Worksheet G

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HAWTHORN GLEN NURSING CENTER
MIDDLETOWN, OH  45044

Medicare Provider Number: 365813
Cost report status: Settled Without Audit
[Record Code 432414 - 1996]
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Balance Sheet
(If you are nonproprietary and do not maintain fund-type
accounting records, complete the "General Fund" column only)
PROVIDER NO:
365813
PERIOD:
FROM 01/01/2010
TO 12/31/2010
WORKSHEET G
Assets
(Omit cents)
General
Fund
Specific
Purpose
Fund
Endowment
Fund
Plant
Fund
  
1 2 3 4
CURRENT ASSETS
1 Cash on hand and in banks ### 1
2 Temporary investments 2
3 Notes receivable 3
4 Accounts receivable ### 4
5 Other receivables 5
6 Less: allowances for uncollectible notes and accounts receivable ( ### ) (  ) (  ) (  ) 6
7 Inventory ### 7
8 Prepaid expenses ### 8
9 Other current assets 9
10 Due from other funds 10
11 TOTAL CURRENT ASSETS (Sum of lines 1 - 10) ### 11
FIXED ASSETS
12 Land ### 12
13 Land improvements ### 13
14 Less: Accumulated depreciation ( ### ) (  ) (  ) (  ) 14
15 Buildings ### 15
16 Less Accumulated depreciation ( ### ) (  ) (  ) (  ) 16
17 Leasehold improvements 17
18 Less: Accumulated Amortization (  ) (  ) (  ) (  ) 18
19 Fixed equipment ### 19
20 Less: Accumulated depreciation ( ### ) (  ) (  ) (  ) 20
21 Automobiles and trucks ### 21
22 Less: Accumulated depreciation ( ### ) (  ) (  ) (  ) 22
23 Major movable equipment 23
24 Less: Accumulated depreciation (  ) (  ) (  ) (  ) 24
25 Minor equipment nondepreciable 25
26 Other fixed assets ### 26
27 TOTAL FIXED ASSETS (Sum of lines 12 - 26) ### 27
OTHER ASSETS
28 Investments 28
29 Deposits on leases ### 29
30 Due from owners/officers ### 30
31 Other assets 31
32 TOTAL OTHER ASSETS (Sum of lines 28 - 31) ### 32
33 TOTAL ASSETS (Sum of lines 11, 27 and 32) ### 33
Liabilities and Fund Balances (Omit cents)  
  CURRENT LIABILITIES
34 Accounts payable ### 34
35 Salaries, wages & fees payable ### 35
36 Payroll taxes payable ### 36
37 Notes & loans payable (Short term) ### 37
38 Deferred income 38
39 Accelerated payments       39
40 Due to other funds ### 40
41 Other current liabilities ### 41
  TOTAL CURRENT LIABILITIES  
42 (Sum of lines 34 - 41) ### 42
  LONG TERM LIABILITIES  
43 Mortgage payable ### 43
44 Notes payable 44
45 Unsecured loans 45
46.01 Loans from owners: a. Prior to 7/1/66 46.01
46.02 b. On or after 7/1/66 46.02
47 Other long term liabilities 47
48           48
49 TOTAL LONG TERM LIABILITIES (Sum of lines 43 - 48) ### 49
50 TOTAL LIABILITIES (Sum of lines 42 and 49) ### 50
CAPITAL ACCOUNTS  
51 General fund balance ###       51
52 Specific purpose fund       52
53 Donor created - endowment fund balance - restricted       53
54 Donor created - endowment fund balance - unrestricted       54
55 Governing body created - endowment fund balance expansion       55
56 Plant fund balance - invested in plant       56
57 Plant fund balance - reserve for plant improvement, replacement and expansion       57
58 TOTAL FUND BALANCES (Sum of lines 51 thru 57) ### 58
59 TOTAL LIABILITIES AND FUND BALANCES (Sum of lines 50 and 58) ### 59
60   60
  ( ) = contra amount