Worksheet S-2

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HERITAGE INN HEALTH AND REHABILITATI
STATESBORO, GA  30458

Medicare Provider Number: 115597
Cost report status: Settled Without Audit
[Record Code 422006 - 1996]
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Skilled Nursing Facility and Skilled Nursing Facility Complex Identification Data
PROVIDER NO:
115597
PERIOD:
FROM 07/01/2009
TO 06/30/2010
 WORKSHEET S-2
Skilled Nursing Facility and Skilled Nursing Facility Complex Address:
1 Street: ### P.O. Box:       1
2 City: ### State: ### Zip Code: ###   2
3 County: ### MSA Code: CBSA Code: ### Urban/Rural: ### 3
3.1 Facility Specific Rate: Transition Period - enter 1, 2, 3 or 100 ###   3.1
3.2 Wage Index Adjustment Factor: Before October 1 = ###   After Sept 30 = ###   3.2
SNF and SNF-Based Component Identification:
  Component
Component Name
 Provider No. NPI Number
Date
Certified
Payment System
(P, O, or N)
  
V XVIII XIX
0 1 2 2.01 3 4 5 6
4 S N F ### ### ### ### 4
5   5
6 Nursing Facility   6
6.01 I C F / M R       6.01
7 SNF-Based O.L.T.C.     7
8 SNF-Based H.H.A.     8
9   9
10 SNF-Based Outpatient Rehabilitation Providers   10
11 SNF-Based R.H.C.     11
12 SNF-Based HOSPICE     12
13 Cost Reporting Period (mm/dd/yyyy) From: 07/01/2009 To: 06/30/2010     13
14 Type of Control (See Instructions) ###     14
Type of Freestanding Skilled Nursing Facility Y / N  
15 Is this an Entirely Participating Skilled Nursing Facility? ### 15
  A notice published in the "Federal Register" Vol. 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003. Congress expected this increase to be used for direct patient care and related expenses. Enter in column 1 the percentage of total expenses for each category to total SNF revenue from Worksheet G-2, Part I line 1 column 3. Indicate in column 2 "Y" for yes or "N" for no if the spending reflects increases associated with direct patient care and related expenses for each category. (See instructions)  
15.01 Staffing ### ###   15.01
15.02 Recruitment   15.02
15.03 Retention of employees   15.03
15.04 Training   15.04
15.05 Other (Specify)   15.05
16 Is this a Partially Participating Skilled Nursing Facility? ### 16
17 Is this Skilled Nursing Facility Unit of a Domiciliary Institution? ### 17
18 Is this Skilled Nursing Facility Unit of a Rehabilitation Center? ### 18
19 Other ( Specify)   19
Miscellaneous Cost Reporting information
20 If this is a low or no Medicare utilization cost report, enter "L" for Low Medicare Utilization, or "N" for No Medicare Utilization.   20
21 If this is an All-Inclusive Provider, enter the method used. (See Instruction)   21
22 Is the difference between total interim payments and the net cost covered service included in the balance sheet? ###   22
Depreciation Enter the amount of depreciation reported in this SNF for the method indicated.
23 Straight Line   ### 23
24 Declining Balance   24
25 Sum of the Year's Digits   25
26 Sum of line 23 thru 25   ### 26
27 If depreciation is funded, enter the balance as of the end of the period.   27
28 Were there any disposal of capital assets during the cost reporting period? (Y/N)   ### 28
29 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period? (Y/N)   ### 29
30 Was accelerated depreciation claimed on assets acquire on or after August 1, 1970 (1) (Y/N)   ### 30
31 Did you cease to participate in the Medicare program at end of the period to which this cost report applies (1)   ### 31
32 Was there a substantial decrease in health insurance proportion of allowable cost from prior cost reports (1)   ### 32
  If this facility contains a public or non-public provider that qualifies for an exemption from the application of the lower of costs or charges enter "Y" for each component and type of service that qualifies for the exemption. Part A Part B Other  
33 Skilled Nursing Facility ### ###   33
34   34
35 Nursing Facility     35
35.10 I C F / M R     35.10
36 SNF-Based O.L.T.C.   36
37 SNF-Based H.H.A.   37
38   38
39 SNF-Based Outpatient Rehabilitation Providers     39
40 SNF-Based R.H.C.     40
41 Is this Skilled Nursing Facility exempt from the cost limits?     41
42 Is this Nursing Facility exempt from the cost limits?     ### 42
43 Is the skilled nursing facility located in a state that certifies the provider as a SNF regardless of the level of care given for titles V and XIX patients.     ### 43
44 Did the provider participate in the NHCMQ Demonstration during the cost reporting period? (See instructions) If yes, enter Phase # 44
45 List malpractice premiums and paid losses: Premiums Paid Losses Self insurance 45
     
46 Are malpractice premiums and paid losses reported in other than the Administrative and General cost center? Enter Y or N. If yes, check box, and submit supporting schedule listing cost centers and amounts   ### 46
47 Are you claiming ambulance costs? Enter Y or N in column 1. If column 1 is Y, enter in column 2 whether this is your first year of operation for rendering ambulance services.   ### 47
48 If line 47, column 1 is yes, enter in column 1 the payment limit provided from your intermediary. If your fiscal year is OTHER than a year beginning on October 1st, enter in column 1 the payment limit for the period prior to October 1, and enter in column 2 the payment limit for the period beginning October 1. NOTE: If line 47, column 2 is yes, no entry is required on line 48 (column 1 or 2).   48
49 Did you operate an Intermediate Care Facility for the Mentally Retarded (ICF/MR) under title XIX?     ### 49
50 Did this facility report less than 1500 Medicare days in its previous year's cost report? (See instructions.)   50
51 If line 50 is yes, did you file your previous years cost report using the "Simplified" step-down method of cost finding? See instructions for qualifications to use the simplified step-down method before answering line 52. 51
52 Is this cost report being filed under 42 CFR 413.321, the "simplified" cost report? Enter "Y" for yes or "N" for no. ### 52
53 Are there any related organizations or home office costs as defined in CMS Pub. 15-1, chapter 10? If yes, and there are costs, for either, enter the applicable provider number Y/N Provider # 53
   
54 Name: FI/Contractor name FI/Contractor Number 54
55 Street: PO Box 55
56 City: State Zip 56
57 Was the cost report filed using the PS&R (either in its entirety or for total charges and days only)? Enter "Y" for yes or "N" for no. 57
58 If line 57 is "Y", enter the "paid through" date of the PS&R (mm/dd/yyyy) 58