Workers Compensation Insurance for Nursing Homes

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					                                                 Wyoming Department of Health - Aging Division
                                                 Wyoming Nursing Home Reimbursement System
Financial Report for Nursing Homes
Period of Report             [11001] From:                         [11002] To:                                [10001] Provider Number

[12101] Name of Facility                                                                                                 [11301] Federal I.D. No.

[12102] Mailing Address                                                       [12103] City                               [12104] State                   [12105] Zip

[12106] Medicaid Year End                                        [12107] Tax Year End                                    [12108] Medicare Year End


  [131] Type of Control - Check One                                                                           [132] Agency Use Only
  Proprietary For-Profit         Voluntary Non-Profit                    Government                           (01)                  (02)                           (03)

 (11)         Individual             (21)             Church           (31)        State
                                            .
 (12)         Partnership            (22)             Other (Specify) (32)         County                     (04)                        (05)                     (06)

 (13)         Corporation                                              (33)        City

 (14)         Other (Specify)                                          (34)        Other (Specify)            (07)                        (08)                     (09)


                                                                           Schedule A
                                                                        STATISTICAL DATA
                                      Description                                                       Line No.                          (01) Licensed Beds
Number of Licensed Beds at Beginning of Period                                                              141
Number of Licensed Beds at End of Period (Should Equal Line 659)                                            142
Total Bed Days Available                                                                                    143
Total Occupant Days - Medicaid                                                                              144
Total Occupant Days - All Patients                                                                          148
Percentage of Occupancy (Line 148/Line 143)                                                                 151
Medicaid Utilization (Line 144/Line 148)                                                                    152
Total Hours Worked During Period (From Schedule E, Line 598)                                                153
Average Hours Worked Per Patient Day (Line 153/Line 148)                                                    158
Weighted Average Private Pay Rate at Report Year End                                                        159

[16100] Accounting Method - Check One                            (1)          Accrual             (2)         Modified Cash         (3)          Cash    If Cash, submit beginning
and ending balances for accounts payable, salaries payable and inventories on a separate sheet.

[16200] Related Party Transaction - Were there any transactions, including working capital loans, with organizations related to the provider, as defined by the Rate
Setting Criteria?      (1)         Yes          (2)        No    If Yes - submit details in cover letter or on separate sheet and report on appropriate schedules of this form.

                                                                        Schedule B
                                                                COST COMPONENT SUBTOTALS
                                                                                          Salaries & Benefits                       Other                           Total
                      Description
                                                                   Line No.                       (01)                               (02)                            (03)
Health Care                                                            171                                                                                                        -
Unique Costs (ICF/MR Only)                                             172                                                                                                        -
Operating                                                              173                                                                                                        -
Capital                                                                174                                                                                                        -
Total                                                                  179                                           -                             -                              -

                                                                       Certification Statement
Misrepresentation or falsification of any information contained in this cost report may be punishable by fine and/or imprisonment under state or federal law.

I hereby certify that I have read the above statement and that I have examined the accompanying cost report and supporting schedules prepared by (provider
name and number)                                                                                        for the cost report period beginning
and ending                                                 and that to the best of my knowledge and belief, it is a true, correct and complete statement prepared from
the books and records of the provider in accordance with applicable instructions, except as noted.



                                Signature                                                                   Title                                               Date


        REV 03/07                                                                   Page 1 of 14
  Financial Report for Nursing Homes                               Provider Name _______________________________________

                                                Schedule C
                                       SCHEDULE OF REVENUES

                                                        Medicaid                    Other                Total
            Revenue Category           Line #
                                                          (01)                       (02)                 (03)

Routine Daily Service                   211                                                                      -

Billable Medical Supplies               231                                                                      -

Pharmacy                                232                                                                      -

Physical Therapy                        233                                                                      -

Speech / Hearing Therapy                234                                                                      -

Inhalation Therapy                      235                                                                      -

X-Ray & Laboratory                      236                                                                      -

Occupational Therapy                    237                                                                      -

Barber / Beauty Shop                    241                                                                      -

Personal Purchases                      242                                                                      -

Meals to Guests                         243                                                                      -

Telephone                               244                                                                      -

TV Rental                               245                                                                      -

Activity Sales                          246                                                                      -

Vending Machines                        247                                                                      -

