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["MISSOURI DEPARTMENT OF SOCIAL SERVICES"]
["MO HEALTHNET DIVISION"]
[]
["FINANCIAL AND STATISTICAL REPORT FOR NURSING FACILITIES"]
["(Title XIX Cost Report)"]
[]
[]
["1.","PROVIDER:",null,null,null,null,null,null,null,"      2. PROVIDER NUMBER:"]
[]
["3.","ADDRESS:"]
[]
["4.","PERIOD OF REPORT:  FROM",null,null,null,null,null,null,null,"TO"]
[]
["5.","FISCAL YEAR ENDS:"]
[]
["6.","TYPE OF CONTROL (SELECT ONE):"]
[null,"             "]
[null,null,"GOVERNMENT",null,null,null,"NONPROFIT ORGANIZATION",null,null,null,null,"PROPRIETARY"]
[]
[null,null,"GS","STATE",null,null,"NCO","CHURCH OPERATED",null,null,null,"PPP","PROPRIETORSHIP"]
[]
[null,null,"GC","COUNTY",null,null,"NCR","CHURCH RELATED",null,null,null,"PPT","PARTNERSHIP"]
[]
[null,null,"GD","DISTRICT",null,null,"NO","OTHER NON-PROFIT",null,null,null,"PC","CORPORATION"]
[]
[null,null,"GM","CITY",null,null,null,null,null,null,null,"PO","OTHER"]
[]
[null,null,"GO","OTHER",null,null,null,null,null,null,null,"LLC","LIMITED LIABILITY CORPORATION"]
[]
["7.","ACCOUNTING BASIS:"]
[]
["8.","STATISTICAL DATA:",null,null,null,null,"(1)",null,"(2)","(3)","(4)","(5)","(6)",null,"(7)","(8)"]
[]
[null,null,null,null,null,null,null,null,null,null,"MENTAL",null,"MEDI-"]
[null,null,null,null,null,null,"MEDICAID",null,"ICF-MR","HOSPICE","HEALTH","V.A.","CARE",null,"PRIVATE","TOTAL"]
[]
[null," 1. Number of beds licensed, beginning of period",null,null,null,null," "]
[null," 2. Number of beds licensed, end of period",null,null,null,null," "]
[null," 3. Number of beds certified, beginning of period",null,null,null,null," "]
[null," 4. Number of beds certified, end of period",null,null,null,null," "]
[null," 5. Total bed days for reporting period"]
[null," 6. Total patient days for reporting period",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(G42:O42)","v":0}]
[null," 7. Percent occupancy (line 6 divided by line 5)",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IFERROR(+P42/P41,0)","v":0}]
[null," 8. Room reservation days",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(P45:P48)","v":0}]
[null,"       1.  Allowable therapeutic home visit days",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(G45:O45)","v":0}]
[null,"       2.  Other home visit days",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(G46:O46)","v":0}]
[null,"       3.  Hospital leave days",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(G47:O47)","v":0}]
[null,"       4.  Other days",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(G48:O48)","v":0}]
[]
[null," 9. Medicaid share of patient days: Line 6, Column (1) divided by Column (8)",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IFERROR(+G42/P42,0)","v":0}]
[]
[null,"10. Are the Allowable therapeutic home visit days included in the total patient days?"]
[]
["9.","CERTIFICATION STATEMENT:"]
[]
[null," MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE"]
[null," PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER STATE AND FEDERAL LAW."]
[]
[]
[null,"CERTIFICATION OF OFFICER OR ADMINISTRATOR OF PROVIDER"]
[]
[null," I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying cost report and "]
[null,"supporting schedules prepared by ______________________________________________________  (provider name)"]
[null,"for the cost report period beginning ______________________ 20____ and ending ______________________ 20 ____, and "]
[null,"that to  the best of my knowledge and belief, it is a true, correct, and complete statement prepared from the books and records"]
[null,"of the provider in accordance with applicable instructions, except as noted."]
[]
[]
[]
[null,"NOTARY PUBLIC",null,null,null,null,null,null,null,"AUTHORIZED SIGNATURE"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,"TITLE"]
[]
[]
[null,"My Commission Expires"]
[null,null,null,null,null,null,null,null,null,"DATE"]
[]
[]
[]
[]
[null,null,null," MO 886-554 (3-95)",null,null,null,null,null,null,null,null,null,null,"MSIR-1"]

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[]
[]
["1.","TYPE OF LICENSE:"]
[null,null,null,null,null,null,"Does the Facility Possess This Type of License",null,"NUMBER OF BEDS"]
[null,null,"SKILLED NURSING FACILITY"]
[null,null,"INTERMEDIATE CARE FACILITY"]
[null,null,"ASSISTED LIVING FACILITY"]
[null,null,"RESIDENTIAL CARE FACILITY (RCF I AND/OR RCF II)"]
[]
[]
["2.","DATE OF TITLE XIX CERTIFICATION "]
[]
["3.","Are you Medicare certified?",null,null,null,null,null,null,null,null,"3."]
["","  If Yes, Date of Certification"]
[null,"  Also submit a copy of Medicare cost report.  "]
[]
["4.","Were purchases of services, facilities, or supplies made from a related party during the reporting period?",null,null,null,null,null,null,null,null,"4."]
["","  If Yes, complete Schedule G."]
[]
["5.","Did an individual or an organization which had or has a direct or indirect ownership interest in this Missouri",null,null,null,null,null,null,null,null,"5."]
[null,"Medicaid Nursing Facility entity have a direct or indirect ownership interest in another Medicaid Nursing"]
[null,"Facility entity during the reporting period?"]
[null,"  If Yes, complete Schedule G."]
[]
["6.","Is the administrator an owner, partner, or stockholder, or is the administrator related by consanguinity or ",null,null,null,null,null,null,null,null,"6."]
[null,"affinity to an owner, partner, or stockholder in this facility?"]
[]
["7.","Is the assistant administrator an owner, partner, or stockholder, or is the assistant administrator related by ",null,null,null,null,null,null,null,null,"7."]
[null,"consanguinity or affinity to an owner, partner, or stockholder in this facility?"]
[]
["8.","Is this provider part of a parent or controlling entity?",null,null,null,null,null,null,null,null,"8."]
[null,"  If Yes, complete section below."]
[]
[null,"Name of parent or controlling entity",null,null,null,null,null,null,"       Telephone"]
[]
[]
[null," Address (street, city, state, zip code)"]
[]
[]
["9.","Were any expenses of a home office reported in this cost report?",null,null,null,null,null,null,null,null,"9."]
[null,"  If Yes, complete section below and Worksheet 3 of this cost report or submit Medicare Home Office cost report."]
[]
[null,"Name of home office entity",null,null,null,null,null,null,"       Telephone"," "]
[]
[]
[null," Address (street, city, state, zip code)"]
[]
[]
["10.","Does an outside management firm manage this facility under a contract with the provider?",null,null,null,null,null,null,null,null,"10."]
[null,"  If Yes, attach a signed copy of the management agreement, if not previously submitted in a cost report filing."]
[]
["11.","Is this facility leased?",null,null,null,null,null,null,null,null,"11."]
[null,"  If Yes, attach a signed copy of the lease agreement, if not previously submitted in a cost report filing."]
[null,"  If the lease agreement is between related parties, complete Worksheet 2 of the cost report."]
[]
["12.","Did the provider incur costs for an audit of its financial statements?",null,null,null,null,null,null,null,null,"12."]
[null,"  If Yes, a copy of the audit report is required to be submitted with this cost report filing."]
[null,"  Also, an audit is required for the first two full fiscal year end filing cost reports."]
[]
["13.","Please give the name, title, address and telephone number of the person to contact in your organization if "]
[null,"there are any questions about this report:"]
[]
[null,"Name of Contact Person",null,null,null,"Title",null,null,"       Telephone"," "]
[]
[]
[null,"Name of Business",null,null,null,null,null,null,"Fax Number"]
[]
[]
[null,"Mailing Address",null,null,null,null,null,null,"E-Mail Address for Facility"]
[]
[]
["14.","Please give the name, title, address and telephone number of the person preparing this report."]
[]
[null,"Name of Contact Preparer",null,null,null,"Title",null,null,"       Telephone"]
[]
[]
[null,"Name of Business"]
[]
[]
[null,"Mailing Address"]

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[null,"PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT: FROM",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[null,"SCHEDULE A"]
[]
[null,null,null,null,null,"(1)","(2)","(3)","(4)","(5)"]
[null,null,null,null,null,null,null,"REVENUE","PATIENT","OFFSET TO"]
[null,"REVENUES",null,null,null,"GENERAL","WORKSHEET 1","OFFSETS/","RELATED","LINE # ON"]
[null,null,null,null,null,"LEDGER","ADJUSTMENTS","NON-ALLOWABLE","REVENUE","SCHEDULE B"]
[null,"ROUTINE SERVICES"]
[null,10," Room and Board",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I14-'WS 1 Rev (NC)'!I14","v":0},null,{"$f":"ROUND(+F12+G12+H12,0)","v":0}]
[]
[null,"ANCILLARY SERVICES"]
[null,11," Physician Services",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I16-'WS 1 Rev (NC)'!I16","v":0},null,{"$f":"ROUND(+F15+G15+H15,0)","v":0}]
[null,12," Physical Therapy",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I17-'WS 1 Rev (NC)'!I17","v":0},null,0]
[null,13," Occupational Therapy",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I18-'WS 1 Rev (NC)'!I18","v":0},null,0]
[null,14," Pharmacy",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I19-'WS 1 Rev (NC)'!I19","v":0},null,0]
[null,15," Medicial Supplies",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I20-'WS 1 Rev (NC)'!I20","v":0},null,0]
[null,16," Speech and Hearing",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I21-'WS 1 Rev (NC)'!I21","v":0},null,0]
[null,17," Laboratory and X-Ray",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I22-'WS 1 Rev (NC)'!I22","v":0},null,0]
[null,18," Inhalation Therapy",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I23-'WS 1 Rev (NC)'!I23","v":0},null,0]
[null,19," Equipment Rental",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I24-'WS 1 Rev (NC)'!I24","v":0},null,0]
[null,20," Nutritional Therapy/PEN ",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I25-'WS 1 Rev (NC)'!I25","v":0},null,0]
[null,21," Other - Schedule A-1 ",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I26-'WS 1 Rev (NC)'!I26","v":0},null,0]
[null,22," SUBTOTAL - ANCILLARY SERVICES",null,null,{"$f":"ROUND(SUM(F15:F25),0)","v":0},{"$f":"ROUND(SUM(G15:G25),0)","v":0},{"$f":"ROUND(SUM(H15:H25),0)","v":0},0]
[]
[null,"OTHER REVENUE"]
[null,23," Meals Sold",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I30-'WS 1 Rev (NC)'!I30","v":0},null,{"$f":"ROUND(+F29+G29+H29,0)","v":0}]
[null,24," Telephone ",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I31-'WS 1 Rev (NC)'!I31","v":0},null,0]
[null,25," Purchase Discount",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I32-'WS 1 Rev (NC)'!I32","v":0},null,0]
[null,26," Room Reservation",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I33-'WS 1 Rev (NC)'!I33","v":0},null,0]
[null,27," Barber and Beauty Shop",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I34-'WS 1 Rev (NC)'!I34","v":0},null,0]
[null,28," Personal Services",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I35-'WS 1 Rev (NC)'!I35","v":0},null,0]
[null,29," Activity Income",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I36-'WS 1 Rev (NC)'!I36","v":0},null,0]
[null,30," Donated Services",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I37-'WS 1 Rev (NC)'!I37","v":0},null,0]
[null,31," Donated Commodities",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I38-'WS 1 Rev (NC)'!I38","v":0},null,0]
[null,"32a","Gifts - Restricted",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I39-'WS 1 Rev (NC)'!I39","v":0},null,0]
[null,"32b","Gifts - Unrestricted",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I40-'WS 1 Rev (NC)'!I40","v":0},null,0]
[null,33," Rental Income",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I41-'WS 1 Rev (NC)'!I41","v":0},null,0]
[null,34," Interest Income ",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I42-'WS 1 Rev (NC)'!I42","v":0},null,0]
[null,35," Tax Revenues",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I43-'WS 1 Rev (NC)'!I43","v":0},null,0]
[null,36," Personal Laundry",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I44-'WS 1 Rev (NC)'!I44","v":0},null,0]
[null,37," Other - Schedule A-1",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I45-'WS 1 Rev (NC)'!I45","v":0},null,0]
[null,38," SUBTOTAL - OTHER REVENUES",null,null,{"$f":"ROUND(SUM(F29:F44),0)","v":0},{"$f":"ROUND(SUM(G29:G44),0)","v":0},{"$f":"ROUND(SUM(H29:H44),0)","v":0},0]
[null,39," GROSS REVENUES",null,null,{"$f":"+F45+F26+F12","v":0},{"$f":"+G45+G26+G12","v":0},{"$f":"+H45+H26+H12","v":0},0]
[]
[null,"DEDUCTIONS FROM REVENUES"]
[null,40," Charity Services",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I50-'WS 1 Rev (NC)'!I50","v":0},null,{"$f":"ROUND(+F49+G49+H49,0)","v":0}]
[null,41," Contractual Allowance",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I51-'WS 1 Rev (NC)'!I51","v":0},null,{"$f":"ROUND(+F50+G50+H50,0)","v":0}]
[null,42," Provision for Bad Debts",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I52-'WS 1 Rev (NC)'!I52","v":0},null,{"$f":"ROUND(+F51+G51+H51,0)","v":0}]
[null,43," Other - Schedule A-1",null,null,null,{"$f":"-'WS 1 Rev (NR)'!I53-'WS 1 Rev (NC)'!I53","v":0},null,{"$f":"ROUND(+F52+G52+H52,0)","v":0}]
[null,44," TOTAL DEDUCTIONS",null,null,{"$f":"ROUND(SUM(F49:F52),0)","v":0},{"$f":"ROUND(SUM(G49:G52),0)","v":0},{"$f":"ROUND(SUM(H49:H52),0)","v":0},{"$f":"ROUND(+F53+G53+H53,0)","v":0}]
[null,null," "]
[null,45," NET REVENUES",null,null,{"$f":"+F46-F53","v":0},{"$f":"+G46-G53","v":0},{"$f":"+H46-H53","v":0},{"$f":"ROUND(+F55+G55+H55,0)","v":0}]
[]
[null," "," "," ",null," "]

