         0.00%
    490   Miscellaneous (Attach Detail Schedule)                                               $0               $0             $0                             $0         0.00%
          TOTAL DIETARY                                                                        $0               $0             $0            $0               $0         0.00%

050-000   LAUNDRY AND LINEN
    012   Salaries and Wages                                                                   $0               $0             $0                             $0         0.00%              0            0
    040   Payroll Taxes & Emp Benefits                                                         $0               $0             $0                             $0         0.00%
    110   Supplies                                                                             $0               $0             $0                             $0         0.00%
    310   Purchased Services/Consultants                                                       $0               $0             $0                             $0         0.00%
    410   Linen and Bedding                                                                    $0               $0             $0                             $0         0.00%
    490   Miscellaneous (Attach Detail Schedule)                                               $0               $0             $0                             $0         0.00%
          TOTAL LAUNDRY & LINEN                                                                $0               $0             $0            $0               $0         0.00%

060-000   HOUSEKEEPING
    012   Salaries and Wages                                                                   $0               $0             $0                             $0         0.00%              0            0
    040   Payroll Taxes & Benefits                                                             $0               $0             $0                             $0         0.00%
    110   Supplies                                                                             $0               $0             $0                             $0         0.00%
    310   Purchased Service/Consultants                                                        $0               $0             $0                             $0         0.00%
    490   Miscellaneous (Attach Detail Schedule)                                               $0               $0             $0                             $0         0.00%
          TOTAL HOUSEKEEPING                                                                   $0               $0             $0            $0               $0         0.00%

070-000 NURSING
    012 Nurse Admin Sal-Med Rec, In Ser
                                                             Medical Director                  $0               $0             $0                             $0         0.00%              0            0
                                                            Registered Nurses                  $0               $0             $0                             $0         0.00%              0            0
                                                    Licensed Practical Nurses                  $0               $0             $0                             $0         0.00%              0            0
                                                      Certified Nursing Aides                  $0               $0             $0                             $0         0.00%              0            0
                                                                       Others                  $0               $0             $0                             $0         0.00%              0            0
    013 Nurse Admin Payroll Tax and Benefits
                                                             Medical Director                  $0               $0             $0                             $0         0.00%
                                                            Registered Nurses                  $0               $0             $0                             $0         0.00%
                                                    Licensed Practical Nurses                  $0               $0             $0                             $0         0.00%
                                                      Certified Nursing Aides                  $0               $0             $0                             $0         0.00%
                                                                       Others                  $0               $0             $0                             $0         0.00%
    040 Nurse Dir Care Salaries & Wages
                                                            Registered Nurses                  $0               $0             $0                             $0         0.00%              0            0
                                                    Licensed Practical Nurses                  $0               $0             $0                             $0         0.00%              0            0
                                                      Certified Nursing Aides                  $0               $0             $0                             $0         0.00%              0            0
                                                                       Others                  $0               $0             $0                             $0         0.00%              0            0
    041 Nurse Dir Care Payroll Tax & Benefits
                                                            Registered Nurses                  $0               $0             $0                             $0         0.00%
                                                    Licensed Practical Nurses                  $0               $0             $0                             $0         0.00%
                                                      Certified Nursing Aides                  $0               $0             $0                             $0         0.00%
                                                                       Others                  $0               $0             $0                             $0         0.00%
    050 Purchased Nursing Services
                                                             Medical Director                  $0               $0             $0                             $0         0.00%              0            0
                                                            Registered Nurses                  $0               $0             $0                             $0         0.00%              0            0
                                                    Licensed Practical Nurses                  $0               $0             $0                             $0         0.00%              0            0
                                                      Certified Nursing Aides                  $0               $0             $0                             $0         0.00%              0            0
                                                                       Others                  $0               $0             $0                             $0         0.00%              0            0
    110   Medical Supplies                                                                     $0               $0             $0                             $0         0.00%
    111   Non Medical Supplies (Charts & Forms)                                                $0               $0             $0                             $0         0.00%
    230   Oxygen Equipment and Rental                                                          $0               $0             $0                             $0         0.00%
    430   Respiration/Inhalation Therapy                                                       $0               $0             $0                             $0         0.00%
          Nurs Aide Trg Costs (by formula from Sch D)
  440.1                                                Evaluation Costs                        $0               $0             $0                             $0         0.00%
  440.2                                                 Instructor Costs                       $0               $0             $0                             $0         0.00%
  440.3                                                   Testing Costs                        $0               $0             $0                             $0         0.00%
  440.4                                                  Material Costs                        $0               $0             $0                             $0         0.00%
  440.5                                                     Misc. Costs                        $0               $0             $0                             $0         0.00%
    490 Miscellaneous Nursing (Attach Detail Schedule)                                         $0               $0             $0                             $0         0.00%
        TOTAL NURSING                                                                          $0               $0             $0            $0               $0         0.00%