Investment Income                       248                                                                      -

Program Transportation                  249                                                                      -

Misc. Income                            251                                                                      -

Other -                                 252                                                                      -
Other -                                 253                                                                      -

 Gross Revenues                         261                           -                     -                    -


Bad Debts                               262     (                          ) (                   )               -

Contract / Charity                      263     (                          ) (                   )               -

Other                                   267     (                          ) (                   )               -


Net Revenues                            297                           -                     -                    -


Credit Balance                          300                                                                      -



  REV 03/07                                         Page 2 of 14
   Financial Report for Nursing Homes                            Provider Name ____________________________________


                                                 Schedule D
                             SCHEDULE OF NON-REIMBURSABLE EXPENSES

            Note: The Non-Reimbursable amounts must also be adjusted from Schedule E - Column 6
                                                                                      Non-
                                                            General Ledger        Reimbursable        Line(s)
                  Expense Description                Line #
                                                              Account #              Amount          Reported
                                                                 (01)                 (02)              (03)
Advertising - Promotional                             311
Attorney Fees - Litigation                            331
Ancillary Services Covered by Medicare                332
Costs Attributable to Sale after 07/18/84:
   Legal Fees                                         334
   Accounting Fees                                    335
   Administrative Costs                               336
   Travel Costs                                       337
   Costs of Feasibility Studies                       341
Donations                                             342
Interest on Related Party Loans in Excess of
Allowable Interest Rate                               343
Meals and Lodging Sold to Guests and Employees        344
Provisions for Income or Excess Profits Tax           345
Prescription Drugs                                    346
Public Relations Expense                              347
Residential Personal Purchases                        348
Self-Employment Taxes                                 349
Telephone in Resident Room                            351
Television/Radio in Resident Room                     352
Vending Machines                                      353
Physician Care                                        354
Dental Care                                           355
Eye Care                                              356
Costs Related to Hospice Service                      361
Other -                                               362
 Total                                                363                                    -



   REV 03/07                                      Page 3 of 14
      Financial Report for Nursing Homes                                        Provider Name _________________________________

                                                           Schedule E
                                                    SCHEDULE OF EXPENSES
                                                      Provider
                                            Hours     Adjust-       Hours         Personnel     Other       Provider    Reported
      Expense Description            Line
                                             Paid      ment         Worked         Expense     Expense     Adjustment     Cost
                                             (01)       (02)         (03)            (04)        (05)         (06)        (07)
Nursing & Nursing Services:
 Director of Nursing                 411                                   -                                                      -
 Registered Nurses                   412                                   -                                                      -
 Licensed Practical Nurse            413                                   -                                                      -
 Nurses Aide                         414                                   -                                                      -
 Orderlies                           415                                   -                                                      -
 Attendants                          416                                   -                                                      -
 Medical Director                    417                                   -                                                      -
 Physical Therapy                    418                                   -                                                      -
 Activity Director                   419                                   -                                                      -
 Social Services                     421                                   -                                                      -
 Nursing Consultants & Other         422                                   -                                                      -
 Payroll Taxes                       425                                                                                          -
 Health & Life Insurance             426                                                                                          -
 Group Life Insurance                427                                                                                          -
 Workers' Compensation               428                                                                                          -
 Qualifying Pension Plan             429                                                                                          -
 Other Qualifying Benefits           431                                                                                          -
 Nursing Supply, (non-OTC)           432                                                                                          -
 OTC Drugs                           433                                                                                          -
 Inservices Training                 434                                   -                                                      -
 Continuing Education                435                                   -                                                      -
 Nurse Aide Training                 436                                   -                                                      -
 Travel (Training)                   441                                   -                                                      -
 Unique Costs (ICF/MR Only)       442                                      -                                                      -
                    Total Nursing 449           -           -              -             -            -            -              -

Dietary:
 Dietary Supervisor                  451                                   -                                                      -
 Dietary Personnel                   452                                   -                                                      -
 Dietician                           453                                   -                                                      -
 Purchases Services                  454                                   -                                                      -
 Food Service Training               455                                   -                                                      -
 Other Dietary Expense               456                                   -                                                      -
 Payroll Taxes                       457                                                                                          -
 Health & Life Insurance             458                                                                                          -
 Group Life Insurance                459                                                                                          -
 Workers' Compensation               461                                                                                          -
 Qualifying Pension Plan             462                                                                                          -
 Other Qualifying Benefits           463                                                                                          -
 Other                               464                                   -                                                      -
                        Total Dietary 469       -           -              -             -            -            -              -