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[null,"PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT:  FROM",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE B"]
[]
[null,null,null,null,null,null,"ADJUSTMENTS"]
[null,null,null,null,null,"GENERAL",null,"REVENUE","PATIENT"]
[null,"EXPENDITURES",null,null,null,"LEDGER","WORKSHEET 1","OFFSETS/","RELATED"]
[null,null,null,null,null,null,"ADJUSTMENTS","NON-ALLOWABLE","EXPENSES"]
[null,"PATIENT CARE"]
[null,46," Professional Services",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H12-'WS 1 Exp 1st (NC)'!H12","v":0},null,{"$f":"ROUND(+F13+G13+H13,0)","v":0}]
[null,47," Activities - Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H13-'WS 1 Exp 1st (NC)'!H13","v":0},null,0]
[null,48," Activities - Supplies",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H14-'WS 1 Exp 1st (NC)'!H14","v":0},null,0]
[null,49," Social Services - Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H15-'WS 1 Exp 1st (NC)'!H15","v":0},null,0]
[null,50," Social Services - Supplies",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H16-'WS 1 Exp 1st (NC)'!H16","v":0},null,0]
[null,51," RN ",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H17-'WS 1 Exp 1st (NC)'!H17","v":0},null,0]
[null,52," LPN",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H18-'WS 1 Exp 1st (NC)'!H18","v":0},null,0]
[null,53," Aides and Orderlies",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H19-'WS 1 Exp 1st (NC)'!H19","v":0},null,0]
[null,54," Medical Supplies",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H20-'WS 1 Exp 1st (NC)'!H20","v":0},null,0]
[null,55," Non-prescription Drugs",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H21-'WS 1 Exp 1st (NC)'!H21","v":0},null,0]
[null,56," Utilization Review",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H22-'WS 1 Exp 1st (NC)'!H22","v":0},null,0]
[null,57," Nurse Aide Training ",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H23-'WS 1 Exp 1st (NC)'!H23","v":0},null,0]
[null,"58a"," Contracted Nursing Services - RN",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H24-'WS 1 Exp 1st (NC)'!H24","v":0},null,0]
[null,"58b"," Contracted Nursing Services - LPN",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H25-'WS 1 Exp 1st (NC)'!H25","v":0},null,0]
[null,"58c"," Contracted Nursing Services - Aides",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H26-'WS 1 Exp 1st (NC)'!H26","v":0},null,0]
[null,59," Other Patient Care - Schedule B-1",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H27-'WS 1 Exp 1st (NC)'!H27","v":0},null,0]
[null,60," Dietary Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H28-'WS 1 Exp 1st (NC)'!H28","v":0},null,0]
[null,61," Dietary Consultant",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H29-'WS 1 Exp 1st (NC)'!H29","v":0},null,0]
[null,62," Raw Food",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H30-'WS 1 Exp 1st (NC)'!H30","v":0},null,0]
[null,63," Dietary Supplies",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H31-'WS 1 Exp 1st (NC)'!H31","v":0},null,0]
[null,64," Other Dietary - Schedule B-1",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H32-'WS 1 Exp 1st (NC)'!H32","v":0},null,0]
[null,65," In-Service Education",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H33-'WS 1 Exp 1st (NC)'!H33","v":0},null,0]
[null,66," Payroll Taxes",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H34-'WS 1 Exp 1st (NC)'!H34","v":0},null,0]
[null,67," Employee Benefits",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H35-'WS 1 Exp 1st (NC)'!H35","v":0},null,0]
[null,68," Workers' Compensation",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H36-'WS 1 Exp 1st (NC)'!H36","v":0},null,0]
[null,69,null,null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H37-'WS 1 Exp 1st (NC)'!H37","v":0},null,0]
[null,70," SUBTOTAL - PATIENT CARE",null,null,{"$f":"ROUND(SUM(F13:F38),0)","v":0},{"$f":"ROUND(SUM(G13:G38),0)","v":0},{"$f":"ROUND(SUM(H13:H38),0)","v":0},0]
[null,"ANCILLARY "]
[null,71," Physician Service",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H40-'WS 1 Exp 1st (NC)'!H40","v":0},null,{"$f":"ROUND(+F41+G41+H41,0)","v":0}]
[null,72," Physical Therapy Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H41-'WS 1 Exp 1st (NC)'!H41","v":0},null,0]
[null,73," Physical Therapy Supplies/Contracted Services",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H42-'WS 1 Exp 1st (NC)'!H42","v":0},null,0]
[null,74," Occupational Therapy Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H43-'WS 1 Exp 1st (NC)'!H43","v":0},null,0]
[null,75," Occupational Therapy Supplies/Contracted Svcs",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H44-'WS 1 Exp 1st (NC)'!H44","v":0},null,0]
[null,76," Pharmacy and Drugs Sold",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H45-'WS 1 Exp 1st (NC)'!H45","v":0},null,0]
[null,77," Medical Supplies Sold",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H46-'WS 1 Exp 1st (NC)'!H46","v":0},null,0]
[null,78," Speech Therapy Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H47-'WS 1 Exp 1st (NC)'!H47","v":0},null,0]
[null,79," Speech Therapy Supplies/Contracted Services",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H48-'WS 1 Exp 1st (NC)'!H48","v":0},null,0]
[null,80," Lab & X-Ray",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H49-'WS 1 Exp 1st (NC)'!H49","v":0},null,0]
[null,81," Inhalation Therapy Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H50-'WS 1 Exp 1st (NC)'!H50","v":0},null,0]
[null,82," Inhalation Therapy Supplies/Contracted Services",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H51-'WS 1 Exp 1st (NC)'!H51","v":0},null,0]
[null,83," Nutritional Therapy/PEN Supplies",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H52-'WS 1 Exp 1st (NC)'!H52","v":0},null,0]
[null,"84a"," Other Ancillary - Schedule B-1",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H53-'WS 1 Exp 1st (NC)'!H53","v":0},null,0]
[null,"84b"," Central Supply Clerk Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H54-'WS 1 Exp 1st (NC)'!H54","v":0},null,{"$f":"ROUND(+F55+G55+H55,0)","v":0}]
[null,85," Laundry Salaries",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H55-'WS 1 Exp 1st (NC)'!H55","v":0},null,0]
[null,86," Laundry Supplies",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H56-'WS 1 Exp 1st (NC)'!H56","v":0},null,0]
[null,87," Linen and Bedding",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H57-'WS 1 Exp 1st (NC)'!H57","v":0},null,0]
[null,88," Outside Laundry Service",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H58-'WS 1 Exp 1st (NC)'!H58","v":0},null,0]
[null,89," Other Laundry - Schedule B-1",null,null,null,{"$f":"-'WS 1 Exp 1st (NR)'!H59-'WS 1 Exp 1st (NC)'!H59","v":0},null,0]
[null,90," SUBTOTAL - CARRY FORWARD",null,null,{"$f":"ROUND(SUM(F41:F60),0)","v":0},{"$f":"ROUND(SUM(G41:G60),0)","v":0},{"$f":"ROUND(SUM(H41:H60),0)","v":0},0]

{"sheet":"Sch B Page 2","index":4,"n_rows":58,"n_cols":9,"rows_kept":58,"cut":false,"hidden":false,"merged":[[0,3,0,8],[2,4,2,5],[2,7,2,8]]}
[null,"PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT:  FROM",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE B"]
[]
[null,null,null,null,null,null,"ADJUSTMENTS"]
[null,null,null,null,null,"GENERAL",null,"REVENUE","PATIENT"]
[null,"EXPENDITURES",null,null,null,"LEDGER","WORKSHEET 1","OFFSETS/","RELATED"]
[null,null,null,null,null,null,"ADJUSTMENTS","NON-ALLOWABLE","EXPENSES"]
[null,"ANCILLARY - Continued"]
[null,null," SUBTOTAL - CARRIED FORWARD",null,null,{"$f":"+'Sch B Page 1'!F61","v":0},{"$f":"+'Sch B Page 1'!G61","v":0},{"$f":"+'Sch B Page 1'!H61","v":0},{"$f":"ROUND(+F13+G13+H13,0)","v":0}]
[null,91," Housekeeping Salaries",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H12-'WS 1 Exp 2nd (NC)'!H12","v":0},null,0]
[null,92," Housekeeping Supplies",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H13-'WS 1 Exp 2nd (NC)'!H13","v":0},null,0]
[null,93," Other Housekeeping - Schedule B-1",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H14-'WS 1 Exp 2nd (NC)'!H14","v":0},null,0]
[null,94," Beauty and Barber Shop Salaries",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H15-'WS 1 Exp 2nd (NC)'!H15","v":0},null,0]
[null,95," Beauty and Barber Shop Supplies/Contracted",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H16-'WS 1 Exp 2nd (NC)'!H16","v":0},null,0]
[null,96," In-Service Education",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H17-'WS 1 Exp 2nd (NC)'!H17","v":0},null,0]
[null,97," Payroll Taxes",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H18-'WS 1 Exp 2nd (NC)'!H18","v":0},null,0]
[null,98," Employee Benefits",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H19-'WS 1 Exp 2nd (NC)'!H19","v":0},null,0]
[null,99," Workers' Compensation",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H20-'WS 1 Exp 2nd (NC)'!H20","v":0},null,0]
[null,100,null,null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H21-'WS 1 Exp 2nd (NC)'!H21","v":0},null,0]
[null,101," SUBTOTAL - ANCILLARY",null,null,{"$f":"ROUND(SUM(F13:F23),0)","v":0},{"$f":"ROUND(SUM(G13:G23),0)","v":0},{"$f":"ROUND(SUM(H13:H23),0)","v":0},0]
[null,"CAPITAL"]
[null,102," Amortization (excluding organizational costs)",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H24-'WS 1 Exp 2nd (NC)'!H24","v":0},null,{"$f":"ROUND(+F26+G26+H26,0)","v":0}]
[null,103," Rent/Lease (excluding vehicles)",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H25-'WS 1 Exp 2nd (NC)'!H25","v":0},null,0]
[null,104," Depreciation (excluding vehicles)",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H26-'WS 1 Exp 2nd (NC)'!H26","v":0},null,0]
[null,105," Interest - Real Estate ",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H27-'WS 1 Exp 2nd (NC)'!H27","v":0},null,0]
[null,106," Interest - Other (excluding vehicles)",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H28-'WS 1 Exp 2nd (NC)'!H28","v":0},null,0]
[null,107," Insurance - Property",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H29-'WS 1 Exp 2nd (NC)'!H29","v":0},null,0]
[null,108," Real Estate Taxes",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H30-'WS 1 Exp 2nd (NC)'!H30","v":0},null,0]
[null,109," Personal Property Taxes",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H31-'WS 1 Exp 2nd (NC)'!H31","v":0},null,0]
[null,110," SUBTOTAL - CAPITAL",null,null,{"$f":"ROUND(SUM(F26:F33),0)","v":0},{"$f":"ROUND(SUM(G26:G33),0)","v":0},{"$f":"ROUND(SUM(H26:H33),0)","v":0},0]
[null,"ADMINISTRATION"]
[null,111," Plant Operation Salaries",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H34-'WS 1 Exp 2nd (NC)'!H34","v":0},null,{"$f":"ROUND(+F36+G36+H36,0)","v":0}]
[null,112," Administrator Salary",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H35-'WS 1 Exp 2nd (NC)'!H35","v":0},null,0]
[null,113," Assistant Administrator Salary",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H36-'WS 1 Exp 2nd (NC)'!H36","v":0},null,0]
[null,114," Other Administrative Salaries",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H37-'WS 1 Exp 2nd (NC)'!H37","v":0},null,0]
[null,115," Medical Records Salaries",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H38-'WS 1 Exp 2nd (NC)'!H38","v":0},null,0]
[null,116," Utilities",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H39-'WS 1 Exp 2nd (NC)'!H39","v":0},null,0]
[null,117," Maintenance and Repairs",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H40-'WS 1 Exp 2nd (NC)'!H40","v":0},null,0]
[null,118," Plant Operation Supplies",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H41-'WS 1 Exp 2nd (NC)'!H41","v":0},null,0]
[null,119," Other Plant Operations - Schedule B-1",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H42-'WS 1 Exp 2nd (NC)'!H42","v":0},null,0]
[null,120," Medical Records Supplies/Contracted Svcs",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H43-'WS 1 Exp 2nd (NC)'!H43","v":0},null,0]
[null,121," Management Fees",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H44-'WS 1 Exp 2nd (NC)'!H44","v":0},null,0]
[null,122," Home Office",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H45-'WS 1 Exp 2nd (NC)'!H45","v":0},null,0]
[null,"123a"," Owners' Compensation",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H46-'WS 1 Exp 2nd (NC)'!H46","v":0},null,0]
[null,"123b"," Directors' Fees",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H47-'WS 1 Exp 2nd (NC)'!H47","v":0},null,{"$f":"ROUND(+F49+G49+H49,0)","v":0}]
[null,124," Legal",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H48-'WS 1 Exp 2nd (NC)'!H48","v":0},null,0]
[null,125," Accounting ",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H49-'WS 1 Exp 2nd (NC)'!H49","v":0},null,0]
[null,126," Advertising - Employment Ads",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H50-'WS 1 Exp 2nd (NC)'!H50","v":0},null,0]
[null,127," Advertising - Promotional and Other",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H51-'WS 1 Exp 2nd (NC)'!H51","v":0},null,0]
[null,128," Amortization (organizational costs)",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H52-'WS 1 Exp 2nd (NC)'!H52","v":0},null,0]
[null,129," Telephone",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H53-'WS 1 Exp 2nd (NC)'!H53","v":0},null,0]
[null,130," Travel and Entertainment",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H54-'WS 1 Exp 2nd (NC)'!H54","v":0},null,0]
[null,131," Seminars",null,null,null,{"$f":"-'WS 1 Exp 2nd (NR)'!H55-'WS 1 Exp 2nd (NC)'!H55","v":0},null,0]
[null,132," SUBTOTAL - CARRY FORWARD",null,null,{"$f":"ROUND(SUM(F36:F57),0)","v":0},{"$f":"ROUND(SUM(G36:G57),0)","v":0},{"$f":"ROUND(SUM(H36:H57),0)","v":0},0]

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[null,"PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT:  FROM",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE B"]
[]
[null,null,null,null,null,null,"ADJUSTMENTS"]
[null,null,null,null,null,"GENERAL",null,"REVENUE","PATIENT"]
[null,"EXPENDITURES",null,null,null,"LEDGER","WORKSHEET 1","OFFSETS/","RELATED"]
[null,null,null,null,null,null,"ADJUSTMENTS","NON-ALLOWABLE","EXPENSES"]
[null,"ADMINISTRATION - Continued"]
[null,null," SUBTOTAL - CARRIED FORWARD",null,null,{"$f":"+'Sch B Page 2'!F58","v":0},{"$f":"+'Sch B Page 2'!G58","v":0},{"$f":"+'Sch B Page 2'!H58","v":0},{"$f":"ROUND(+F13+G13+H13,0)","v":0}]
[null,133," Vehicle Depreciation ",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H12-'ws 1Exp 3rd (NC)'!H12","v":0},null,0]
[null,134," Interest - Vehicle Loans",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H13-'ws 1Exp 3rd (NC)'!H13","v":0},null,0]
[null,135," Vehicle Expense (Including lease)",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H14-'ws 1Exp 3rd (NC)'!H14","v":0},null,0]
[null,136," Insurance (other than property and life)",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H15-'ws 1Exp 3rd (NC)'!H15","v":0},null,0]
[null,137," Office Supplies",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H16-'ws 1Exp 3rd (NC)'!H16","v":0},null,0]
[null,138," Data Processing",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H17-'ws 1Exp 3rd (NC)'!H17","v":0},null,0]
[null,139," Life Insurance",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H18-'ws 1Exp 3rd (NC)'!H18","v":0},null,0]
[null,140," Dues and Subscriptions",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H19-'ws 1Exp 3rd (NC)'!H19","v":0},null,0]
[null,141," Licenses ",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H20-'ws 1Exp 3rd (NC)'!H20","v":0},null,0]
[null,142," Vending ",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H21-'ws 1Exp 3rd (NC)'!H21","v":0},null,0]
[null,143," Cable T V",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H22-'ws 1Exp 3rd (NC)'!H22","v":0},null,0]
[null,144," In-Service Education",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H23-'ws 1Exp 3rd (NC)'!H23","v":0},null,0]
[null,145," Payroll Taxes",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H24-'ws 1Exp 3rd (NC)'!H24","v":0},null,0]
[null,146," Employee Benefits",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H25-'ws 1Exp 3rd (NC)'!H25","v":0},null,0]
[null,147," Workers' Compensation",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H26-'ws 1Exp 3rd (NC)'!H26","v":0},null,0]
[null,148,null,null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H27-'ws 1Exp 3rd (NC)'!H27","v":0},null,0]
[null,149," Other Administration - Schedule B-1",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H28-'ws 1Exp 3rd (NC)'!H28","v":0},null,{"$f":"ROUND(+F30+G30+H30,0)","v":0}]
[null,150," SUBTOTAL - ADMINISTRATION",null,null,{"$f":"ROUND(SUM(F13:F30),0)","v":0},{"$f":"ROUND(SUM(G13:G30),0)","v":0},{"$f":"ROUND(SUM(H13:H30),0)","v":0},0]
[null,"OTHER"]
[null,151," Income Tax",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H31-'ws 1Exp 3rd (NC)'!H31","v":0},null,{"$f":"ROUND(+F33+G33+H33,0)","v":0}]
[null,152," Contributions",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H32-'ws 1Exp 3rd (NC)'!H32","v":0},null,0]
[null,153," Gift Shop",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H33-'ws 1Exp 3rd (NC)'!H33","v":0},null,0]
[null,154," Life Insurance",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H34-'ws 1Exp 3rd (NC)'!H34","v":0},null,0]
[null,155," Penalties",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H35-'ws 1Exp 3rd (NC)'!H35","v":0},null,0]
[null,156," Nursing Facility Reimbursement Allowance",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H36-'ws 1Exp 3rd (NC)'!H36","v":0},null,0]
[null,"157a"," Non-emergency Medical Transportation",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H37-'ws 1Exp 3rd (NC)'!H37","v":0},null,0]
[null,"157b"," Emergency Medical Transportation",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H38-'ws 1Exp 3rd (NC)'!H38","v":0},null,{"$f":"ROUND(+F40+G40+H40,0)","v":0}]
[null,158," Other - Schedule B-1",null,null,null,{"$f":"-'ws 1Exp 3rd (NR)'!H39-'ws 1Exp 3rd (NC)'!H39","v":0},null,0]
[null,159," SUBTOTAL OTHER",null,null,{"$f":"ROUND(SUM(F33:F41),0)","v":0},{"$f":"ROUND(SUM(G33:G41),0)","v":0},{"$f":"ROUND(SUM(H33:H41),0)","v":0},0]
[]
[null,160," TOTAL EXPENSES",null,null,{"$f":"+'Sch B Page 1'!F39+'Sch B Page 2'!F24+'Sch B Page 2'!F34+'Sch B Page 3'!F31+'Sch B Page 3'!F42","v":0},{"$f":"+'Sch B Page 1'!G39+'Sch B Page 2'!G24+'Sch B Page 2'!G34+'Sch B Page 3'!G31+'Sch B Page 3'!G42","v":0},{"$f":"+'Sch B Page 1'!H39+'Sch B Page 2'!H24+'Sch B Page 2'!H34+'Sch B Page 3'!H31+'Sch B Page 3'!H42","v":0},{"$f":"ROUND(+F44+G44+H44,0)","v":0}]

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[null,"PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT:  FROM",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE A-1 AND B-1"]
[]
[]
[null,"LINE",null,null,null,null,null,"LINE"]
[null,"NO.","DESCRIPTION",null,null,"AMOUNT",null,"NO.","DESCRIPTION",null,null,"AMOUNT"]
[]
[null,21,"Other Ancillary Revenue",null,null,null,null,89,"Other Laundry Expense"]
[]
[]
[]
[]
[]
[null,37,"Other Revenue",null,null,null,null,93,"Other Housekeeping Expense"]
[null," "]
[]
[null," "]
[]
[]
[null,null,null,null,null,null,null,119,"Other Plant Operations Expense"]
[]
[]
[]
[null," "]
[]
[]
[]
[null,43,"Other Deductions from Revenue"]
[]
[]
[]
[]
[]
[null,59,"Other Patient Care Expense",null,null,null,null,149,"Other Administration Expense"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,64,"Other Dietary  Expense"]
[]
[]
[]
[]
[]
[null,"84a","Other Ancillary Expense",null,null,null,null,158,"Other Expenses"]

