SNFData - 146015 - 06/2013

HEARTHSTONE MANOR
WOODSTOCK, IL 60098

Medicare Provider Number: 146015

Cost report status: Settled Without Audit

[Record Code 1055078 - 2010]

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STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES		Provider CCN: 146015	PERIOD: FROM 07/01/2012 TO 06/30/2013	WORKSHEET G - 2 PARTS I & II
PART I - PATIENT REVENUES
Revenue Center		INPATIENT	OUTPATIENT	TOTAL
Revenue Center		1	2	3
General Inpatient Routine Care Services
1	Skilled nursing facility	###		###	1
2	Nursing facility	###		###	2
3	ICF/IID				3
4	Other long term care				4
5	Total general inpatient care services	###		###	5
	(sum of lines 1 - 4)
All Other Care Service
6	Ancillary services	###		###	6
7	Clinic				7
8	Home health agency				8
9	Ambulance				9
10	RHC/FQHC				10
11	CMHC				11
12	Hospice				12
13	Other (specify)	###		###	13
14	Total patient revenues (sum of lines 5 - 13) (transfer to Wkst. G-3, col. 3, line 1 )	###		###	14

PART II - OPERATING EXPENSES
1	Operating Expenses (per Wkst. A, col. 3, line 100)			###	1
2	Add ( Specify )				2
3					3
4					4
5					5
6					6
7					7
8	Total Additions (sum of lines 2 - 7)				8
9	Deduct (Specify)				9
10					10
11					11
12					12
13					13
14	Total Deductions (sum of lines 9 - 13)				14
15	Total Operating Expenses (sum of lines 1 and 8, minus line 14)			###	15
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4140)
08-16				Rev. 7

Worksheet G-2