TOTAL HEALTHCARE                     470        -           -              -             -            -            -              -


      REV 03/07                                                  Page 4 of 14
      Financial Report for Nursing Homes                                       Provider Name _________________________________

                                                          Schedule E
                                                   SCHEDULE OF EXPENSES
                                                     Provider
                                           Hours     Adjust-       Hours         Personnel     Other       Provider    Reported
      Expense Description           Line
                                            Paid      ment         Worked         Expense     Expense     Adjustment     Cost
                                            (01)       (02)         (03)            (04)        (05)         (06)        (07)
Property:
 Interest on Property               481                                                                                          -
 Depreciation-Fixed                 482                                                                                          -
 Depreciation -Moveable             483                                                                                          -
 Amortization-Lease Imprv           484                                                                                          -
 Building - Lease/Rent              485                                                                                          -
 Movable Equip Lease/Rent           486                                                                                          -

TOTAL CAPITAL                       487                                                              -            -              -

Laundry & Housekeeping:
 Laundry Supervisor                 501                                   -                                                      -
 Laundry Personnel                  502                                   -                                                      -
 Housekeeping Supervisor            503                                   -                                                      -
 Housekeeping Personnel             504                                   -                                                      -
 Payroll Taxes                      505                                                                                          -
 Health & Life Insurance            506                                                                                          -
 Group Life Insurance               507                                                                                          -
 Workers' Compensation              508                                                                                          -
 Qualifying Pension Plan            509                                                                                          -
 Other Qualifying Benefits          510                                                                                          -
 Laundry Supply & Services          511                                                                                          -
 Housekeeping Supply & Srvcs        512                                                                                          -
 Other                              513                                   -                                                      -
            Total Laundry & Hskping 514        -           -              -             -            -            -              -

Plant Operations:
 Plant Operations Supervisor        521                                   -                                                      -
 Plant Operations Personnel         522                                   -                                                      -
 Payroll Taxes                      523                                                                                          -
 Health & Life Insurance            524                                                                                          -
 Group Life Insurance               525                                                                                          -
 Workers' Compensation              526                                                                                          -
 Qualifying Pension Plan            527                                                                                          -
 Other Qualifying Benefits          528                                                                                          -
 Repairs & Maint-Building           529                                                                                          -
 Repairs & Maint-Equipment          531                                                                                          -
 Real Estate Taxes                  532                                                                                          -
 Personal Property Taxes            533                                                                                          -
 Property Insurance                 534                                                                                          -
 Other Ownership Costs              535                                                                                          -
              Total Plant Operations 539       -           -              -             -            -            -              -




      REV 03/07                                                 Page 5 of 14
      Financial Report for Nursing Homes                                           Provider Name _________________________________

                                                              Schedule E
                                                       SCHEDULE OF EXPENSES
                                                         Provider
                                               Hours     Adjust-       Hours         Personnel     Other       Provider    Reported
      Expense Description               Line
                                                Paid      ment         Worked         Expense     Expense     Adjustment     Cost
                                                (01)       (02)         (03)            (04)        (05)         (06)        (07)
Administration:
 Administrator's Salary                 541                                   -                                                      -
 Co-Administrator's Salary              542                                   -                                                      -
 Owner & Related Party
 Management (Schedule K)                543                                   -                                                      -
 Director Fees                          544                                   -                                                      -
 Management Contract
 Personnel                              545                                   -                                                      -
 Home Office Management                 546                                   -                                                      -
 Other Home Office                      547                                   -                                                      -
 Office Manager                         548                                   -                                                      -
 Data Processing Personnel              549                                   -                                                      -
 Training Instructors                   551                                   -                                                      -
 Office & Clerical Personnel            552                                   -                                                      -
 Payroll Taxes                          553                                                                                          -
 Health & Life Insurance                554                                                                                          -
 Group Life Insurance                   555                                                                                          -
 Workers' Compensation                  556                                                                                          -
 Qualifying Pension Plan                557                                                                                          -
 Other Qualifying Benefits              558                                                                                          -
 Accounting Fees                        559                                                                                          -
 Legal Fees                             561                                                                                          -
 Advertising-Promotional                562                                                                                          -
 Advertising-Other                      563                                                                                          -
 Travel Expense                         564                                                                                          -
 Telephone                              565                                                                                          -