{"sheet":"Sch C","index":7,"n_rows":55,"n_cols":15,"rows_kept":55,"cut":false,"hidden":false,"merged":[[50,2,50,4],[0,3,0,12],[34,1,34,14],[6,1,6,14],[20,2,20,4],[14,2,14,4],[2,4,2,5],[2,8,2,9],[2,11,2,12]]}
[null,"PROVIDER NAME:",null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT:  FROM",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[null,"SCHEDULE C"]
[" "]
[null,"REVENUES"]
[]
[]
[null,null,null,null,null,"(1)","(2)","(3)","(4)","(5)","(6)","(7)","(8)","(9)","(10)"]
[null,null,null,null,null,null,null,null,"Mental"]
[null,null,null,null,null,"Medicaid","ICF-MR","Hospice","Health","V.A.","Medicare A","Medicare B","Private","Other","Total"]
[]
[null,161," PATIENT DAYS",null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(F14:N14)","v":0}]
[null,null,"REVENUES"]
[null,162," ROUTINE SERVICE",null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(F16:N16)","v":0}]
[null,163," Per Patient Day",null,null,{"$f":"IFERROR(+F16/F14,0)","v":0},0,0,0,0,0,null,{"$f":"IFERROR(+M16/M14,0)","v":0},null,{"$f":"IFERROR(+O16/O14,0)","v":0}]
[]
[null,164," ANCILLARY CHARGES",null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(F19:N19)","v":0}]
[null,165," Per Patient Day",null,null,{"$f":"IFERROR(+F19/F14,0)","v":0},0,0,0,0,0,null,{"$f":"IFERROR(+M19/M14,0)","v":0},null,{"$f":"IFERROR(+O19/O14,0)","v":0}]
[null,null,"   ROOM RESERVATION REVENUE"]
[]
[null,null," Allowable Therapeutic",null,"  Days",null,null,null,null,null,null,null,null,null,{"$f":"SUM(F23:N23)","v":0}]
[null,166,"     Home Leave/Visits",null,"  Revenues",null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,"  Days",null,null,null,null,null,null,null,null,null,0]
[null,167," Other Home Leave/Visits",null,"  Revenues",null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,"  Days",null,null,null,null,null,null,null,null,null,0]
[null,168," Hospital Leave",null,"  Revenues",null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,"  Days",null,null,null,null,null,null,null,null,null,0]
[null,169," Other",null,"  Revenues",null,null,null,null,null,null,null,null,null,0]
[null,170," CONTRACTUAL ALLOWANCE",null,null,null,null,null,null,null,null,null,null,null,0]
[null,171," BAD DEBTS",null,null,null,null,null,null,null,null,null,null,null,0]
[]
[]
[null,"ANCILLARY SERVICE REVENUE AND DEDUCTIONS FROM REVENUES "]
[]
[]
[null,"SCHEDULE A",null,null,null,null,null,null,"Mental"]
[null,"LINE #",null,null,null,"Medicaid","ICF-MR","Hospice","Health","V.A.","Medicare A","Medicare B","Private","Other","Total"]
[null,"11"," Physician Service",null,null,null,null,null,null,null,null,null,null,null,{"$f":"ROUND(SUM(F40:N40),0)","v":0}]
[null,"12"," Physical Therapy",null,null,null,null,null,null,null,null,null,null,null,{"$f":"ROUND(SUM(F41:N41),0)","v":0}]
[null,"13"," Occupational Therapy",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"14"," Pharmacy",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"15"," Medical Supplies",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"16"," Speech and Hearing",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"17"," Laboratory and X-Ray",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"18"," Inhalation Therapy",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"19"," Equipment Rental",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"20"," Nutritional Therapy/PEN",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"21"," Other - Schedule A-1",null,null,null,null,null,null,null,null,null,null,null,0]
[null,null,"Total Ancillary less Physician, RX, Lab & X-Ray",null,null,{"$f":"ROUND(SUM(F40:F50)-F43-F46-F40,0)","v":0},{"$f":"ROUND(SUM(G40:G50)-G43-G46-G40,0)","v":0},0,0,0,0,0,0,0,0]
[null,"40"," Charity Services",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"41"," Contractual Allowance",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"42"," Provision for Bad Debts",null,null,null,null,null,null,null,null,null,null,null,0]
[null,"43"," Other - Schedule A-1",null,null,null,null,null,null,null,null,null,null,null,0]

{"sheet":"Sch D","index":8,"n_rows":87,"n_cols":12,"rows_kept":87,"cut":false,"hidden":false,"merged":[[16,1,16,2],[2,4,2,5],[9,1,9,4],[15,7,15,8],[15,3,15,4],[15,1,15,2],[16,7,16,8],[62,6,62,7],[18,3,18,4],[21,3,21,4],[19,1,19,2],[22,3,22,4],[61,6,61,7],[22,7,22,8],[21,7,21,8],[18,1,18,2],[42,1,42,4],[20,1,20,2],[21,1,21,2],[0,4,0,10],[2,7,2,8],[9,7,9,9],[20,7,20,8],[20,3,20,4],[18,7,18,8],[17,7,17,8],[16,3,16,4],[14,3,14,4],[19,7,19,8],[17,3,17,4],[19,3,19,4],[86,9,86,10],[66,1,66,4],[67,1,67,4],[72,6,72,7],[86,3,86,5],[83,1,83,3],[82,1,82,3],[80,1,80,3],[81,1,81,3],[73,6,73,7],[17,1,17,2],[29,1,29,4],[22,1,22,2],[79,1,79,3],[68,1,68,4],[63,1,63,4],[62,1,62,4],[65,1,65,4],[64,1,64,4]]}
[null,"PROVIDER NAME: ",null,null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT: FROM",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE D"]
[]
[null,"ASSET SCHEDULE "]
[]
[null,"DESCRIPTION",null,null,null,"COST",null,"DESCRIPTION",null,null,"COST"]
[]
[]
[null," EQUIPMENT:",null,null,null,null,null," BUILDINGS:"]
[null," Balance At Beginning of Year",null,null,null,null,null," Balance At Beginning of Year"]
[null," Purchases During Year:",null,null,null,null,null," Improvements During Year:"]
[]
[]
[]
[]
[]
[]
[]
[]
[null," Total Purchases",null,null,null,{"$f":"SUM(D16:E23)","v":0},null," Total Improvements",null,null,{"$f":"SUM(J16:J23)","v":0}]
[null," Disposal During Year",null,null,null,null,null," Disposal During Year"]
[null," Balance At End of Year",null,null,null,{"$f":"+F14+F24-F25","v":0},null," Balance At End of Year",null,null,{"$f":"+K14+K24-K25","v":0}]
[]
[]
[null,"VEHICLE SCHEDULE"]
[null,"DESCRIPTIONS:",null,null,null,null,"Vehicle 1","Vehicle 2","Vehicle 3","Vehicle 4","Vehicle 5"]
[null,"Year"]
[null,"Make"]
[null,"Model"]
[null,"Purchase Date:","Month"]
[null,null,"Year"]
[null,"Purchase Price"]
[null,"Purpose of Vehicle (Indicate each area below with % used for each purpose, if vehicle is used only for one, please indicate 100%.)"]
[null,"Administrative"]
[null,"Maintenance"]
[null,"Resident Transportation - Medical"]
[null,"Resident Transportation - Activities/Outings"]
[null,"Other"]
[null,"Vehicle Expenses:"]
[null,"Interest"]
[null,"Reported on CR Line #"]
[null,"Lease Payments"]
[null,"Reported on CR Line #"]
[null,"Insurance"]
[null,"Reported on CR Line #"]
[null,"Maintenance & Gas"]
[null,"Reported on CR Line #"]
[null,"Personal Property Taxes"]
[null,"Reported on CR Line #"]
[null,"Depreciation"]
[null,"Reported on CR Line #"]
[null,"Other Exp. - Description"]
[null,"Amount"]
[null,"Reported on CR Line #"]
[]
[]
[null,"AMORTIZATION SCHEDULE - Capital Asset Debt"]
[null,null,null,null,null,null,null,null,null,"PRIOR"]
[null,"LOAN",null,null,null," ","DATE",null," ","ACCUMULATED ","BOOK","STRAIGHT"]
[null,"DESCRIPTION",null,null,null,"COST","MONTH","YEAR","PERIOD ","AMORTIZATION","EXPENSE","LINE"]
[]
[]
[]
[]
[]
[null," TOTAL AMORTIZATION",null,null,null,{"$f":"SUM(F65:F69)","v":0},null,null,null,{"$f":"SUM(J65:J69)","v":0},{"$f":"SUM(K65:K69)","v":0},{"$f":"SUM(L65:L69)","v":0}]
[]
[null,"AMORTIZATION SCHEDULE - Organizational and Start-Up Costs"]
[null,null,null,null,null,null,null,null,null,"PRIOR"]
[null," ",null,null,null," ","DATE",null," ","ACCUMULATED ","BOOK","STRAIGHT"]
[null,"DESCRIPTION",null,null,null,"COST","MONTH","YEAR","PERIOD ","AMORTIZATION","EXPENSE","LINE"]
[null,"Organizational Costs"]
[null," "]
[null,null,null,null,"Reported on"]
[null,"Start-Up Costs",null,null,"CR Line #"]
[]
[]
[]
[]
[]
[null," TOTAL AMORTIZATION",null,null,null,{"$f":"SUM(F76:F84)","v":0},null,null,null,{"$f":"SUM(J76:J84)","v":0},{"$f":"SUM(K76:K84)","v":0},{"$f":"SUM(L76:L84)","v":0}]
[]
[null," Number of Acres  :",null,null,null,null,"          Total Facility Square Footage :"]

{"sheet":"Sch E","index":9,"n_rows":77,"n_cols":7,"rows_kept":77,"cut":false,"hidden":false,"merged":[[0,3,0,6]]}
["PROVIDER NAME: ",null,null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[null,"SCHEDULE E"]
[]
[null,"COMPARATIVE BALANCE SHEET "]
[null,"(NOTE: This schedule should be prepared from the Nursing Facility's general ledger or other general records)."]
[]
[null,null,null,null,null,"BALANCE AT END OF"]
[null,"ASSETS",null,null,null,"Current Year","Prior Year"]
[null,"Current Assets:"]
[null,null,"Cash on hand"]
[null,null,"Receivables from patients"]
[null,null,"Receivables from Medicaid"]
[null,null,"Receivables from Medicare"]
[null,null,"Receivables from others (attach schedule)"]
[null,null,"Inventory"]
[null,null,"Prepaid expenses"]
[null,null,"Short-term investments"]
[null,null,"Other current assets (attach schedule)"]
[null,null,"     Total Current Assets",null,null,{"$f":"SUM(F12:F21)","v":0},{"$f":"SUM(G12:G21)","v":0}]
[null,"Long-Term Assets:"]
[null,null,"Equipment"]
[null,null,"    Less: accumulated depreciation (per books)"]
[null,null,"Vehicles"]
[null,null,"    Less: accumulated depreciation (per books)"]
[null,null,"Buildings and improvements"]
[null,null,"    Less: accumulated depreciation (per books)"]
[null,null,"Land"]
[null,null,"Investments (long term)"]
[null,null,"Other fixed assets (attach schedule)"]
[null,null,"     Total Long-Term Assets",null,null,{"$f":"SUM(F23:F32)","v":0},{"$f":"SUM(G23:G32)","v":0}]
[null,"Other Assets"]
[null,null,"Loan cost"]
[null,null,"    Less: accumulated amortization (per books)"]
[null,null,"Organizational cost"]
[null,null,"Start-up Cost"]
[null,null,"Goodwill"]
[null,null,"Other (attach schedule)"]
[null,null,"     Total Other Assets",null,null,{"$f":"SUM(F34:F40)","v":0},{"$f":"SUM(G34:G40)","v":0}]
[null,null,"            TOTAL ASSETS",null,null,{"$f":"+F22+F33+F41","v":0},{"$f":"+G22+G33+G41","v":0}]
[]
[null,"LIABILITIES AND EQUITY"]
[]
[null,"Current Liabilities:"]
[null,null,"Accounts payable"]
[null,null,"Accounts payable Medicaid/Medicare"]
[null,null,"Accrued taxes (payroll and property)"]
[null,null,"Accrued expenses"]
[null,null,"Notes and mortgage payable (current portion)"]
[null,null,"Notes and loans payable (current portion)"]
[null,null,"Other liabilities (attach schedule)"]
[null,null,"     Total Current Liabilities",null,null,{"$f":"SUM(F46:F53)","v":0},{"$f":"SUM(G46:G53)","v":0}]
[null,"Long-Term Liabilities:"]
[null,null,"Mortgage payable"]
[null,null,"Notes payable"]
[null,null,"Notes and mortgage payable to stockholders, officers, owners, etc."]
[null,null,"Notes and mortgage payable to related party organizations, etc."]
[null,null,"     Total Long-Term Liabilities",null,null,{"$f":"SUM(F55:F59)","v":0},{"$f":"SUM(G55:G59)","v":0}]
[null,null,"            TOTAL LIABILITIES",null,null,{"$f":"+F60+F54","v":0},{"$f":"+G60+G54","v":0}]
[null,"Equity:"]
[null,null,"Corporation:"]
[null,null,"    Capital stock"]
[null,null,"    Additional paid-in capital"]
[null,null,"    Treasury stock"]
[null,null,"    Retained earnings"]
[null,null,"Partnership/Proprietor's :"]
[null,null,"    Partners'/proprietor's capital account(s)"]
[null,null,"    Partners'/proprietor's drawing account(s)"]
[]
[null,null,"Other:"]
[null,null,"    Non-profit organization"]
[null,null,"    Inter-company account"]
[null,null,"    Other (explain)"]
[null,null,"            TOTAL EQUITY",null,null,{"$f":"SUM(F62:F75)","v":0},{"$f":"SUM(G62:G75)","v":0}]
[null,null,"            TOTAL LIABILITIES AND EQUITY",null,null,{"$f":"+F76+F61","v":0},{"$f":"+G76+G61","v":0}]

{"sheet":"Sch F and G","index":10,"n_rows":83,"n_cols":10,"rows_kept":83,"cut":false,"hidden":false,"merged":[[43,3,43,4],[48,3,48,4],[0,2,0,9],[44,3,44,4],[36,1,36,9],[43,1,43,2],[5,1,5,9],[2,7,2,8],[2,3,2,4],[32,1,32,9],[7,1,7,9],[49,3,49,4],[45,3,45,4],[50,3,50,4],[49,1,49,2],[50,1,50,2],[46,1,46,2],[48,1,48,2],[46,3,46,4],[47,1,47,2],[47,3,47,4],[51,3,51,4],[51,1,51,2],[55,3,55,4],[52,1,52,2],[54,3,54,4],[52,3,52,4],[53,3,53,4],[54,1,54,2],[53,1,53,2],[58,1,58,2],[59,3,59,4],[55,1,55,2],[57,1,57,2],[56,1,56,2],[56,3,56,4],[57,3,57,4],[58,3,58,4],[63,3,63,4],[62,1,62,2],[64,1,64,2],[63,1,63,2],[59,1,59,2],[60,3,60,4],[64,3,64,4],[62,3,62,4],[61,3,61,4],[60,1,60,2],[61,1,61,2],[70,3,70,4],[71,1,71,2],[68,1,68,2],[65,3,65,4],[65,1,65,2],[67,3,67,4],[71,3,71,4],[66,3,66,4],[69,3,69,4],[68,3,68,4],[67,1,67,2],[70,1,70,2],[66,1,66,2],[69,1,69,2],[83,1,83,3],[72,1,72,2],[72,3,72,4],[75,3,75,4],[76,3,76,4],[81,4,81,5],[73,3,73,4],[74,1,74,2],[74,3,74,4],[79,4,79,7],[76,1,76,2],[75,1,75,2],[83,6,83,7],[83,4,83,5],[73,1,73,2],[88,6,88,7],[88,4,88,5],[88,1,88,3],[87,1,87,3],[84,1,84,3],[86,1,86,3],[87,4,87,5],[87,6,87,7],[86,4,86,5],[86,6,86,7],[85,1,85,3],[84,4,84,5],[85,6,85,7],[85,4,85,5],[84,6,84,7]]}
[null,"PROVIDER NAME: ",{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT: FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE F"]
[]
[null,"RECONCILIATION OF OWNERS EQUITY "]
[]
[]
[null,"BALANCE AT BEGINNING OF PERIOD"]
[null,"Increases"]
[null,"    Revenue per cost report",null,null,null,"Schedule A - line 45",null,null,{"$f":"+'Sch A'!F55","v":0}]
[null,"    Investment by owners"]
[null,"    Common stock sold"]
[null,"    Other"]
[null,"        TOTAL",null,null,null,null,null,null,null,{"$f":"SUM(I13:I16)","v":0}]
[]
[null,"Decreases"]
[null,"    Expenses per cost report",null,null,null,"Schedule B - line 160",null,null,{"$f":"+'Sch B Page 3'!F44","v":0}]
[null,"    Withdrawals by owners"]
[null,"    Dividends paid"]
[null,"    Other"]
[null,"        TOTAL",null,null,null,null,null,null,null,{"$f":"SUM(I20:I23)","v":0}]
[]
[null,"BALANCE AT END OF PERIOD",null,null,null,null,null,null,null,{"$f":"+J11+J17-J24","v":0}]
[]
[]
[null,"SCHEDULE G"]
[]
[null,"TRANSACTIONS WITH RELATED ORGANIZATIONS "]
[]
[null,"An adjustment may be necessary to reduce operating expenses.  Provider costs for purchases from firms related to the provider by "]
[null,"common ownership or control shall not exceed the lower of the cost to the related organization or the price of comparable services,"]
[null,"facilities or supplies that could have been purchased elsewhere."]
[]
[null,"1.  Are any of the expenses (costs) reflected in this report the result of purchases or transactions with business"]
[null,"     firms related to the provider through common ownership?"]
[]
[null,"     If Yes, complete sections 2 and 3 below."]
[]
[null,"2."]
[]
[null,"NAME OF RELATED",null," ",null,null,null,"AMOUNT","COST INCURRED","DIFFERENCE"]
[null,"ORGANIZATION OR",null,"DESCRIPTION",null,"SCHEDULE","LINE","OF","BY RELATED PARTY","AS"]
[null,"RELATED PARTY",null,"OF EXPENSE ITEM",null,"A or B","NO.","EXPENSE","OR ORGANIZATION","ADJUSTMENT"]
[null,null,null,null,null,null,null,null,null,{"$f":"SUM(I47-H47)","v":0}]
[null,null,null,null,null,null,null,null,null,{"$f":"SUM(I48-H48)","v":0}]
[null,null,null,null,null,null,null,null,null,{"$f":"SUM(I49-H49)","v":0}]
[null,null,null,null,null,null,null,null,null,{"$f":"SUM(I50-H50)","v":0}]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,0]
[null,"Total",null,null,null,null,null,{"$f":"SUM(H47:H76)","v":0},{"$f":"SUM(I47:I76)","v":0},{"$f":"SUM(I77-H77)","v":0}]
[]
[null,"3. Name and Percentage of Ownership"]
[null,null,null,null,"PERCENT OF OWNERSHIP",null,null,null,"COMMON OWNERS"]
[null," ",null,null,"RELATED",null,"NURSING HOME ",null,"% OWNERSHIP IN","% OWNERSHIP"]
[null,"NAME OF RELATED ORGANIZATION ",null,null,"ORGANIZATION IN",null,"IN RELATED",null,"NURSING ","IN RELATED"]
[null,"OR INDIVIDUAL",null,null,"NURSING HOME",null,"ORGANIZATION",null,"HOME","FIRM"]