080-000   ANCILLARIES NOT IN MEDICAID DAILY RATE
    013   Physician & Psychiatrist-Staff Salaries                                              $0           $0                 $0                             $0         0.00%              0            0
    014   Physician & Psychiatrist Payroll tax & Benefit                                       $0           $0                 $0                             $0         0.00%
    017   Physical Therapy - Staff Salaries                                                    $0           $0                 $0                             $0         0.00%              0            0
    018   Physical Therapy Payroll tax & Benefit                                               $0           $0                 $0                             $0         0.00%
    019   Speech Therapy-Staff Salaries                                                        $0           $0                 $0                             $0         0.00%              0            0
    040   Speech Therapy Payroll tax & Benefit                                                 $0           $0                 $0                             $0         0.00%
    041   Audiology Therapy-Staff Salaries                                                     $0           $0                 $0                             $0         0.00%              0            0
    042   Audiology Therapy Payroll tax & Benefit                                              $0           $0                 $0                             $0         0.00%
    043   Occupational Therapy-Staff Salaries                                                  $0           $0                 $0                             $0         0.00%              0            0
          Name of Nursing Facility                                                0
          PERIOD BEGINNING -------------->                                      7/1/2010
          PERIOD ENDING ------------------>                                     6/30/2011

                                                                                   1                    2                3                4               5              6                7            7
                                                                              FCP AS FILED          FCP ADJ'S         ADJ FCP           AUDIT        AUDITED FCP        % OF        HOURS WORKED   HOURS PAID
                                                                                                                     (COL 1 + 2)        ADJ'S         (COL 3 + 4)      TOTAL
   044    Occupational Therapy Payroll tax & Benefits                                        $0             $0                 $0                                 $0        0.00%
   045    Laboratory & Radiology-Staff Salaries                                              $0             $0                 $0                                 $0        0.00%              0            0
   046    Laboratory & Radiology Payroll tax & Benefits                                      $0             $0                 $0                                 $0        0.00%
   112    Physician & Psychiatrist-Supplies/Other                                            $0             $0                 $0                                 $0        0.00%
   113    Physical Therapy -Supplies/Other                                                   $0             $0                 $0                                 $0        0.00%
   114    Speech Therapy-Supplies/Other                                                      $0             $0                 $0                                 $0        0.00%
   115    Audiology Therapy-Supplies/Other                                                   $0             $0                 $0                                 $0        0.00%
   116    Occupational Therapy-Supplies/Other                                                $0             $0                 $0                                 $0        0.00%
   117    Laboratory & Radiology-Supplies/Other                                              $0             $0                 $0                                 $0        0.00%
   311    Purchased Physician & Psychiatrist(non-emp)                                        $0             $0                 $0                                 $0        0.00%
   312    Purchased Physical Therapy (non-employee)                                          $0             $0                 $0                                 $0        0.00%
   313    Purch. Serv.-Speech Therapy (non-employee)                                         $0             $0                 $0                                 $0        0.00%
   314    Purch. Serv.-Aud.Therapy(non-employee)                                             $0             $0                 $0                                 $0        0.00%
   315    Purch. Serv.-Occup.Therapy(non-employee)                                           $0             $0                 $0                                 $0        0.00%
   316    Laboratory & Radiology Service                                                     $0             $0                 $0                                 $0        0.00%
   350    Other direct care (i.e. psychologists, podiatrists, optometrists)                  $0             $0                 $0                                 $0        0.00%
   360    Dental Services                                                                    $0             $0                 $0                                 $0        0.00%
   370    Emergency Ambulance                                                                $0             $0                 $0                                 $0        0.00%
   380    Eye Glasses, Dentures, Hearing Aids                                                $0             $0                 $0                                 $0        0.00%
   390    Special Equipment Approved by Medicaid                                             $0             $0                 $0                                 $0        0.00%
   400    Prosthetic Devices                                                                 $0             $0                 $0                                 $0        0.00%
   450    Prescription Drugs                                                                 $0             $0                 $0                                 $0        0.00%
   460    Oxygen Gas                                                                         $0             $0                 $0                                 $0        0.00%
   490    Miscellaneous (Attach Detail Schedule if greater than $100)                        $0             $0                 $0                                 $0        0.00%
          TOTAL ANCILLARIES NOT IN MEDICAID RATE                                             $0                 $0             $0               $0                $0        0.00%

