SNFData - 675593 - 12/2011

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Form G000
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3536, REV 1

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WISTERIA PLACE SNF
ABILENE, TX 79605

Medicare Provider Number: 675593

Cost report status: As Submitted

[Record Code 1011492 - 2010]

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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 CCN: 675593	PERIOD: FROM 01/01/2011 TO 12/31/2011	WORKSHEET G
Assets		General Fund	Specific Purpose Fund	Endowment Fund	Plant Fund
Assets		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 - Depreciable					25
26	Minor equipment nondepreciable					26
27	Other fixed assets					27
28	TOTAL FIXED ASSETS (sum of lines 12 - 27)					28
OTHER ASSETS
29	Investments	###				29
30	Deposits on leases					30
31	Due from owners/officers					31
32	Other assets	###				32
33	TOTAL OTHER ASSETS (sum of lines 29 - 32)	###				33
34	TOTAL ASSETS (sum of lines 11, 28 and 33)	###				34
Liabilities and Fund Balances		General Fund	Specific Purpose Fund	Endowment Fund	Plant Fund
Liabilities and Fund Balances		1	2	3	4
CURRENT LIABILITIES
35	Accounts payable	###				35
36	Salaries, wages & fees payable	###				36
37	Payroll taxes payable	###				37
38	Notes & loans payable (short term)					38
39	Deferred income					39
40	Accelerated payments					40
41	Due to other funds					41
42	Other current liabilities	###				42
43	TOTAL CURRENT LIABILITIES (sum of lines 35 - 42)	###				43
LONG TERM LIABILITIES
44	Mortgage payable					44
45	Notes payable					45
46	Unsecured loans					46
47	Loans from owners:					47
48	Other long term liabilities	###				48
49	Other (specify)					49
50	TOTAL LONG TERM LIABILITIES (sum of lines 44 - 49)	###				50
51	TOTAL LIABILITIES (sum of lines 43 and 50)	###				51
CAPITAL ACCOUNTS
52	General fund balance					52
53	Specific purpose fund					53
54	Donor created - endowment fund balance - restricted					54
55	Donor created - endowment fund balance - unrestricted					55
56	Governing body created - endowment fund balance					56
57	Plant fund balance - invested in plant					57
58	Plant fund balance - reserve for plant improvement, replacement and expansion					58
59	TOTAL FUND BALANCES (sum of lines 52 thru 58)					59
60	TOTAL LIABILITIES AND FUND BALANCES (sum of lines 51 and 59)	###				60
( ) = contra amount
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)
05-11					Rev. 1

Worksheet G