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[null,"PROVIDER NAME: ",{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT: FROM",{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[null,"SCHEDULE H"]
[]
[]
[null,"STATEMENT OF OWNERS/DIRECTORS COMPENSATION "]
[]
[]
[null,null,null,null,null,"ESTIMATED",null,null,null,"(1)",null,"(2)","(1-2)","(3)",null,"(4)","(3-4)"]
[null,null,null,null,"ESTIMATED","HOURS PER",null,null,null,null,null," ","COMPENSATION",null,null," ","DIRECTORS FEES"]
[null,null,null,null,"HOURS PER","WEEK DEVOTED",null,null,null," ",null,"MAXIMUM","IN EXCESS"," ",null,"MAXIMUM","IN EXCESS"]
[null,null," ",null,"WEEK DEVOTED","TO OTHER","PERCENTAGE",null,null,null,null,"ALLOWABLE","MAXIMUM",null,null,"ALLOWABLE","MAXIMUM"]
[null,null,null,"DESCRIPTION OF","TO THIS","NURSING","OF OWNERSHIP","SALARIES ","OTHER","TOTAL","Line Number","COMPENSATION","ALLOWABLE","DIRECTORS","Line Number","DIRECTORS FEES","ALLOWABLE"]
[null,"NAME","TITLE","DUTIES PERFORMED","FACILITY","FACILITIES","IN BUSINESS","AND WAGES","COMPENSATION","COMPENSATION","Reported On","(a)","(b)","FEES","Reported On","(a)","(b)"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H17+I17","v":0},null,null,{"$f":"IF(J17>L17,L17-J17,\"0\")","v":"0"},null,null,null,{"$f":"IF(N17>P17,P17-N17,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H22+I22","v":0},null,null,{"$f":"IF(J22>L22,L22-J22,\"0\")","v":"0"},null,null,null,{"$f":"IF(N22>P22,P22-N22,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H27+I27","v":0},null,null,{"$f":"IF(J27>L27,L27-J27,\"0\")","v":"0"},null,null,null,{"$f":"IF(N27>P27,P27-N27,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H32+I32","v":0},null,null,{"$f":"IF(J32>L32,L32-J32,\"0\")","v":"0"},null,null,null,{"$f":"IF(N32>P32,P32-N32,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H37+I37","v":0},null,null,{"$f":"IF(J37>L37,L37-J37,\"0\")","v":"0"},null,null,null,{"$f":"IF(N37>P37,P37-N37,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H42+I42","v":0},null,null,{"$f":"IF(J42>L42,L42-J42,\"0\")","v":"0"},null,null,null,{"$f":"IF(N42>P42,P42-N42,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H47+I47","v":0},null,null,{"$f":"IF(J47>L47,L47-J47,\"0\")","v":"0"},null,null,null,{"$f":"IF(N47>P47,P47-N47,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H52+I52","v":0},null,null,{"$f":"IF(J52>L52,L52-J52,\"0\")","v":"0"},null,null,null,{"$f":"IF(N52>P52,P52-N52,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H57+I57","v":0},null,null,{"$f":"IF(J57>L57,L57-J57,\"0\")","v":"0"},null,null,null,{"$f":"IF(N57>P57,P57-N57,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H62+I62","v":0},null,null,{"$f":"IF(J62>L62,L62-J62,\"0\")","v":"0"},null,null,null,{"$f":"IF(N62>P62,P62-N62,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H67+I67","v":0},null,null,{"$f":"IF(J67>L67,L67-J67,\"0\")","v":"0"},null,null,null,{"$f":"IF(N67>P67,P67-N67,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,null,null,null,{"$f":"+H72+I72","v":0},null,null,{"$f":"IF(J72>L72,L72-J72,\"0\")","v":"0"},null,null,null,{"$f":"IF(N72>P72,P72-N72,\"0\")","v":"0"}]
[]
[]
[null,"Is Individual the Administrator?"]
[null,"Is Individual part of Home Office?"]
[null,null,null,null,null,null,"Totals",{"$f":"SUM(H17:H76)","v":0},0,0,null,0,0,{"$f":"SUM(N17:N76)","v":0},null,{"$f":"SUM(P17:P76)","v":0},{"$f":"SUM(Q17:Q76)","v":0}]
[]
[null,"(a) See cost report instructions and reimbursement regulations as to calculation of maximum allowable compensation."]
[null,"(b) The compensation in excess of the allowable maximum should be recorded as a non-allowable cost adjustment on Schedule B."]
[]
[null,"   NOTE: ALL owners and their relatives who receive any type of compensation from this home must be listed on this schedule."]

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[null,"PROVIDER NAME: ",{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT: FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE I"]
[]
[null,"STATEMENT OF ORGANIZATION AND OWNERSHIP "]
[]
[]
[null,"CORPORATION ORGANIZATION"]
[null," "]
[null,"   Corporate Name"]
[]
[null,"   Date Incorporated"]
[]
[null,"OFFICERS OF THE CORPORATION"]
[]
[null,"NAME",null,null,null,null,null,"TITLE",null,"% OF OWNERSHIP"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"STOCKHOLDERS OWNING GREATER THAN 5% OF THE STOCK"]
[null,"NAME",null,null,null,null,null,null,null,"% OF OWNERSHIP"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"PARTNERSHIP / PROPRIETORSHIP"]
[null,"NAME",null,null,null,null,null,null,null,"% OF OWNERSHIP"]
[]
[]
[]
[]
[]
[]
[]
[null,"STATEMENT OF INTEREST IN OTHER"]
[]
[null,null,null,null,null,null,"  DESCRIBE NATURE AND EXTENT OF RELATIONSHIP, SUCH AS"]
[null,"NAME OF RELATED PROVIDER",null,null,null,null,"  COMMON OWNERSHIP, MANAGEMENT, DIRECTORS, ETC."]

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[null,"PROVIDER NAME: ",{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT: FROM",{"$f":"+'Front Page'!E12","v":"00:00:00"},"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"},null," "]
[]
[null,"SCHEDULE J"]
[]
[null,"STATEMENT OF LOANS OUTSTANDING "]
[]
[]
[null,null,null,null,null,null,null,"BALANCE END OF YEAR",null,"INTEREST","Expense"]
[null,null,null,"ORIGINAL","MATURING","ORIGINAL",null,null,null,"EXPENSE FOR","Reported"]
[null,"DESCRIPTION",null,"DATE OF LOAN","DATE OF LOAN","AMOUNT ","INTEREST","CURRENT","LONG","REPORTING","On Line"]
[null,null,null,"MONTH/YEAR","MONTH/YEAR","OF LOAN","RATE","MATURITY","TERM","PERIOD","Number"]
[]
[null," 1a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null," 2a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null," 3a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null," 4a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null," 5a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null," 6a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null," 7a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null," 8a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null," 9a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[]
[null,"10a. Lender name"]
[null,"   b. Is lender a related party?"]
[null,"   c. Purpose of loan"]
[]
[null,null,null,"TOTALS",null,{"$f":"SUM(F14:F63)","v":0},null,{"$f":"SUM(H14:H63)","v":0},{"$f":"SUM(I14:I63)","v":0},{"$f":"SUM(J14:J63)","v":0}]

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[null,"PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT:  FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE K"]
[]
[null,"NUMBER OF STAFF HOURS "]
[]
[]
[null,null,null,null,"NUMBER OF","NUMBER OF","NUMBER OF","NUMBER OF",null,null,"SALARIES"]
[null," ",null,null,"EMPLOYEES","EMPLOYEES","EMPLOYEES WHO","EMPLOYEES",null,"PATIENT","PATIENT","Average"]
[null,"SCHEDULE B",null,null,"AT BEGINNING","HIRED DURING","LEFT EMPLOYMENT","AT THE END","TOTAL ","RELATED","RELATED","Hourly"]
[null,"LINE #",null,null,"OF THE YEAR","THE YEAR","DURING THE YEAR","OF THE YEAR","HOURS","HOURS","(SCHED. B)","Rate"]
[null,"47"," Activities",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I14","v":0},{"$f":"IFERROR(ROUND(+K15/J15,2),0)","v":0}]
[null,"49"," Social Services",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I16","v":0},{"$f":"IFERROR(ROUND(+K16/J16,2),0)","v":0}]
[null,"51"," RN",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I18","v":0},0]
[null,"52"," LPN",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I19","v":0},0]
[null,"53"," Aides and Orderlies",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I20","v":0},0]
[null,"58a"," Contracted Nursing Services - RN",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I25","v":0},0]
[null,"58b"," Contracted Nursing Services - LPN",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I26","v":0},0]
[null,"58c"," Contracted Nursing Services - Aides",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I27","v":0},0]
[null,59," Other Patient Care",null,null,null,null,null,null,null,null,0]
[null,"60"," Dietary",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I29","v":0},0]
[null,"72"," Physical Therapy",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I42","v":0},0]
[null,"74"," Occupational Therapy",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I44","v":0},0]
[null,"78"," Speech Therapy",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I48","v":0},0]
[null,"81"," Inhalation Therapy",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I51","v":0},0]
[null,"84b"," Central Supply Clerk Salaries",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I55","v":0},{"$f":"IFERROR(ROUND(+K29/J29,2),0)","v":0}]
[null,"85"," Laundry",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 1'!I56","v":0},0]
[null,"91"," Housekeeping",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 2'!I14","v":0},0]
[null,"94"," Beauty and Barber",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 2'!I17","v":0},0]
[null,111," Plant Operations",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 2'!I36","v":0},0]
[null,112," Administrator",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 2'!I37","v":0},0]
[null,113," Assistant Administrator",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 2'!I38","v":0},0]
[null,114," Other Administrative Salaries",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 2'!I39","v":0},0]
[null,115," Medical Records",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 2'!I40","v":0},0]
[null,"123a"," Owners' Compensation",null,null,null,null,null,null,null,{"$f":"+'Sch B Page 2'!I48","v":0},0]
[null,149," Other Administration",null,null,null,null,null,null,null,null,0]
[]
[]
[]
[null,172," NON-REIMBURSABLE / NON-ALLOWABLE COSTS",null,null,null,null,"AMOUNT",null,"LINE #"]
[null,null,"Outpatient Revenues"]
[null,null,"Pharmacy - Prescriptions Drugs Revenues"]
[null,null,"Lab and X-Ray Revenues"]
[null,null,"Prior Year Adjustments - Contractual Allowance"]
[null,null,"Outpatient Contractual Allowance"]
[null,null,"Pharmacy, Lab & X-Ray Contractual Allowance"]
[null,null,"Nurse Aide Training Expenses"]
[null,null,"Outpatient Expenses"]
[null,null,"Pharmacy - Prescriptions Drugs Expenses"]
[null,null,"Lab and X-Ray Expenses"]
[null,null,"Depreciation in Excess of Straight Line"]
[null,null,"Depreciation of Donated Assets and Gifts"]
[null,null,"Depreciation of Assets Purchased with Restricted Funds"]
[null,null,"Excess Owner's Compensation"]
[null,null,"Legal"]
[null,null," a)","Non-patient Related"]
[null,null," b) ","Litigation involving the Department of Social Services "]
[null,null,"Life Insurance Premiums"]
[null,null,"Taxes - Income and Exemption Available"]
[null,null,"Contributions and Donations"]
[null,null,"Gift Shop"]
[null,null,"Nursing Facility Reimbursement Allowance"]
[null,null,"Other Items Billable to Other Programs"]
[null,null,"Ambulance / Emergency medical transportation - residents"]
[null,null,"Non-emergency medical transportation - residents"]
[null,null,"Fund Raising"]
[null,null,"Increased Capital Cost as a Result of Change of Ownership"]
[null,null,"Loss on Disposal of Assets"]
[null,null,"Prior Year Adjustments - Other Expenses"]
[null,null,"Related Party Transactions"]
[null,null," a)"]
[null,null," b)"]
[null,null," c)"]
[null,null," d)"]
[null,null," e)"]
[null,null," f)"]
[null,null,"Research "]
[null,null,"Resident Personal Purchases Expense"]
[null,null,"Social Services - Title XX"]
[null,null,"Other (list)"]
[null,null,null,null,null,null,null,"                                                                                                                                                                                                                                                                                                                                                                                                                                                            "]

{"sheet":"Sch M","index":15,"n_rows":39,"n_cols":9,"rows_kept":39,"cut":false,"hidden":false,"merged":[[5,1,5,8],[7,1,7,8],[0,3,0,8],[2,3,2,4],[2,6,2,7]]}
[null,"PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
[null,"PERIOD OF REPORT:  FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
[null,"SCHEDULE M"]
[]
[null,"NURSE AIDE TRAINING"]
[]
[]
[null,"Nurse aide training is an unallowable cost after October 1, 1990.  The cost of nurse aide training needs to be removed from "]
[null,"allowable cost.  Nurse aide training cost includes, but is not limited to, the following:  RN instructor; books, supplies, contracted"]
[null,"cost such as vocational school, supervisor for the 100 hours on-the-job training, etc.  Nurse aide training cost does not include "]
[null,"aide salary during training and testing, aide salary for the 100 hours on-the-job training, and any indirect allocated costs such "]
[null,"as utilities, depreciation, etc.  Each facility may have unique circumstances that may need to be addressed individually."]
[]
[]
[null,"SCHEDULE B",null,null,null,null,null,null,"PATIENT RELATED"]
[null,"LINE #",null,null,null,null,null,null,"EXPENSES"]
[null,"51"," RN Instructor (include time for classroom and on-the-job training)"]
[null,"52"," LPN Instructor (include time for on-the-job training)"]
[null,"57"," Nurse Aide Training - Books, supplies, contracted cost, etc."]
[null,null," List Others:"]
[null,null,null,"Reimbursement to certified nurses aide"]
[null,null,null,"Examiners"]
[]
[]
[null,66,null,"Payroll Tax"]
[null,67,null,"Employee Benefits"]
[null,68,null,"Workers' Compensation "]
[]
[]
[null,"NUMBER OF AIDES ATTENDING TRAINING"]
[]
[null,"NUMBER OF AIDES RECEIVING CERTIFICATION"]
[]
[null,"NUMBER OF RN HOURS FOR ABOVE SALARY INCLUDED ON SCHEDULE K"]
[]
[null,"NUMBER OF LPN HOURS FOR ABOVE SALARY INCLUDED ON SCHEDULE K"]

