FLORENCE HOME
OMAHA, NE  68112

Medicare Provider Number: 285173
Cost report status: Settled Without Audit
[Record Code 1334074 - 2010]

You are not logged in or you have not purchased this report. This report has had its actual values replaced with dummy text ('###').

If you would like to become a subscriber, please look at our subscription details.

If you are already a subscriber, please login.

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