 Licenses, Dues &       Subscriptions   566                                                                                          -
 Contributions & Donations              567                                                                                          -
 Interest-Working Capital               568                                                                                          -
 Amortization - Non Cap. Asset          569                                                                                          -
 Income Taxes                           571                                                                                          -
 Utilization Review                     572                                                                                          -
 Liability Insurance                    573                                                                                          -
 Mgmt Contract Fees-Other               574                                                                                          -
 Management Consulting Fees             575                                                                                          -
 Other Admin (attach list)              576                                                                                          -
              Total Administration 579             -           -              -             -            -            -              -


TOTAL OPERATING                         589        -           -              -             -            -            -              -


GRAND TOTAL                             598        -           -              -             -            -            -              -


      REV 03/07                                                     Page 6 of 14
     Financial Report for Nursing Homes                                                Provider Name __________________________________


                                                                Schedule F
                                                     ANALYSIS OF PROPERTY

                                              Historical                                          Historical                       Depreciation
                                               Cost at                            Disposals*       Cost at                          Expense
       Property Description           Line    Beginning                             (key as        End of        Accumulated          This
                                              of Period       Additions*           negative)       Period        Depreciation        Period
                                                 (01)           (02)                  (03)           (04)            (05)              (06)
Land                                  631                                                                  -

Land Improvements                     632                                                                  -

Buildings & Bldg Components           633                                                                  -

Building Improvements                 634                                                                  -

Moveable Equipment                    635                                                                  -

Leasehold Improvmnts - Bldg           636                                                                  -

Leasehold Improvmnts - Other          637                                                                  -

Vehicles                              638                                                                  -

Other                                 641                                                                  -
             Total **                 649               -                -                 -               -                   -            -


* Please submit detailed information for any addition or disposal in excess of $5,000 including: date placed into service or
  disposed, description and purpose of property, location, and cost basis.

**Line 649, Column 6 should equal the sum of lines 482, 483, and 484.

[67102] Was any item included in this schedule acquired, directly or indirectly, from a related party?              (1) Yes
        If yes, please explain:                                                                                     (2) No




                                                   HISTORY OF BED CHANGES
     Description of Beds                                                             Number of Beds                 Total Number of Beds
    (Acquired, Leased, or             Line         Date of Service                   Added / (Deleted)                  After Change
          Deleted)                                      (01)                              (02)                               (03)
                                      651                                                                                                   -
                                      652
                                      653
                                      654
                                      655
 Total Beds (should equal line 142)   659                                                                 -                                 -




     REV 03/07                                                     Page 7 of 14
  Financial Report for Nursing Homes                                            Provider Name ______________________________________


                                                             Schedule G
                                                RECONCILIATION OF EXPENSES

                                                                          Financials or
                 Item Description                         Line             Tax Return                       Schedule E
                                                                              (01)                             (02)
Total Expenses from (check source)                    √
                Financial Statements/General Ledger       611
                                        Tax Return

 Total Expenses per Schedule E - Line 598                 612                                                               -
(Sum of Columns 4 and 5)
Expenses on Financials or Tax Return
not on Schedule E (specify on lines 613,
                                                          613
614, & 615)


                                                          614
                                                          615
Expenses on Schedule E not on Financials or
Tax Return (specify on lines 616,
617, & 618)                                               616


                                                          617
                                                          618

        Total (Column 01 and 02 should be equal)          619                                 -                             -




  REV 03/07                                                      Page 8 of 14
    Financial Report for Nursing Homes                                      Provider Name _____________________________________


                                                        Schedule H
                                                 ANALYSIS OF FINANCING


             Item Description                    Line   Financing #1     Financing #2   Financing #3   Financing #4   Financing #5


ID Number - For Ratesetter Use Only               701

Name of Lender                                    711
Are Lender and Borrower Related Parties?          712
              (1) Yes
                                                  √
              (2) No
Type of Financing                                 713
               (1) Working Capital
                                                  √
               (2) Property Financing