{"sheet":"WS 1 - Non Related (NR)","index":16,"n_rows":64,"n_cols":6,"rows_kept":64,"cut":false,"hidden":false,"merged":[[13,1,13,2],[18,1,18,2],[19,1,19,2],[0,2,0,7],[2,2,2,3],[2,5,2,6],[5,0,5,7],[7,0,7,7],[12,1,12,2],[41,1,41,2],[29,1,29,2],[20,1,20,2],[14,1,14,2],[15,1,15,2],[16,1,16,2],[17,1,17,2]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT: FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
["WORKSHEET 1"]
[]
["ADJUSTMENT FOR NON-RELATED ACTIVITIES"]
[]
[]
["I.  What types of services are included in the facility's complex? "]
[]
[null,null,null,null,"Are Separate","Are Expenses"]
[null,null,null,"Number of","Accounts Maintained","Included on"]
[null,null,null,"Beds/Units","For These Areas","Sch B"]
[null,"Skilled Nursing Facility"]
[null,"Intermediate Care Facility"]
[null,"Assisted Living Facility"]
[null,"Assisted Living Facility **"]
[null,"Residential Care Facility (RCF I)"]
[null,"Residential Care Facility (RCF II) *"]
[null,"Independent Living Quarters"]
[null,"Apartments"]
[null,"Houses"]
[null,"Adult Day Care"]
[null,"Child Day Care"]
[null,"Management Services"]
[null,"Leasing"]
[null,"Other (Provide Description)"]
[]
[]
[null,"*  Continues to comply with former RCFII requirements"]
[null,"** Able to admit residents needing more than minimal assistance to safely evacuate"]
[]
["II.  NON-CERTIFIED ACTIVITIES"]
[]
["The provider's operating revenues and expenses may be allocated between Certified and Non-Certified activities based upon"]
["patient days, bed days, the allocation basis specified below (See Worksheet 1 instructions), or another approved allocation basis.  "]
["Prior written approval must be obtained from the Missouri Department of Social Services, Division of Medical Services, if any other "]
["allocation basis is to be utilized or changed from the prior year."]
[]
[null,"SECTION",null,null,"ALLOCATION BASIS"]
[]
[null,"Revenue"]
[]
[null,"   Routine Services",null,null,"Actual Revenue Generated"]
[null,"   Ancillary Services",null,null,"Actual Revenue Generated"]
[null,"   Other Revenues",null,null,"Actual Revenue Generated / Patient Days"]
[null,"   Deductions from Revenue",null,null,"Actual deductions incurred"]
[]
[]
[null,"Expenses"]
[]
[null,"   Patient Care",null,null,"Staff Hours / Patient Days"]
[null,null,null,null,"(Attach time study for staff hours allocation)"]
[null,"   Dietary ",null,null,"Meals Served / Patient Days"]
[null,"   Therapies and Related Supplies",null,null,"Charge Ratio / Patient Days"]
[null,"   Laundry",null,null,"Pounds of Laundry Processed / Patient Days"]
[null,"   Housekeeping *",null,null,"Square Feet / Bed Days / Patient Days"]
[null,"   Plant Operations *",null,null,"Square Feet / Bed Days / Patient Days"]
[null,"   Adminstrative ",null,null,"Accumulated Cost / Patient Days"]
[]
[null,"* If occupancy difference between the certified and non-certified area is greater than 5%, "]
[null,"then bed days or square footage must be used."]

{"sheet":"WS 1 Alloc basis (NR)","index":17,"n_rows":60,"n_cols":9,"rows_kept":60,"cut":false,"hidden":false,"merged":[[59,0,59,7],[58,0,58,7],[57,0,57,7],[56,0,56,7],[28,0,28,7],[52,0,52,7],[51,0,51,7],[44,0,44,7],[43,0,43,7],[42,0,42,7],[36,0,36,7],[45,0,45,7],[50,0,50,7],[49,0,49,7],[38,0,38,7],[37,0,37,7],[0,2,0,8],[2,6,2,7],[7,0,7,8],[2,2,2,4],[14,0,14,7],[16,0,16,7],[15,0,15,7],[30,0,30,7],[29,0,29,7],[35,0,35,7],[31,0,31,7],[17,0,17,7]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT: FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
["WORKSHEET 1"]
[]
["ALLOCATION BASIS - STATISTICS"]
[]
["ACTUAL - Record amounts of actual in appropriate column."]
[]
[]
["PATIENT DAYS"]
[]
["Total Patient Days Non-Certified"]
["Total Patient Days Certified"]
["Total Patient Days",null,null,null,null,null,null,null,{"$f":"SUM(H15:I16)","v":0}]
["    Percentage of Non-Certified Patient Days to Total Patient Days",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I15/I17,4),0)","v":0}]
[]
["STAFF HOURS"]
[null,null,null,null,null,null,"RN","LPN","Aides"]
["Staff Hours in Non-Certified Area"]
["Staff Hours in Certified Area"]
["Total Staff Hours",null,null,null,null,null,{"$f":"SUM(G22:G23)","v":0},{"$f":"SUM(H22:H23)","v":0},{"$f":"SUM(I22:I23)","v":0}]
["    Percentage of Staff Hours in Non-Certified Area to Total Staff Hours",null,null,null,null,null,{"$f":"IFERROR(ROUND(+G22/G24,4),0)","v":0},{"$f":"IFERROR(ROUND(+H22/H24,4),0)","v":0},{"$f":"IFERROR(ROUND(+I22/I24,4),0)","v":0}]
[]
["MEALS SERVED"]
[]
["Meals Served to Patients in Non-Certified Area"]
["Meals Served to Patients in Certified Area"]
["Total Meals Served",null,null,null,null,null,null,null,{"$f":"SUM(I29:I30)","v":0}]
["    Percentage of Meals Served to Patients in Non-Certified Area to Total Meals Served",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I29/I31,4),0)","v":0}]
[]
["POUNDS OF LAUNDRY"]
[]
["Pounds of Laundry from Non-Certified Area"]
["Pounds of Laundry from Certified Area"]
["Total Pounds of Laundry",null,null,null,null,null,null,null,{"$f":"SUM(I36:I37)","v":0}]
["    Percentage of Laundry Pounds from Non-Certified Area to Total Laundry Pounds",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I36/I38,4),0)","v":0}]
[]
["SQUARE FEET"]
[]
["Square Feet in Non-Certified Area"]
["Square Feet in Certified Area"]
["Total Square Feet",null,null,null,null,null,null,null,{"$f":"SUM(I43:I44)","v":0}]
["    Percentage of Square Feet in Non-Certified Area to Total Square Feet",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I43/I45,4),0)","v":0}]
[]
["BED DAYS"]
[]
["Bed Days in Non-Certified Area"]
["Bed Days in Certified Area"]
["Total Bed Days",null,null,null,null,null,null,null,{"$f":"SUM(I50:I51)","v":0}]
["    Percentage of Bed Days in Non-Certified Area to Total Bed Days",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I50/I52,4),0)","v":0}]
[]
["ACCUMULATED COST"]
[]
["Accumulated Cost for Non-Certified Area"]
["Accumulated Cost for Certified Area"]
["Total Accumulated Cost",null,null,null,null,null,null,null,{"$f":"SUM(I57:I58)","v":0}]
["    Percentage of Accumulated Cost for Non-Certified Area to Total Accumulated Cost",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I57/I59,4),0)","v":0}]

{"sheet":"WS 1 Rev (NR)","index":18,"n_rows":56,"n_cols":9,"rows_kept":56,"cut":false,"hidden":false,"merged":[[48,0,48,5],[0,2,0,8],[2,3,2,4],[2,6,2,7],[10,0,10,5],[12,0,12,5],[28,0,28,5]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
["WORKSHEET 1"]
[]
[]
[]
[null,null,null,null,null,null,"GENERAL","NON-CERTIFIED","NON-CERTIFIED"]
["ALLOCATION OF REVENUES",null,null,null,null,null,"LEDGER","ALLOCATION","COST"]
[null,null,null,null,null,null,"ADJUSTED COST","PERCENTAGE","ADJUSTMENT"]
["ROUTINE SERVICES"]
[10," Room and Board"]
["ANCILLARY SERVICES"]
[11," Physician Services"]
[12," Physical Therapy"]
[13," Occupational Therapy"]
[14," Pharmacy"]
[15," Medicial Supplies"]
[16," Speech and Hearing"]
[17," Laboratory and X-Ray"]
[18," Inhalation Therapy"]
[19," Equipment Rental"]
[20," Nutritional Therapy/PEN "]
[21," Other - Schedule A-1 "]
[22," SUBTOTAL - ANCILLARY SERVICES",null,null,null,null,{"$f":"SUM(G16:G26)","v":0},null,{"$f":"SUM(I16:I26)","v":0}]
[]
["OTHER REVENUE"]
[23," Meals Sold"]
[24," Telephone "]
[25," Purchase Discount"]
[26," Room Reservation"]
[27," Barber and Beauty Shop"]
[28," Personal Services"]
[29," Activity Income"]
[30," Donated Services"]
[31," Donated Commodities"]
["32a","Gifts - Restricted"]
["32b","Gifts - Unrestricted"]
[33," Rental Income"]
[34," Interest Income "]
[35," Tax Revenues"]
[36," Personal Laundry"]
[37," Other - Schedule A-1"]
[38," SUBTOTAL - OTHER REVENUES",null,null,null,null,{"$f":"SUM(G30:G45)","v":0},null,{"$f":"SUM(I30:I45)","v":0}]
[39," GROSS REVENUES",null,null,null,null,{"$f":"+G14+G27+G46","v":0},null,{"$f":"+I14+I27+I46","v":0}]
[]
["DEDUCTIONS FROM REVENUES"]
[40," Charity Services"]
[41," Contractual Allowance"]
[42," Provision for Bad Debts"]
[43," Other - Schedule A-1"]
[44," TOTAL DEDUCTIONS",null,null,null,null,{"$f":"SUM(G50:G53)","v":0},null,{"$f":"SUM(I50:I53)","v":0}]
[null," "]
[45," NET REVENUES",null,null,null,null,{"$f":"+G47-G54","v":0},null,{"$f":"+I47-I54","v":0}]

{"sheet":"WS 1 Exp 1st (NR)","index":19,"n_rows":62,"n_cols":8,"rows_kept":62,"cut":false,"hidden":false,"merged":[[38,0,38,4],[0,2,0,6],[2,2,2,3],[2,5,2,6],[4,0,4,7],[8,0,8,4],[10,0,10,4]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
["WORKSHEET 1"]
[]
[null,null,null,null,null,"GENERAL","NON-CERTIFIED ","NON-CERTIFIED"]
[null,null,null,null,null,"LEDGER","ALLOCATION","COST"]
["ALLOCATION OF EXPENDITURES",null,null,null,null,"ADJUSTED COST","PERCENTAGE","ADJUSTMENT"]
[]
["PATIENT CARE"]
[46," Professional Services"]
[47," Activities - Salaries"]
[48," Activities - Supplies"]
[49," Social Services - Salaries"]
[50," Social Services - Supplies"]
[51," RN "]
[52," LPN"]
[53," Aides and Orderlies"]
[54," Medical Supplies"]
[55," Non-Prescription Drugs"]
[56," Utilization Review"]
[57," Nurse Aide Training "]
["58a"," Contracted Nursing Services - RN"]
["58b"," Contracted Nursing Services - LPN"]
["58c"," Contracted Nursing Services - Aides"]
[59," Other Patient Care - Schedule B-1"]
[60," Dietary Salaries"]
[61," Dietary Consultant"]
[62," Raw Food"]
[63," Dietary Supplies"]
[64," Other Dietary - Schedule B-1"]
[65," In-Service Education"]
[66," Payroll Taxes"]
[67," Employee Benefits"]
[68," Workers' Compensation"]
[69]
[70," SUBTOTAL - PATIENT CARE",null,null,null,{"$f":"SUM(F12:F37)","v":0},null,{"$f":"SUM(H12:H37)","v":0}]
["ANCILLARY "]
[71," Physician Service"]
[72," Physical Therapy Salaries"]
[73," Physical Therapy Supplies/Contracted Services"]
[74," Occupational Therapy Salaries"]
[75," Occupational Therapy Supplies/Contracted Services"]
[76," Pharmacy and Drugs Sold"]
[77," Medical Supplies Sold"]
[78," Speech Therapy Salaries"]
[79," Speech Therapy Supplies/Contracted Services"]
[80," Lab & X-Ray"]
[81," Inhalation Therapy Salaries"]
[82," Inhalation Therapy Supplies/Contracted Services"]
[83," Nutritional Therapy/PEN Supplies"]
["84a"," Other Ancillary - Schedule B-1"]
["84b"," Central Supply Clerk Salaries"]
[85," Laundry Salaries"]
[86," Laundry Supplies"]
[87," Linen and Bedding"]
[88," Outside Laundry Service"]
[89," Other Laundry - Schedule B-1"]
[90," SUBTOTAL CARRY FORWARD",null,null,null,{"$f":"SUM(F40:F59)","v":0},null,{"$f":"SUM(H40:H59)","v":0}]
[]
[null,null,null,null," "]

{"sheet":"WS 1 Exp 2nd (NR)","index":20,"n_rows":56,"n_cols":8,"rows_kept":56,"cut":false,"hidden":false,"merged":[[22,0,22,4],[32,0,32,4],[0,2,0,6],[2,2,2,3],[2,5,2,6],[4,0,4,7],[8,0,8,4],[9,0,9,4]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
["WORKSHEET 1"]
[" "]
[null,null,null,null,null,"GENERAL","NON-CERTIFIED ","NON-CERTIFIED"]
[null,null,null,null,null,"LEDGER","ALLOCATION","COST"]
["ALLOCATION OF EXPENDITURES",null,null,null,null,"ADJUSTED COST","PERCENTAGE","ADJUSTMENT"]
["ANCILLARY - Continued"]
[null,"SUBTOTAL - CARRIED FORWARD",null,null,null,{"$f":"+'WS 1 Exp 1st (NR)'!F60","v":0},null,{"$f":"+'WS 1 Exp 1st (NR)'!H60","v":0}]
[91," Housekeeping Salaries"]
[92," Housekeeping Supplies"]
[93," Other Housekeeping - Schedule B-1"]
[97," Beauty and Barber Shop Salaries"]
[95," Beauty and Barber Shop Supplies/Contracted Services"]
[96," In-Service Education"]
[97," Payroll Taxes"]
[98," Employee Benefits"]
[99," Workers' Compensation"]
[100]
[101," SUBTOTAL - ANCILLARY",null,null,null,{"$f":"SUM(F11:F21)","v":0},null,{"$f":"SUM(H11:H21)","v":0}]
["CAPITAL"]
[102," Amortization (excluding organizational costs)"]
[103," Rent/Lease"]
[104," Depreciation (excluding vehicles)"]
[105," Interest - Real Estate "]
[106," Interest - Other (excluding vehicles)"]
[107," Insurance - Property"]
[108," Real Estate Taxes"]
[109," Personal Property Taxes"]
[110," SUBTOTAL - CAPITAL",null,null,null,{"$f":"SUM(F24:F31)","v":0},null,{"$f":"SUM(H24:H31)","v":0}]
["ADMINISTRATION"]
[111," Plant Operation Salaries"]
[112," Administrator Salary"]
[113," Assistant Administrator Salary"]
[114," Other Administrative Salaries"]
[115," Medical Records Salaries"]
[116," Utilities"]
[117," Maintenance and Repairs"]
[118," Plant Operation Supplies"]
[119," Other Plant Operations - Schedule B-1"]
[120," Medical Records Supplies/Contracted Services"]
[121," Management Fees"]
[122," Home Office"]
["123a"," Owners' Compensation"]
["123b"," Directors' Fees"]
[124," Legal"]
[125," Accounting "]
[126," Advertising - Employment Ads"]
[127," Advertising - Promotional and Other"]
[128," Amortization (organizational costs)"]
[129," Telephone"]
[130," Travel and Entertainment"]
[131," Seminars"]
[132," SUBTOTAL - CARRY FORWARD",null,null,null,{"$f":"SUM(F34:F55)","v":0},null,{"$f":"SUM(H34:H55)","v":0}]

