Worksheet G-3
- Return to Cost Report Summary
- Form G300
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
FLORENCE HOME
OMAHA, NE 68112
OMAHA, NE 68112
Medicare Provider Number: 285173
Cost report status: Settled Without Audit
[Record Code 1334074 - 2010]
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| STATEMENT OF REVENUES AND EXPENSES | Provider CCN: 285173 | PERIOD: FROM 01/01/2021 TO 12/31/2021 |
WORKSHEET G-3 | |||
| 1 | Total patient revenues (from Wkst. G-2, Pt. I, col. 3, line 14) | ### | 1 | |||
| 2 | Less: contractual allowances and discounts on patients accounts | ### | 2 | |||
| 3 | Net patient revenues (line 1 minus line 2) | ### | 3 | |||
| 4 | Less: total operating expenses (form Wkst. G-2, Pt. II, line 15) | ### | 4 | |||
| 5 | Net income from service to patients (line 3 minus 4) | ### | 5 | |||
| Other income: | ||||||
| 6 | Contributions, donations, bequests, etc. | ### | 6 | |||
| 7 | Income from investments | 7 | ||||
| 8 | Revenues from communications (telephone and internet service) | 8 | ||||
| 9 | Revenue from television and radio service | 9 | ||||
| 10 | Purchase discounts | 10 | ||||
| 11 | Rebates and refunds of expenses | 11 | ||||
| 12 | Parking lot receipts | 12 | ||||
| 13 | Revenue from laundry and linen service | 13 | ||||
| 14 | Revenue from meals sold to employees and guests | ### | 14 | |||
| 15 | Revenue from rental of living quarters | 15 | ||||
| 16 | Revenue from sale of medical and surgical supplies to other than patients | 16 | ||||
| 17 | Revenue from sale of drugs to other than patients | 17 | ||||
| 18 | Revenue from sale of medical records and abstracts | 18 | ||||
| 19 | Tuition (fees, sale of textbooks, uniforms, etc.) | 19 | ||||
| 20 | Revenue from gifts, flower, coffee shops, canteen | 20 | ||||
| 21 | Rental of vending machines | 21 | ||||
| 22 | Rental of skilled nursing space | ### | 22 | |||
| 23 | Governmental appropriations | 23 | ||||
| 24 | Other miscellaneous revenue (specify __ASSISTED LIVING OTHER INCOME____) | ### | 24 | |||
| 24.01 | MISC INCOME | ### | 24.01 | |||
| 24.02 | CRISS TRUST INCOME | ### | 24.02 | |||
| 24.03 | TRANSFER FROM AFFILIATE | ### | 24.03 | |||
| 24.04 | INSURANCE SETTLEMENTS | 24.04 | ||||
| 24.05 | GRANT INCOME | ### | 24.05 | |||
| 24.06 | GAIN ON DISPOSAL/SALE OF ASSET | ### | 24.06 | |||
| 24.50 | COVID-19 PHE Funding | ### | 24.50 | |||
| 25 | Total other income (sum of lines 6 - 24) | ### | 25 | |||
| 26 | Total (line 5 plus line 25) | ### | 26 | |||
| 27 | Other expenses (specify ___LOSS ON DISPOSAL/SALE OF ASSET__) | 27 | ||||
| 28 | LOSS ON EARLY EXTINGUISHMENT OF DEBT | 28 | ||||
| 29 | TRANSFER TO AFFILIATE | 29 | ||||
| 29.01 | CLINIC SPACE RENTAL NET | ### | 29.01 | |||
| 30 | Total other expenses (sum of lines 27 - 29) | 30 | ||||
| 31 | Net income (or loss) for the period (line 26 minus line 30) | ### | 31 | |||
| FORM CMS-2540-10 (06/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140) | ||||||
| 06-21 | Rev. 10 | |||||