Description of Property Financed                  716

Original Commitment Date                          717

Beginning Date of Payments                        718

Term of Loan - Amortization Period in Years       719

Original Amount of Loan                           721

Date of Most Recent Refinancing, if any           722

Reason for Refinancing                            724

Unpaid Balance at Beginning of Period             725

Unpaid Balance at End of Period                   726
Is Interest Fixed or Variable?                    731
                (1) Fixed
                                                  √
                (2) Variable

If Fixed, Give Interest Rate                      732

If Variable, Give Average Annual Interest Rate    737

Amount of Debt Service this Period                741

Interest Expense this Period                      742

Sch E Line # on Which Expense is Reported         743

Were the proceeds of this financing
arrangement used entirely for patient-
related working capital or to acquire patient
related property?                                 748
                (1) Yes
                                                  √
                (2) No

 If no, attach allocation Schedule




    REV 03/07                                             Page 9 of 14
     Financial Report for Nursing Homes                             Provider Name ___________________________________


                                                                           Schedule I
                                                          ANALYSIS OF LEASED PROPERTY

                                                       Line
                Item Description                                 Lease #1              Lease #2              Lease #3               Lease #4              Lease #5
                                                       No.
Name of Lessor                                          761



Are Lessor and Lessee Related Parties? #                762
                   (1) Yes
                                                          √
                   (2) No

Description of Property Leased                          763



Does lease pertain to any property that is not
patient-related to beds listed on Schedule F?
##                                                      765
                   (1) Yes
                                                          √
                   (2) No

Is the historical cost basis of this property
included on Schedule F?                                 766
                   (1) Yes
                                                          √
                   (2) No

Date of Commitment on Current Lease.                    772
Amount of Annual Lease Payment
(Excluding Executory Costs) for the Latest              775
Report Year.

Has an independent accountant ever made a
determination as to type of lease according
to GAAP? *                                              778
                   (1) Yes
                                                          √
                   (2) No

Indicate type of lease in accordance with
GAAP. *                                                 779
                   (1) Operating
                   (2) Capital                            √
                   (3) Unknown

Inception date of original lease agreement. *           781
Minimum annual lease payment (excluding
executory costs) at inception date of original
lease. *                                                782
Incremental borrowing rate at date of
inception. *                                            783
Lessors implicit interest rate.                         784
Term of lease in years                                  785
Economic life of leased assets. *                       786
# If the answer to line 762 is "Yes", include the historical cost basis on Schedule F, any related financing on Schedule H, and answer only through question 774.
## If the answer to line 765 is "Yes", attach allocation plan.
* These items are technical questions relating to FASB 13 and subsequent pronouncement of the AICPA.
If 778 is yes and 779 is operating, do not complete questions 781 - 786.
If 778 is no, attach a signed copy of the lease agreement.



     REV 03/07                                                               Page 10 of 14
  Financial Report for Nursing Homes                            Provider Name ___________________________________

                                                       Schedule J
                                                      BALANCE SHEET


Balance Sheet shall reflect the asset, liability and residual accounts of this facility only.
                                                                          Beginning of                  End of
                                                         Line
                                                                            Period                      Period
                                                         No.                  (01)                       (02)
Assets
 Cash                                                    811
 Accounts Receivable                                     812
   Less: Allowance for Bad Debts (key as negative)       813    (                               )   (                )
 Inventories and Supplies                                814
 Loans to Officers, Owners, & Related Parties            815
 All Assets not Related to Patient Care*                 816
 Assets Held for Investment*                             817
 Nursing Home Property, Plant, & Equipment               818
   Less: Accumulated Depreciation (key as negative)      819    (                               )   (                )
   Less: Other (key as negative)                         821    (                               )   (                )
 Other Assets                                            822
                     Total Assets                        839                             -                       -


Liabilities
 Accounts Payable                                        841
 Nonrelated Party Working Capital Loans                  842
 Related Party Working Capital Loans                     843
 Property Financing Patient Related                      844
 Property Financing not Related to Patient Care          845
Owner's Equity or Fund Balance
 Owner's Capital - Individual Proprietor                 851
 Partner's Capital Account - Partnership                 852
 Fund Balance - Not for Profit Entity                    853
 Capital Stock - Preferred Stock                         854
 Capital Stock - Common Stock                            855
 Additional Paid in Capital                              856
 Retained Earnings                                       857
     Less: Cost of Treasury Stock                        858
TOTAL LIABILITIES AND OWNER'S EQUITY                     869                             -                       -