{"sheet":"ws 1Exp 3rd (NR)","index":21,"n_rows":41,"n_cols":8,"rows_kept":41,"cut":false,"hidden":false,"merged":[[29,0,29,4],[0,2,0,6],[2,2,2,3],[2,5,2,6],[4,0,4,7],[7,0,7,4],[9,0,9,4]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
["WORKSHEET 1"]
[" "]
[null,null,null,null,null,"GENERAL","NON-CERTIFIED ","NON-CERTIFIED"]
["ALLOCATION OF EXPENDITURES",null,null,null,null,"LEDGER","ALLOCATION","COST"]
[null,null,null,null,null,"ADJUSTED COST","PERCENTAGE","ADJUSTMENT"]
["ADMINISTRATION - Continued"," SUBTOTAL - CARRY FORWARD"]
[null,"SUBTOTAL - CARRIED FORWARD",null,null,null,{"$f":"+'WS 1 Exp 2nd (NR)'!F56","v":0},null,{"$f":"+'WS 1 Exp 2nd (NR)'!H56","v":0}]
[133," Vehicle Depreciation "]
[134," Interest - Vehicle Loans"]
[135," Vehicle Expense"]
[136," Insurance (other than property and life)"]
[137," Office Supplies"]
[138," Data Processing"]
[139," Life Insurance"]
[140," Dues and Subscriptions"]
[141," Licenses "]
[142," Vending "]
[143," Cable T V"]
[144," In-Service Education"]
[145," Payroll Taxes"]
[146," Employee Benefits"]
[147," Workers' Compensation"]
[148]
[149," Other Administration - Schedule B-1"]
[150," SUBTOTAL - ADMINISTRATION",null,null,null,{"$f":"SUM(F11:F28)","v":0},null,{"$f":"SUM(H11:H28)","v":0}]
["OTHER"]
[151," Income Tax"]
[152," Contributions"]
[153," Gift Shop"]
[154," Life Insurance"]
[155," Penalties"]
[156," Nursing Facility Reimbursement Allowance"]
["157a"," Non-emergency Medical Transportation"]
["157b"," Emergency Medical Transportation"]
[158," Other - Schedule B-1"]
[159," SUBTOTAL - OTHER",null,null,null,{"$f":"SUM(F31:F39)","v":0},null,{"$f":"SUM(H31:H39)","v":0}]
[160," TOTAL EXPENSES",null,null,null,{"$f":"+F40+F29+'WS 1 Exp 2nd (NR)'!F32+'WS 1 Exp 2nd (NR)'!F22+'WS 1 Exp 1st (NR)'!F38","v":0},null,{"$f":"+H40+H29+'WS 1 Exp 2nd (NR)'!H32+'WS 1 Exp 2nd (NR)'!H22+'WS 1 Exp 1st (NR)'!H38","v":0}]

{"sheet":"WS 1 - Non Certified (NC)","index":22,"n_rows":64,"n_cols":6,"rows_kept":64,"cut":false,"hidden":false,"merged":[[12,1,12,2],[0,2,0,7],[2,2,2,3],[2,5,2,6],[5,0,5,7],[7,0,7,7],[19,1,19,2],[20,1,20,2],[41,1,41,2],[13,1,13,2],[14,1,14,2],[15,1,15,2],[16,1,16,2],[17,1,17,2],[18,1,18,2],[29,1,29,2]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT: FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
["WORKSHEET 1"]
[]
["ADJUSTMENT FOR NON-CERTIFIED ACTIVITIES"]
[]
[]
["I.  What types of services are included in the facility's complex? "]
[]
[null,null,null,null,"Are Separate","Are Expenses"]
[null,null,null,"Number of","Accounts Maintained","Included on"]
[null,null,null,"Beds/Units","For These Areas","Sch B"]
[null,"Skilled Nursing Facility"]
[null,"Intermediate Care Facility"]
[null,"Assisted Living Facility"]
[null,"Assisted Living Facility **"]
[null,"Residential Care Facility (RCF I)"]
[null,"Residential Care Facility (RCF II) *"]
[null,"Independent Living Quarters"]
[null,"Apartments"]
[null,"Houses"]
[null,"Adult Day Care"]
[null,"Child Day Care"]
[null,"Management Services"]
[null,"Leasing"]
[null,"Other (Provide Description)"]
[]
[]
[null,"*  Continues to comply with former RCFII requirements"]
[null,"** Able to admit residents needing more than minimal assistance to safely evacuate"]
[]
["II.  NON-CERTIFIED ACTIVITIES"]
[]
["The provider's operating revenues and expenses may be allocated between Certified and Non-Certified activities based upon"]
["patient days, bed days, the allocation basis specified below (See Worksheet 1 instructions), or another approved allocation basis.  "]
["Prior written approval must be obtained from the Missouri Department of Social Services, Division of Medical Services, if any other "]
["allocation basis is to be utilized or changed from the prior year."]
[]
[null,"SECTION",null,null,"ALLOCATION BASIS"]
[]
[null,"Revenue"]
[]
[null,"   Routine Services",null,null,"Actual Revenue Generated"]
[null,"   Ancillary Services",null,null,"Actual Revenue Generated"]
[null,"   Other Revenues",null,null,"Actual Revenue Generated / Patient Days"]
[null,"   Deductions from Revenue",null,null,"Actual deductions incurred"]
[]
[]
[null,"Expenses"]
[]
[null,"   Patient Care",null,null,"Staff Hours / Patient Days"]
[null,null,null,null,"(Attach time study for staff hours allocation)"]
[null,"   Dietary ",null,null,"Meals Served / Patient Days"]
[null,"   Therapies and Related Supplies",null,null,"Charge Ratio / Patient Days"]
[null,"   Laundry",null,null,"Pounds of Laundry Processed / Patient Days"]
[null,"   Housekeeping *",null,null,"Square Feet / Bed Days / Patient Days"]
[null,"   Plant Operations *",null,null,"Square Feet / Bed Days / Patient Days"]
[null,"   Adminstrative ",null,null,"Accumulated Cost / Patient Days"]
[]
[null,"* If occupancy difference between the certified and non-certified area is greater than 5%, "]
[null,"then bed days or square footage must be used."]

{"sheet":"WS 1 Alloc basis (NC)","index":23,"n_rows":60,"n_cols":9,"rows_kept":60,"cut":false,"hidden":false,"merged":[[38,0,38,7],[0,2,0,8],[2,6,2,7],[7,0,7,8],[2,2,2,4],[30,0,30,7],[14,0,14,7],[16,0,16,7],[29,0,29,7],[28,0,28,7],[15,0,15,7],[52,0,52,7],[51,0,51,7],[31,0,31,7],[42,0,42,7],[59,0,59,7],[58,0,58,7],[57,0,57,7],[56,0,56,7],[43,0,43,7],[36,0,36,7],[35,0,35,7],[50,0,50,7],[49,0,49,7],[44,0,44,7],[45,0,45,7],[37,0,37,7]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT: FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
["WORKSHEET 1"]
[]
["ALLOCATION BASIS - STATISTICS"]
[]
["ACTUAL - Record amounts of actual in appropriate column."]
[]
[]
["PATIENT DAYS"]
[]
["Total Patient Days Non-Certified"]
["Total Patient Days Certified"]
["Total Patient Days",null,null,null,null,null,null,null,{"$f":"SUM(H15:I16)","v":0}]
["     Percentage of Non-Certified Patient Days to Total Patient Days",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I15/I17,4),0)","v":0}]
[]
["STAFF HOURS"]
[null,null,null,null,null,null,"RN","LPN","Aides"]
["Staff Hours in Non-Certified Area"]
["Staff Hours in Certified Area"]
["Total Staff Hours",null,null,null,null,null,{"$f":"SUM(G22:G23)","v":0},{"$f":"SUM(H22:H23)","v":0},{"$f":"SUM(I22:I23)","v":0}]
["    Percentage of Staff Hours in Non-Certified Area to Total Staff Hours",null,null,null,null,null,{"$f":"IFERROR(ROUND(+G22/G24,4),0)","v":0},{"$f":"IFERROR(ROUND(+H22/H24,4),0)","v":0},{"$f":"IFERROR(ROUND(+I22/I24,4),0)","v":0}]
[]
["MEALS SERVED"]
[]
["Meals Served to Patients in Non-Certified Area"]
["Meals Served to Patients in Certified Area"]
["Total Meals Served",null,null,null,null,null,null,null,{"$f":"SUM(H29:I30)","v":0}]
["    Percentage of Meals Served to Patients in Non-Certified Area to Total Meals Served",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I29/I31,4),0)","v":0}]
[]
["POUNDS OF LAUNDRY"]
[]
["Pounds of Laundry from Non-Certified Area"]
["Pounds of Laundry from Certified Area"]
["Total Pounds of Laundry",null,null,null,null,null,null,null,{"$f":"SUM(H36:I37)","v":0}]
["    Percentage of Laundry Pounds from Non-Certified Area to Total Laundry Pounds",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I36/I38,4),0)","v":0}]
[]
["SQUARE FEET"]
[]
["Square Feet in Non-Certified Area"]
["Square Feet in Certified Area"]
["Total Square Feet",null,null,null,null,null,null,null,{"$f":"SUM(H43:I44)","v":0}]
["    Percentage of Square Feet in Non-Certified Area to Total Square Feet",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I43/I45,4),0)","v":0}]
[]
["BED DAYS"]
[]
["Bed Days in Non-Certified Area"]
["Bed Days in Certified Area"]
["Total Bed Days",null,null,null,null,null,null,null,{"$f":"SUM(H50:I51)","v":0}]
["    Percentage of Bed Days in Non-Certified Area to Total Bed Days",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I50/I52,4),0)","v":0}]
[]
["ACCUMULATED COST"]
[]
["Accumulated Cost for Non-Certified Area"]
["Accumulated Cost for Certified Area"]
["Total Accumulated Cost",null,null,null,null,null,null,null,{"$f":"SUM(H57:I58)","v":0}]
["    Percentage of Accumulated Cost for Non-Certified Area to Total Accumulated Cost",null,null,null,null,null,null,null,{"$f":"IFERROR(ROUND(+I57/I59,4),0)","v":0}]

{"sheet":"WS 1 Rev (NC)","index":24,"n_rows":56,"n_cols":9,"rows_kept":56,"cut":false,"hidden":false,"merged":[[48,0,48,5],[0,2,0,8],[2,3,2,4],[2,6,2,7],[10,0,10,5],[12,0,12,5],[28,0,28,5]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
[]
["WORKSHEET 1"]
[]
[]
[]
[null,null,null,null,null,null,"GENERAL","NON-CERTIFIED","NON-CERTIFIED"]
["ALLOCATION OF REVENUES",null,null,null,null,null,"LEDGER","ALLOCATION","COST"]
[null,null,null,null,null,null,"ADJUSTED COST","PERCENTAGE","ADJUSTMENT"]
["ROUTINE SERVICES"]
[10," Room and Board"]
["ANCILLARY SERVICES"]
[11," Physician Services"]
[12," Physical Therapy"]
[13," Occupational Therapy"]
[14," Pharmacy"]
[15," Medicial Supplies"]
[16," Speech and Hearing"]
[17," Laboratory and X-Ray"]
[18," Inhalation Therapy"]
[19," Equipment Rental"]
[20," Nutritional Therapy/PEN "]
[21," Other - Schedule A-1 "]
[22," SUBTOTAL - ANCILLARY SERVICES",null,null,null,null,{"$f":"SUM(G16:G26)","v":0},null,{"$f":"SUM(I16:I26)","v":0}]
[]
["OTHER REVENUE"]
[23," Meals Sold"]
[24," Telephone "]
[25," Purchase Discount"]
[26," Room Reservation"]
[27," Barber and Beauty Shop"]
[28," Personal Services"]
[29," Activity Income"]
[30," Donated Services"]
[31," Donated Commodities"]
["32a","Gifts - Restricted"]
["32b","Gifts - Unrestricted"]
[33," Rental Income"]
[34," Interest Income "]
[35," Tax Revenues"]
[36," Personal Laundry"]
[37," Other - Schedule A-1"]
[38," SUBTOTAL - OTHER REVENUES",null,null,null,null,{"$f":"SUM(G30:G45)","v":0},null,{"$f":"SUM(I30:I45)","v":0}]
[39," GROSS REVENUES",null,null,null,null,{"$f":"+G14+G27+G46","v":0},null,{"$f":"+I14+I27+I46","v":0}]
[]
["DEDUCTIONS FROM REVENUES"]
[40," Charity Services"]
[41," Contractual Allowance"]
[42," Provision for Bad Debts"]
[43," Other - Schedule A-1"]
[44," TOTAL DEDUCTIONS",null,null,null,null,{"$f":"SUM(G50:G53)","v":0},null,{"$f":"SUM(I50:I53)","v":0}]
[null," "]
[45," NET REVENUES",null,null,null,null,{"$f":"+G47-G54","v":0},null,{"$f":"+I47-I54","v":0}]

{"sheet":"WS 1 Exp 1st (NC)","index":25,"n_rows":62,"n_cols":8,"rows_kept":62,"cut":false,"hidden":false,"merged":[[38,0,38,4],[0,2,0,6],[2,2,2,3],[2,5,2,6],[4,0,4,7],[8,0,8,4],[10,0,10,4]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
["WORKSHEET 1"]
[]
[null,null,null,null,null,"GENERAL","NON-CERTIFIED ","NON-CERTIFIED"]
[null,null,null,null,null,"LEDGER","ALLOCATION","COST"]
["ALLOCATION OF EXPENDITURES",null,null,null,null,"ADJUSTED COST","PERCENTAGE","ADJUSTMENT"]
[]
["PATIENT CARE"]
[46," Professional Services"]
[47," Activities - Salaries"]
[48," Activities - Supplies"]
[49," Social Services - Salaries"]
[50," Social Services - Supplies"]
[51," RN "]
[52," LPN"]
[53," Aides and Orderlies"]
[54," Medical Supplies"]
[55," Non-Prescription Drugs"]
[56," Utilization Review"]
[57," Nurse Aide Training "]
["58a"," Contracted Nursing Services - RN"]
["58b"," Contracted Nursing Services - LPN"]
["58c"," Contracted Nursing Services - Aides"]
[59," Other Patient Care - Schedule B-1"]
[60," Dietary Salaries"]
[61," Dietary Consultant"]
[62," Raw Food"]
[63," Dietary Supplies"]
[64," Other Dietary - Schedule B-1"]
[65," In-Service Education"]
[66," Payroll Taxes"]
[67," Employee Benefits"]
[68," Workers' Compensation"]
[69]
[70," SUBTOTAL - PATIENT CARE",null,null,null,{"$f":"SUM(F12:F37)","v":0},null,{"$f":"SUM(H12:H37)","v":0}]
["ANCILLARY "]
[71," Physician Service"]
[72," Physical Therapy Salaries"]
[73," Physical Therapy Supplies/Contracted Services"]
[74," Occupational Therapy Salaries"]
[75," Occupational Therapy Supplies/Contracted Services"]
[76," Pharmacy and Drugs Sold"]
[77," Medical Supplies Sold"]
[78," Speech Therapy Salaries"]
[79," Speech Therapy Supplies/Contracted Services"]
[80," Lab & X-Ray"]
[81," Inhalation Therapy Salaries"]
[82," Inhalation Therapy Supplies/Contracted Services"]
[83," Nutritional Therapy/PEN Supplies"]
["84a"," Other Ancillary - Schedule B-1"]
["84b"," Central Supply Clerk Salaries"]
[85," Laundry Salaries"]
[86," Laundry Supplies"]
[87," Linen and Bedding"]
[88," Outside Laundry Service"]
[89," Other Laundry - Schedule B-1"]
[90," SUBTOTAL CARRY FORWARD",null,null,null,{"$f":"SUM(F40:F59)","v":0},null,{"$f":"SUM(H40:H59)","v":0}]
[]
[null,null,null,null," "]

{"sheet":"WS 1 Exp 2nd (NC)","index":26,"n_rows":56,"n_cols":8,"rows_kept":56,"cut":false,"hidden":false,"merged":[[22,0,22,4],[32,0,32,4],[0,2,0,6],[2,2,2,3],[2,5,2,6],[4,0,4,7],[8,0,8,4],[9,0,9,4]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
["WORKSHEET 1"]
[" "]
[null,null,null,null,null,"GENERAL","NON-CERTIFIED ","NON-CERTIFIED"]
[null,null,null,null,null,"LEDGER","ALLOCATION","COST"]
["ALLOCATION OF EXPENDITURES",null,null,null,null,"ADJUSTED COST","PERCENTAGE","ADJUSTMENT"]
["ANCILLARY - Continued"]
[null,"SUBTOTAL - CARRIED FORWARD",null,null,null,{"$f":"+'WS 1 Exp 1st (NC)'!F60","v":0},null,{"$f":"+'WS 1 Exp 1st (NC)'!H60","v":0}]
[91," Housekeeping Salaries"]
[92," Housekeeping Supplies"]
[93," Other Housekeeping - Schedule B-1"]
[97," Beauty and Barber Shop Salaries"]
[95," Beauty and Barber Shop Supplies/Contracted Services"]
[96," In-Service Education"]
[97," Payroll Taxes"]
[98," Employee Benefits"]
[99," Workers' Compensation"]
[100]
[101," SUBTOTAL - ANCILLARY",null,null,null,{"$f":"SUM(F11:F21)","v":0},null,{"$f":"SUM(H11:H21)","v":0}]
["CAPITAL"]
[102," Amortization (excluding organizational costs)"]
[103," Rent/Lease"]
[104," Depreciation (excluding vehicles)"]
[105," Interest - Real Estate "]
[106," Interest - Other (excluding vehicles)"]
[107," Insurance - Property"]
[108," Real Estate Taxes"]
[109," Personal Property Taxes"]
[110," SUBTOTAL - CAPITAL",null,null,null,{"$f":"SUM(F24:F31)","v":0},null,{"$f":"SUM(H24:H31)","v":0}]
["ADMINISTRATION"]
[111," Plant Operation Salaries"]
[112," Administrator Salary"]
[113," Assistant Administrator Salary"]
[114," Other Administrative Salaries"]
[115," Medical Records Salaries"]
[116," Utilities"]
[117," Maintenance and Repairs"]
[118," Plant Operation Supplies"]
[119," Other Plant Operations - Schedule B-1"]
[120," Medical Records Supplies/Contracted Services"]
[121," Management Fees"]
[122," Home Office"]
["123a"," Owners' Compensation"]
["123b"," Directors' Fees"]
[124," Legal"]
[125," Accounting "]
[126," Advertising - Employment Ads"]
[127," Advertising - Promotional and Other"]
[128," Amortization (organizational costs)"]
[129," Telephone"]
[130," Travel and Entertainment"]
[131," Seminars"]
[132," SUBTOTAL - CARRY FORWARD",null,null,null,{"$f":"SUM(F34:F55)","v":0},null,{"$f":"SUM(H34:H55)","v":0}]