090-000   RECREATIONAL ACTIVITIES & SPECIAL SERVICES
    012   Salaries & Wages                                                                   $0                 $0             $0                                $0         0.00%              0            0
    040   Payroll Taxes & Emp Benefits                                                       $0                 $0             $0                                $0         0.00%
    310   Purchased Services/Consultants                                                     $0                 $0             $0                                $0         0.00%
    470   Recreational Therapy                                                               $0                 $0             $0                                $0         0.00%
    480   Sheltered Workshops                                                                $0                 $0             $0                                $0         0.00%
    490   Miscellaneous (Attach Detail Schedule)                                             $0                 $0             $0                                $0         0.00%
          TOTAL REC ACT & SOCIAL SERVICES                                                    $0                 $0             $0               $0               $0         0.00%

          TOTAL REPORTED EXPENSES PER FCP                                                    $0                 $0             $0               $0               $0         0.00%              0            0


          TOTAL EXPENSES PER G/L                                                             $0
          FCP less G/L must = 0                                                              $0


          PROFIT / (LOSS) (REV - EXP)                                                        $0                 $0             $0               $0               $0


                           CENSUS (SCH D)
          MEDICAID DAYS - UTAH                                                                 0                                   0                              0         0.00%
          MEDICAID DAYS - NON UTAH                                                             0                                   0                              0         0.00%
          MEDICARE DAYS                                                                        0                                   0                              0         0.00%
          MEDICARE-HMO DAYS                                                                    0                                   0                              0         0.00%
          VETERANS DAYS                                                                        0                                   0                              0         0.00%
          PRIVATE DAYS                                                                         0                                   0                              0         0.00%
          HOSPICE DAYS - MEDICAID                                                              0                                   0                              0         0.00%
          HOSPICE DAYS - NON MEDICAID                                                          0                                   0                              0         0.00%
          OTHER DAYS                                                                           0                                   0                              0         0.00%
          TOTAL PATIENT DAYS                                                                    0                0                  0            0                 0        0.00%

                        OCCUPANCY (SCH D)
          TOTAL LICENSED BEDS                                                                  0                                0                                 0
          MEDICAID CERTIFIED BEDS                                                              0                                0                                 0
          CALENDAR DAYS IN PERIOD                                                            365                              365                               365

          TOTAL PATIENT DAYS AVAILABLE (Total Licensed
          Beds*Calendar Days in Period)                                                        0                                   0                              0
          TOTAL OCCUPANCY (Total Patient Days/Total Patient Days
          Available)                                                                           0                                   0                               0
          MEDICAID OCCUPANCY (Medicaid Days-Utah /Total Patient
          Days Available)                                                                      0                                   0                               0
          MEDICAID OCCUPANCY AS A % OF TOTAL OCCUPANCY
          (Medicaid Occupancy/Total Occupancy)                                                 0                                   0                               0


          Private Revenue Per Day                                                                                                               Q1
                                                                                                                                                Q2
                                                                                                                                                Q3
                                                                                                                                                Q4

								
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