* Attach explanation



  REV 03/07                                               Page 11 of 14
    Financial Report for Nursing Homes                                       Provider Name _________________________________________

                                                           Schedule K
                    ANALYSIS OF RELATED PARTIES (5% or More Ownership Interest)
Also, please include related party information for vendors, employees, or other related party services regardless of percentage of
ownership interest. Home office related party services should be excluded as they are reported on Schedule M.

                                     Position,    %                              Sch E                            Sch E   Related
                Name (01)            Job Title, Owner-      Amount of           Line on   Hours                  Line on   Party
Line
                 City (02)              or      ship in       Comp-              which   Worked Amount of         which    Profit
No.
                State (03)            Service Facility       ensation          Reported in Facility Vendor Pmts Reported Removed?
                                       (04)      (06)          (07)               (08)     (09)         (10)      (011)     (12)
                                                                                                                            Yes      No
871



                                                                                                                            Yes      No
872



                                                                                                                            Yes      No
873



                                                                                                                            Yes      No
874



                                                                                                                            Yes      No
875



                                                                                                                            Yes      No
876



                                                                                                                            Yes      No
877



                                                                                                                            Yes      No
878



                                                                                                                            Yes      No
879



                                                                                                                            Yes      No
881



898             TOTALS                                     $             -                       $           -


    REV 03/07                                                  Page 12 of 14
     Financial Report for Nursing Homes                                                      Provider Name _________________________________

                                                                       Schedule L
                                     ANALYSIS OF MANAGEMENT FEES (Unrelated Parties)

Attach a list of all individuals reimbursed through this contract who provide services above the department head level along with a signed copy of the
management agreement. List below the services rendered and indicate the percent of revenue from each service.

     Line                  Type of Service Rendered                       Percent of Management Fee Revenue                                Amount
     No.                                (01)                                                 (02)                                            (03)
     911
     912
     913
     914
     915
     916
     917
     918
     919
     929           Total (should agree with 545+574)
                                                                                                                                                                 -

Are any services listed above duplicated by facility personnel reimbursed outside of this contract?                           Yes                   No
If yes, attach a full explanation.

                                                                      Schedule M
                                                  ANALYSIS OF HOME OFFICE EXPENSE

                                                                             Note: Do Not Complete if You are Submitting a Home Office Cost Report
Home Office Name
Address
City, State, Zip

                                                                                                    Line          Adjustments                       Total
                                                                                                    No.                (01)                         (02)
Total home office expense per statement of expenses attached.                                       931
Adjustments to Remove Non-Allowable Home Office Costs
(key as negative or positive, whichever applies):
  Services the DHSS pays for separately or by other programs.                                       932
  Travel not related to patient care.                                                               933
  Capital cost due solely to a change of ownership after 07/14/84                                   934
  Advertising not related to patient care                                                           935
  Federal income taxes                                                                              936
  Expenses allocated to facilities outside Wyoming                                                  937
  Legal fees associated with litigation                                                             938
  Expenses allocated to Wyoming facilities not certified by Medicaid                                939
  Other costs not related to patient care                                                           940
  Other -                                                                                           941
  Other -                                                                                           942
  Other -                                                                                           943
  Total Allowable Home Office Expenses to be Allocated                                              949                             -                            -
Method of Allocation: Explain the method used to allocate home office expenses to the individual facilities, i.e., beds available, bed days available, patient
days, etc. Explanation should include allocation between Wyoming and non-Wyoming facilities and allocations among Wyoming facilities.




     REV 03/07                                                            Page 13 of 14
Financial Report for Nursing Homes                                      Provider Name _________________________________


                                            Schedule M (cont)
                       HOME OFFICE ALLOWABLE EXPENSE ALLOCATION

                                                                                                        Reported on
  Provider                           Facility Name or                             Allocation            Schedule E
  Number                                Location                                  Percentage                Total




                 Total (Should agree with Line 949, Total Home Office Expense)                                        -



REV 03/07                                               Page 14 of 14

				
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