{"sheet":"ws 1Exp 3rd (NC)","index":27,"n_rows":41,"n_cols":8,"rows_kept":41,"cut":false,"hidden":false,"merged":[[29,0,29,4],[0,2,0,6],[2,2,2,3],[2,5,2,6],[4,0,4,7],[7,0,7,4],[9,0,9,4]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
["WORKSHEET 1"]
[" "]
[null,null,null,null,null,"GENERAL","NON-CERTIFIED ","NON-CERTIFIED"]
["ALLOCATION OF EXPENDITURES",null,null,null,null,"LEDGER","ALLOCATION","COST"]
[null,null,null,null,null,"ADJUSTED COST","PERCENTAGE","ADJUSTMENT"]
["ADMINISTRATION - Continued"," SUBTOTAL - CARRY FORWARD"]
[null,"SUBTOTAL - CARRIED FORWARD",null,null,null,{"$f":"+'WS 1 Exp 2nd (NC)'!F56","v":0},null,{"$f":"+'WS 1 Exp 2nd (NC)'!H56","v":0}]
[133," Vehicle Depreciation "]
[134," Interest - Vehicle Loans"]
[135," Vehicle Expense"]
[136," Insurance (other than property and life)"]
[137," Office Supplies"]
[138," Data Processing"]
[139," Life Insurance"]
[140," Dues and Subscriptions"]
[141," Licenses "]
[142," Vending "]
[143," Cable T V"]
[144," In-Service Education"]
[145," Payroll Taxes"]
[146," Employee Benefits"]
[147," Workers' Compensation"]
[148]
[149," Other Administration - Schedule B-1"]
[150," SUBTOTAL - ADMINISTRATION",null,null,null,{"$f":"SUM(F11:F28)","v":0},null,{"$f":"SUM(H11:H28)","v":0}]
["OTHER"]
[151," Income Tax"]
[152," Contributions"]
[153," Gift Shop"]
[154," Life Insurance"]
[155," Penalties"]
[156," Nursing Facility Reimbursement Allowance"]
["157a"," Non-emergency Medical Transportation"]
["157b"," Emergency Medical Transportation"]
[158," Other - Schedule B-1"]
[159," SUBTOTAL - OTHER",null,null,null,{"$f":"SUM(F31:F39)","v":0},null,{"$f":"SUM(H31:H39)","v":0}]
[160," TOTAL EXPENSES",null,null,null,{"$f":"+F40+F29+'WS 1 Exp 2nd (NC)'!F32+'WS 1 Exp 2nd (NC)'!F22+'WS 1 Exp 1st (NC)'!F38","v":0},null,{"$f":"+H40+H29+'WS 1 Exp 2nd (NC)'!H32+'WS 1 Exp 2nd (NC)'!H22+'WS 1 Exp 1st (NC)'!H38","v":0}]

{"sheet":"WS 2","index":28,"n_rows":93,"n_cols":10,"rows_kept":93,"cut":false,"hidden":false,"merged":[[0,2,0,8],[2,2,2,4],[2,6,2,8],[8,0,8,8],[14,3,14,8],[16,3,16,8],[64,0,64,3],[10,3,10,8],[77,0,77,3],[12,3,12,8],[50,0,50,7],[51,0,51,7],[52,0,52,7]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT: FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
["WORKSHEET 2"]
[]
["FACILITY LEASE INFORMATION AND ADJUSTMENT SCHEDULE"]
[]
["LESSOR ENTITY IDENTIFICATION"]
[]
["NAME OF LESSOR"]
[]
["ADDRESS (STREET, CITY, STATE, ZIP)"]
[]
[]
[]
["TELEPHONE"]
[]
["STRAIGHT LINE DEPRECIATION EXPENSE"]
[null,null,null,null,null,null,null,"ACCUMULATED","DEPRECIATION"]
[null,null,null,null,"DATE",null,"LIFE ","DEPRECIATION","FOR THE "]
["DESCRIPTION",null,null,null,"ACQUIRED","COST","IN ","BEGINNING OF","REPORTING "]
[null,null,null,null,null,null,"YEARS","PERIOD","PERIOD"]
[]
["BUILDING:"]
[]
["Nursing Home"]
["Additions"]
["Other"]
[]
["Land Improvement"]
[]
["1)  TOTAL BUILDING",null,null,null,null,{"$f":"SUM(F25:F32)","v":0},null,{"$f":"SUM(H25:H32)","v":0},{"$f":"SUM(I25:I32)","v":0}]
[]
[]
["EQUIPMENT:"]
[]
["Building Equipment"]
["Major Movable Equipment"]
["Minor Movable Equipment"]
["Motor Vehicles"]
[]
["2) TOTAL EQUIPMENT",null,null,null,null,{"$f":"SUM(F38:F42)","v":0},null,{"$f":"SUM(H38:H42)","v":0},{"$f":"SUM(I38:I42)","v":0}]
[]
[]
["3) Total Depreciation Expense (sum of items 1 and 2)",null,null,null,null,null,null,null,{"$f":"+I33+I43","v":0}]
["4) Mortgage Interest Expense"]
["5) Property Taxes"]
["6) Property Insurance"]
["7) Miscellaneous (describe):"]
[]
[]
[]
["8) Total",null,null,null,null,null,null,null,{"$f":"SUM(I46:I53)","v":0}]
["9) Total Lease Expense to Provider"]
["10) Adjustment to Allowable Cost",null,null,null,null,null,null,null,{"$f":"+I54-I55","v":0}]
[]
["NOTE:  Information concerning allowable lease expense with related parties or organizations must also be reported on "]
["            Schedule G."]
[]
[]
[]
["VEHICLE SCHEDULE"]
["This table only needs to be completed for the vehicles included under the equipment section above."]
["DESCRIPTIONS:",null,null,null,null,"Vehicle 1","Vehicle 2","Vehicle 3","Vehicle 4","Vehicle 5"]
["Year"]
["Make"]
["Model"]
["Purchase Date:","Month"]
[null,"Year"]
["Purchase Price"]
["Purpose of Vehicle (Indicate each area below with % used for each purpose, if vehicle is used only for one, please indicate 100%.)"]
["Administrative"]
["Maintenance"]
["Resident Transportation - Medical"]
["Resident Transportation - Activities/Outings"]
["Other"]
["Vehicle Expenses:"]
["Interest"]
["Reported on Worksheet 2 Line #"]
["Lease Payments"]
["Reported on Worksheet 2 Line #"]
["Insurance"]
["Reported on Worksheet 2 Line #"]
["Maintenance & Gas"]
["Reported on Worksheet 2 Line #"]
["Personal Property Taxes"]
["Reported on Worksheet 2 Line #"]
["Depreciation"]
["Reported on Worksheet 2 Line #"]
["Other Exp. - Description"]
["Amount"]
["Reported on Worksheet 2 Line #"]

{"sheet":"WS 2 A","index":29,"n_rows":93,"n_cols":10,"rows_kept":93,"cut":false,"hidden":false,"merged":[[12,3,12,8],[0,2,0,8],[2,2,2,4],[2,6,2,8],[8,0,8,8],[10,3,10,8],[77,0,77,3],[14,3,14,8],[16,3,16,8],[50,0,50,7],[51,0,51,7],[52,0,52,7],[64,0,64,3]]}
["PROVIDER NAME: ",null,{"$f":"+'Front Page'!C8","v":0}]
[]
["PERIOD OF REPORT: FROM",null,{"$f":"+'Front Page'!E12","v":"00:00:00"},null,null,"TO",{"$f":"+'Front Page'!K12","v":"00:00:00"}]
[]
["WORKSHEET 2"]
[]
["FACILITY LEASE INFORMATION AND ADJUSTMENT SCHEDULE"]
[]
["LESSOR ENTITY IDENTIFICATION"]
[]
["NAME OF LESSOR"]
[]
["ADDRESS (STREET, CITY, STATE, ZIP)"]
[]
[]
[]
["TELEPHONE"]
[]
["STRAIGHT LINE DEPRECIATION EXPENSE"]
[null,null,null,null,null,null,null,"ACCUMULATED","DEPRECIATION"]
[null,null,null,null,"DATE",null,"LIFE ","DEPRECIATION","FOR THE "]
["DESCRIPTION",null,null,null,"ACQUIRED","COST","IN ","BEGINNING OF","REPORTING "]
[null,null,null,null,null,null,"YEARS","PERIOD","PERIOD"]
[]
["BUILDING:"]
[]
["Nursing Home"]
["Additions"]
["Other"]
[]
["Land Improvement"]
[]
["1)  TOTAL BUILDING",null,null,null,null,{"$f":"SUM(F25:F32)","v":0},null,{"$f":"SUM(H25:H32)","v":0},{"$f":"SUM(I25:I32)","v":0}]
[]
[]
["EQUIPMENT:"]
[]
["Building Equipment"]
["Major Movable Equipment"]
["Minor Movable Equipment"]
["Motor Vehicles"]
[]
["2) TOTAL EQUIPMENT",null,null,null,null,{"$f":"SUM(F38:F42)","v":0},null,{"$f":"SUM(H38:H42)","v":0},{"$f":"SUM(I38:I42)","v":0}]
[]
[]
["3) Total Depreciation Expense (sum of items 1 and 2)",null,null,null,null,null,null,null,{"$f":"+I33+I43","v":0}]
["4) Mortgage Interest Expense"]
["5) Property Taxes"]
["6) Property Insurance"]
["7) Miscellaneous (describe):"]
[]
[]
[]
["8) Total",null,null,null,null,null,null,null,{"$f":"SUM(I46:I53)","v":0}]
["9) Total Lease Expense to Provider"]
["10) Adjustment to Allowable Cost",null,null,null,null,null,null,null,{"$f":"+I54-I55","v":0}]
[]
["NOTE:  Information concerning allowable lease expense with related parties or organizations must also be reported on "]
["            Schedule G."]
[]
[]
[]
["VEHICLE SCHEDULE"]
["This table only needs to be completed for the vehicles included under the equipment section above."]
["DESCRIPTIONS:",null,null,null,null,"Vehicle 1","Vehicle 2","Vehicle 3","Vehicle 4","Vehicle 5"]
["Year"]
["Make"]
["Model"]
["Purchase Date:","Month"]
[null,"Year"]
["Purchase Price"]
["Purpose of Vehicle (Indicate each area below with % used for each purpose, if vehicle is used only for one, please indicate 100%.)"]
["Administrative"]
["Maintenance"]
["Resident Transportation - Medical"]
["Resident Transportation - Activities/Outings"]
["Other"]
["Vehicle Expenses:"]
["Interest"]
["Reported on Worksheet 2 Line #"]
["Lease Payments"]
["Reported on Worksheet 2 Line #"]
["Insurance"]
["Reported on Worksheet 2 Line #"]
["Maintenance & Gas"]
["Reported on Worksheet 2 Line #"]
["Personal Property Taxes"]
["Reported on Worksheet 2 Line #"]
["Depreciation"]
["Reported on Worksheet 2 Line #"]
["Other Exp. - Description"]
["Amount"]
["Reported on Worksheet 2 Line #"]

{"sheet":"WS 3 Front Page","index":30,"n_rows":73,"n_cols":10,"rows_kept":73,"cut":false,"hidden":false,"merged":[[71,4,71,5],[38,1,40,11],[34,6,34,7],[34,8,34,10],[61,7,61,11],[61,1,61,5],[12,4,12,11],[18,2,18,3],[18,8,18,10],[14,4,14,5],[14,7,14,8],[18,5,18,6],[33,6,33,7],[33,8,33,10],[72,7,72,11],[62,7,62,11],[66,7,66,11],[67,7,67,11],[71,7,71,11],[8,4,8,11],[10,4,10,11],[0,0,0,12],[1,0,1,12],[3,0,3,12],[4,0,4,12],[5,0,5,12]]}
["MISSOURI DEPARTMENT OF SOCIAL SERVICES"]
["MO HEALTHNET DIVISION"]
[]
["WORKSHEET 3 "]
["HOME OFFICE COST REPORT "]
["(Related Management Company)"]
[]
[]
["1.","HOME OFFICE NAME:"]
[]
["2.","HOME OFFICE ADDRESS:"]
[]
["3.","TELEPHONE NUMBER:"]
[]
["4.","PERIOD OF REPORT: FROM",null,null,null,null,"TO"]
[]
["5.","TYPE OF CONTROL (SELECT ONE):"]
[null,"             "]
[null,null,"GOVERNMENT",null,null," NONPROFIT ORGANIZATION",null,null," PROPRIETARY"]
[]
[null,null,"GS","STATE",null,"NCO","CHURCH OPERATED",null,"PPP","PROPRIETORSHIP"]
[]
[null,null,"GC","COUNTY",null,"NCR","CHURCH RELATED",null,"PPT","PARTNERSHIP"]
[]
[null,null,"GD","DISTRICT",null,"NO","OTHER NON-PROFIT",null,"PC","CORPORATION"]
[]
[null,null,"GM","CITY",null,null,null,null,"PO","OTHER"]
[]
[null,null,"GO","OTHER",null,null,null,null,"LLC","LIMITED LIABILITY CORPORATION"]
[]
[]
["6."]
[null,null,"NUMBER OF NURSING HOMES AND BEDS:",null,null,null,"HOMES",null,"BEDS"]
[null,null,"Owned and Managed"]
[null,null,"Managed Only"]
[]
[]
["7."," OTHER BUSINESS INTEREST (EXPLAIN)"]
[]
[]
[]
[]
[]
["8."," CERTIFICATION STATEMENT:"]
[]
[null," MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE"]
[]
[null," PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER STATE OR FEDERAL LAW."]
[]
[]
[]
[null," I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying cost report, and"]
[]
[null," supporting schedules, and that to the best of my knowledge and belief, it is a true, correct, and complete statement "]
[]
[null," prepared from the books and records of the Home Office in accordance with applicable instructions, except as noted."]
[]
[]
[]
[]
[]
[]
[null,"NOTARY PUBLIC",null,null,null,null,null,"AUTHORIZED SIGNATURE"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,"TITLE"]
[]
[]
[]
[null," My Commission Expires"]
[null,null,null,null,null,null,null,"DATE"]

{"sheet":"WS 3 Pg 2","index":31,"n_rows":67,"n_cols":9,"rows_kept":67,"cut":false,"hidden":false,"merged":[[63,1,63,4],[64,1,64,4],[29,0,29,4],[0,3,0,8],[2,3,2,5],[2,7,2,8],[12,0,12,4],[23,1,23,4],[24,1,24,4],[25,1,25,4]]}
["Home Office Name:",null,null,{"$f":"+'WS 3 Front Page'!E9","v":0}]
[]
["PERIOD OF REPORT: FROM",null,null,{"$f":"+'WS 3 Front Page'!E15","v":"00:00:00"},null,null,"TO",{"$f":"+'WS 3 Front Page'!H15","v":"00:00:00"}]
[]
["WORKSHEET 3"]
[]
["STATEMENT OF REVENUES AND EXPENSES"]
[]
[]
[null,null,null,null,null,"PER ","ADJUSTMENTS","DIRECT","ADJUSTED"]
["DESCRIPTION",null,null,null,null,"GENERAL","TO ALLOWALBE","ALLOCATION","EXPENSES TO"]
[null,null,null,null,null,"LEDGER","COST","OF EXPENSES","BE ALLOCATED"]
["REVENUES"]
[9," Management Fees (Owned)",null,null,null,null,null,null,{"$f":"+F14+G14+H14","v":0}]
[10," Management Fees (Non-Owned)",null,null,null,null,null,null,{"$f":"+F15+G15+H15","v":0}]
[11," Accounting",null,null,null,null,null,null,0]
[12," Consulting",null,null,null,null,null,null,0]
[13," Maintenance",null,null,null,null,null,null,0]
[14," Rental and Leasing",null,null,null,null,null,null,0]
[15," Sale of Supplies",null,null,null,null,null,null,0]
[16," Interest Income",null,null,null,null,null,null,0]
[17," Sale of Assets",null,null,null,null,null,null,0]
[18," Other ",null,null,null,null,null,null,0]
[19,null,null,null,null,null,null,null,0]
[20,null,null,null,null,null,null,null,0]
[21,null,null,null,null,null,null,null,0]
[]
[22," TOTAL REVENUES",null,null,null,{"$f":"SUM(F14:F26)","v":0},{"$f":"SUM(G14:G26)","v":0},{"$f":"SUM(H14:H26)","v":0},{"$f":"SUM(I14:I26)","v":0}]
[]
["EXPENDITURES"]
[23," Officers Salaries",null,null,null,null,null,null,{"$f":"+F31+G31+H31","v":0}]
[24," Other Salaries",null,null,null,null,null,null,0]
[25," Payroll Taxes",null,null,null,null,null,null,0]
[26," Employee Benefits",null,null,null,null,null,null,0]
[27," Workers' Compensation",null,null,null,null,null,null,0]
[28," Amortization",null,null,null,null,null,null,0]
[29," Depreciation",null,null,null,null,null,null,0]
[30," Rental and Leasing",null,null,null,null,null,null,0]
[31," Interest Expense (Real Estate)",null,null,null,null,null,null,0]
[32," Insurance (Property)",null,null,null,null,null,null,0]
[33," Utilities",null,null,null,null,null,null,0]
[34," Repairs and Maintenance",null,null,null,null,null,null,0]
[35," Legal",null,null,null,null,null,null,0]
[36," Accounting",null,null,null,null,null,null,0]
[37," Telephone",null,null,null,null,null,null,0]
[38," Advertising",null,null,null,null,null,null,0]
[39," Insurance - Other",null,null,null,null,null,null,0]
[40," Interest Working Capital",null,null,null,null,null,null,0]
[41," Vehicle",null,null,null,null,null,null,0]
[42," Transportation",null,null,null,null,null,null,0]
[43," Supplies and Postage",null,null,null,null,null,null,0]
[44," Travel and Entertainment",null,null,null,null,null,null,0]
[45," Data Processing",null,null,null,null,null,null,0]
[46," Taxes and Licenses",null,null,null,null,null,null,0]
[47," Education ",null,null,null,null,null,null,0]
[48," Dues and Subscriptions",null,null,null,null,null,null,0]
[49," Contracted Services",null,null,null,null,null,null,0]
[50," Director Fees",null,null,null,null,null,null,0]
[51," Insurance - Life",null,null,null,null,null,null,0]
[52," Contributions",null,null,null,null,null,null,0]
[53," Bad Debts",null,null,null,null,null,null,0]
[54," Income Tax",null,null,null,null,null,null,0]
[55," Other ",null,null,null,null,null,null,0]
[56,null,null,null,null,null,null,null,0]
[57,null,null,null,null,null,null,null,0]
[]
[58," TOTAL EXPENSES",null,null,null,{"$f":"SUM(F31:F65)","v":0},{"$f":"SUM(G31:G65)","v":0},{"$f":"SUM(H31:H65)","v":0},{"$f":"SUM(I31:I65)","v":0}]

