Worksheet G-3
- Return to Cost Report Summary
- Form G300
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1
ASBURY SOLOMONS ISLAND HCC
SOLOMONS, MD 20866
SOLOMONS, MD 20866
Medicare Provider Number: 215304
Cost report status: Settled Without Audit
[Record Code 1240957 - 2010]
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STATEMENT OF REVENUES AND EXPENSES | Provider CCN: 215304 | PERIOD: FROM 01/01/2018 TO 12/31/2018 |
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 __NUTRITIONAL SUPPLEMENTS____) | ### | 24 | |||
24.01 | HOME CARE | 24.01 | ||||
24.03 | MAINTENANCE CHARGES | ### | 24.03 | |||
24.04 | BEAUTY SHOP | ### | 24.04 | |||
24.06 | TRANSPORTATION REVENUE | ### | 24.06 | |||
24.07 | MEAL CHARGE | ### | 24.07 | |||
24.08 | OTHER RESIDENT CHARGES | ### | 24.08 | |||
24.09 | AR CREDIT ADJUSTMENT | ### | 24.09 | |||
24.14 | WELLNESS CENTER MEMBERSHIP FEE | ### | 24.14 | |||
24.16 | BAR INCOME | ### | 24.16 | |||
24.17 | LEASE SPACE INCOME | ### | 24.17 | |||
24.18 | HOUSEKEEPING FEE | ### | 24.18 | |||
24.19 | RENOVATION & UPGRADE FEE | ### | 24.19 | |||
24.20 | OTHER REVENUE | ### | 24.20 | |||
24.21 | ENTRANCE FEE AMORTIZATION | ### | 24.21 | |||
24.22 | TERMINAL INCOME | ### | 24.22 | |||
24.24 | FOUNDATION ALLOCATION | ### | 24.24 | |||
24.25 | RESIDENT PROGRAM ACTIVITY FEE | ### | 24.25 | |||
24.26 | GAIN ON DISPOSITION OF ASSETS | ### | 24.26 | |||
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 DEBT DEFEASANCE__) | ### | 27 | |||
28 | 28 | |||||
29 | 29 | |||||
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 |