{"sheet":"WS 3 Adjust","index":32,"n_rows":68,"n_cols":9,"rows_kept":68,"cut":false,"hidden":false,"merged":[[59,1,59,4],[0,3,0,8],[2,3,2,4],[2,6,2,7],[10,0,10,4],[54,1,54,4],[55,1,55,4],[56,1,56,4],[57,1,57,4],[58,1,58,4],[65,1,65,4],[66,1,66,4],[60,1,60,4],[61,1,61,4],[62,1,62,4],[63,1,63,4],[64,1,64,4]]}
["HOME OFFICE NAME: ",null,null,{"$f":"+'WS 3 Front Page'!E9","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,null,{"$f":"+'WS 3 Front Page'!E15","v":"00:00:00"},null,"TO",{"$f":"+'WS 3 Front Page'!H15","v":"00:00:00"}]
[]
["WORKSHEET 3"]
[]
["NON-ALLOWABLE COST ADJUSTMENTS"]
[]
[]
[null,null,null,null,null,null,null,"LINE"]
["DESCRIPTION",null,null,null,null,"BASIS","AMOUNT","NO.","COMMENT"]
[]
["1."," Tax Penalties"]
["2."," Contributions"]
["3."," Bad Debts",null,null,null,null,{"$f":"+'WS 3 Pg 2'!F61","v":0},53]
["4."," Income Tax ",null,null,null,null,{"$f":"+'WS 3 Pg 2'!F62","v":0},54]
["5."," Amortization of Goodwill"]
["6."," Non-Compete Agreement Expense"]
["7."," Fund Raising Expenses"]
["8."," Life Insurance Premiums"]
["9."," Disposal Expenses of Non-Patient Care Assets"]
[null," or Subsidiaries"]
["10."," Depreciation in Excess of Straight Line"]
["11."," Excessive Advertising"]
["12."," Excessive Directors' Fees"]
["13."," Excessive Owners' and Directors' Compensation"]
["14."," Non-Working Directors' Salaries"]
["15."," Acquisition Expenses"]
[null,"    Accounting"]
[null,"    Legal"]
[null,"    Travel, transportation and vehicle"]
[null,"    Salaries and related expenses"]
[null,"    Telephone"]
[null,"    Other"]
[]
["16."," Related Party Expense Adjustments"]
[null,"    Rental"]
[null,"    Contracted Services"]
[null,"    Interest"]
[null,"    Depreciation"]
[null,"    Allocated Expenses"]
[null,"    Other"]
[]
["17."," Non-Healthcare Projects"]
[null,"    Accounting"]
[null,"    Legal"]
[null,"    Travel, transportation and vehicle"]
[null,"    Interest"]
[null,"    Depreciation"]
[null,"    Salaries and related expenses"]
[null,"    Facility property cost"]
[null,"    Other"]
[]
["18."," Other - List"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["19."," TOTAL",null,null,null,null,{"$f":"SUM(G13:G67)","v":0}]

{"sheet":"WS 3 Ident Rev","index":33,"n_rows":89,"n_cols":9,"rows_kept":89,"cut":false,"hidden":false,"merged":[[77,1,77,2],[79,1,79,2],[54,1,54,2],[53,1,53,2],[55,1,55,2],[67,1,67,2],[57,1,57,2],[75,1,75,2],[58,1,58,2],[59,1,59,2],[76,1,76,2],[86,0,86,2],[83,1,83,2],[84,1,84,2],[85,1,85,2],[78,1,78,2],[82,1,82,2],[80,1,80,2],[81,1,81,2],[49,1,49,2],[52,1,52,2],[50,1,50,2],[51,1,51,2],[74,1,74,2],[73,1,73,2],[62,1,62,2],[66,1,66,2],[61,1,61,2],[60,1,60,2],[56,1,56,2],[70,1,70,2],[71,1,71,2],[68,1,68,2],[69,1,69,2],[72,1,72,2],[48,1,48,2],[47,1,47,2],[36,1,36,2],[34,1,34,2],[37,1,37,2],[43,1,43,2],[44,1,44,2],[45,1,45,2],[46,1,46,2],[40,1,40,2],[42,1,42,2],[33,1,33,2],[38,1,38,2],[39,1,39,2],[35,1,35,2],[41,1,41,2],[15,1,15,2],[24,1,24,2],[22,1,22,2],[20,1,20,2],[23,1,23,2],[16,1,16,2],[17,1,17,2],[18,1,18,2],[19,1,19,2],[21,1,21,2],[14,1,14,2],[10,0,10,2],[13,1,13,2],[6,0,6,8],[0,2,0,8],[2,2,2,4],[2,6,2,7],[4,0,4,8],[25,1,25,2],[27,1,27,2],[32,1,32,2],[29,1,29,2],[30,1,30,2],[28,1,28,2],[31,1,31,2],[26,1,26,2]]}
["HOME OFFICE NAME: ",null,{"$f":"+'WS 3 Front Page'!E9","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'WS 3 Front Page'!E15","v":"00:00:00"},null,null,"TO",{"$f":"+'WS 3 Front Page'!H15","v":"00:00:00"}]
[]
["WORKSHEET 3"]
[]
["IDENTIFICATION OF REVENUES"]
[]
[]
[null,null,null,null,null,null,null,"RENTAL "]
["CHAIN COMPONENT NAME",null,null,"MANAGEMENT","ACCOUNTING","CONSULTING","MAINTENANCE","LEASING","OTHER"]
[]
[null,"RELATED"]
["1."]
["2."]
["3."]
["4."]
["5."]
["6."]
["7."]
["8."]
["9."]
["10."]
["11."]
["12."]
["13."]
["14."]
["15."]
["16."]
["17."]
["18."]
["19."]
["20."]
["21."]
["22."]
["23."]
["24."]
["25."]
["26."]
["27."]
["28."]
["29."]
["30."]
["31."]
["32."]
["33."]
["34."]
["35."]
["36."]
["37."]
["38."]
["39."]
["40."]
["41."]
["42."]
["43."]
["44."]
["45."]
["46."]
["47."]
["48."]
["49."]
["50."]
["SUBTOTAL",null,null,{"$f":"SUM(D14:D63)","v":0},0,0,0,0,0]
[]
[null,"NON-RELATED"]
["51."]
["52."]
["53."]
["54."]
["55."]
["56."]
["57."]
["58."]
["59."]
["60."]
["61."]
["62."]
["63."]
["64."]
["65."]
["66."]
["67."]
["68."]
["69."]
["70."]
["SUBTOTAL",null,null,{"$f":"SUM(D67:D86)","v":0},0,0,0,0,0]
[]
["71."," TOTAL",null,{"$f":"+D87+D64","v":0},0,0,0,0,0]

{"sheet":"WS 3 Direct All","index":34,"n_rows":87,"n_cols":9,"rows_kept":87,"cut":false,"hidden":false,"merged":[[58,1,58,3],[68,1,68,3],[67,1,67,3],[69,1,69,3],[65,1,65,3],[73,1,73,3],[84,1,84,3],[80,1,80,3],[81,1,81,3],[82,1,82,3],[83,1,83,3],[51,1,51,3],[52,1,52,3],[79,1,79,3],[64,0,64,3],[61,1,61,3],[66,1,66,3],[70,1,70,3],[72,1,72,3],[57,1,57,3],[78,1,78,3],[77,1,77,3],[71,1,71,3],[75,1,75,3],[76,1,76,3],[74,1,74,3],[60,1,60,3],[56,1,56,3],[59,1,59,3],[47,1,47,3],[40,1,40,3],[45,1,45,3],[46,1,46,3],[44,1,44,3],[48,1,48,3],[49,1,49,3],[42,1,42,3],[41,1,41,3],[43,1,43,3],[55,1,55,3],[53,1,53,3],[54,1,54,3],[50,1,50,3],[34,1,34,3],[36,1,36,3],[37,1,37,3],[38,1,38,3],[39,1,39,3],[35,1,35,3],[33,1,33,3],[29,1,29,3],[27,1,27,3],[28,1,28,3],[30,1,30,3],[32,1,32,3],[31,1,31,3],[16,1,16,3],[14,1,14,3],[23,1,23,3],[0,2,0,8],[2,2,2,4],[2,6,2,7],[10,1,10,3],[12,1,12,3],[13,1,13,3],[15,1,15,3],[22,1,22,3],[26,1,26,3],[20,1,20,3],[17,1,17,3],[18,1,18,3],[19,1,19,3],[21,1,21,3],[25,1,25,3],[24,1,24,3]]}
["HOME OFFICE NAME: ",null,{"$f":"+'WS 3 Front Page'!E9","v":0}]
[]
["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'WS 3 Front Page'!E15","v":"00:00:00"},null,null,"TO",{"$f":"+'WS 3 Front Page'!H15","v":"00:00:00"}]
[]
["WORKSHEET 3"]
[]
["DIRECT ALLOCATION OF EXPENSES"]
[]
[null," ",null,"TYPE OF EXPENSE"]
[" ",null,null,"BASIS OF ALLOCATION"," "]
[null,"CHAIN COMPONENT NAME",null,null,"AMOUNT","AMOUNT","AMOUNT","AMOUNT","TOTAL"]
["RELATED"]
["1.",{"$f":"+'WS 3 Ident Rev'!B14:C14","v":0},null,null,null,null,null,null,{"$f":"+E13+F13+G13+H13","v":0}]
["2.",{"$f":"+'WS 3 Ident Rev'!B15:C15","v":0},null,null,null,null,null,null,0]
["3.",{"$f":"+'WS 3 Ident Rev'!B16:C16","v":0},null,null,null,null,null,null,0]
["4.",{"$f":"+'WS 3 Ident Rev'!B17:C17","v":0},null,null,null,null,null,null,0]
["5.",{"$f":"+'WS 3 Ident Rev'!B18:C18","v":0},null,null,null,null,null,null,0]
["6.",{"$f":"+'WS 3 Ident Rev'!B19:C19","v":0},null,null,null,null,null,null,0]
["7.",{"$f":"+'WS 3 Ident Rev'!B20:C20","v":0},null,null,null,null,null,null,0]
["8.",{"$f":"+'WS 3 Ident Rev'!B21:C21","v":0},null,null,null,null,null,null,0]
["9.",{"$f":"+'WS 3 Ident Rev'!B22:C22","v":0},null,null,null,null,null,null,0]
["10.",{"$f":"+'WS 3 Ident Rev'!B23:C23","v":0},null,null,null,null,null,null,0]
["11.",{"$f":"+'WS 3 Ident Rev'!B24:C24","v":0},null,null,null,null,null,null,0]
["12.",{"$f":"+'WS 3 Ident Rev'!B25:C25","v":0},null,null,null,null,null,null,0]
["13.",{"$f":"+'WS 3 Ident Rev'!B26:C26","v":0},null,null,null,null,null,null,0]
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["35.",{"$f":"+'WS 3 Ident Rev'!B48:C48","v":0},null,null,null,null,null,null,0]
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["37.",{"$f":"+'WS 3 Ident Rev'!B50:C50","v":0},null,null,null,null,null,null,0]
["38.",{"$f":"+'WS 3 Ident Rev'!B51:C51","v":0},null,null,null,null,null,null,0]
["39.",{"$f":"+'WS 3 Ident Rev'!B52:C52","v":0},null,null,null,null,null,null,0]
["40.",{"$f":"+'WS 3 Ident Rev'!B53:C53","v":0},null,null,null,null,null,null,0]
["41.",{"$f":"+'WS 3 Ident Rev'!B54:C54","v":0},null,null,null,null,null,null,0]
["42.",{"$f":"+'WS 3 Ident Rev'!B55:C55","v":0},null,null,null,null,null,null,0]
["43.",{"$f":"+'WS 3 Ident Rev'!B56:C56","v":0},null,null,null,null,null,null,0]
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["46.",{"$f":"+'WS 3 Ident Rev'!B59:C59","v":0},null,null,null,null,null,null,0]
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["50.",{"$f":"+'WS 3 Ident Rev'!B63:C63","v":0},null,null,null,null,null,null,0]
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["53.",{"$f":"+'WS 3 Ident Rev'!B69:C69","v":0},null,null,null,null,null,null,0]
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["56.",{"$f":"+'WS 3 Ident Rev'!B72:C72","v":0},null,null,null,null,null,null,0]
["57.",{"$f":"+'WS 3 Ident Rev'!B73:C73","v":0},null,null,null,null,null,null,0]
["58.",{"$f":"+'WS 3 Ident Rev'!B74:C74","v":0},null,null,null,null,null,null,0]
["59.",{"$f":"+'WS 3 Ident Rev'!B75:C75","v":0},null,null,null,null,null,null,0]
["60.",{"$f":"+'WS 3 Ident Rev'!B76:C76","v":0},null,null,null,null,null,null,0]
["61.",{"$f":"+'WS 3 Ident Rev'!B77:C77","v":0},null,null,null,null,null,null,0]
["62.",{"$f":"+'WS 3 Ident Rev'!B78:C78","v":0},null,null,null,null,null,null,0]
["63.",{"$f":"+'WS 3 Ident Rev'!B79:C79","v":0},null,null,null,null,null,null,0]
["64.",{"$f":"+'WS 3 Ident Rev'!B80:C80","v":0},null,null,null,null,null,null,0]
["65.",{"$f":"+'WS 3 Ident Rev'!B81:C81","v":0},null,null,null,null,null,null,0]
["66.",{"$f":"+'WS 3 Ident Rev'!B82:C82","v":0},null,null,null,null,null,null,0]
["67.",{"$f":"+'WS 3 Ident Rev'!B83:C83","v":0},null,null,null,null,null,null,0]
["68.",{"$f":"+'WS 3 Ident Rev'!B84:C84","v":0},null,null,null,null,null,null,0]
["69.",{"$f":"+'WS 3 Ident Rev'!B85:C85","v":0},null,null,null,null,null,null,0]
["70.",{"$f":"+'WS 3 Ident Rev'!B86:C86","v":0},null,null,null,null,null,null,{"$f":"+E85+F85+G85+H85","v":0}]
["SUBTOTAL",null,null,null,{"$f":"SUM(E66:E85)","v":0},{"$f":"SUM(F66:F85)","v":0},{"$f":"SUM(G66:G85)","v":0},{"$f":"SUM(H66:H85)","v":0},{"$f":"SUM(I66:I85)","v":0}]
["71."," TOTAL",null,null,{"$f":"+E86+E63","v":0},{"$f":"+F86+F63","v":0},{"$f":"+G86+G63","v":0},{"$f":"+H86+H63","v":0},{"$f":"+I86+I63","v":0}]

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["PERIOD OF REPORT:  FROM                                ",null,{"$f":"+'WS 3 Front Page'!E15","v":"00:00:00"},null,null,"TO",{"$f":"+'WS 3 Front Page'!H15","v":"00:00:00"}]
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["WORKSHEET 3"]
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["ALLOCATION OF EXPENSES AND BASIS"]
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["RELATED"]
["1.",{"$f":"+'WS 3 Direct All'!B13:D13","v":0},null,null,null,{"$f":"IFERROR(ROUND(+E13/$E$87,6),0)","v":0},{"$f":"+F13*$G$87","v":0},{"$f":"+'WS 3 Direct All'!I13","v":0},{"$f":"+G13+H13","v":0}]
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["18.",{"$f":"+'WS 3 Direct All'!B30:D30","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I30","v":0},0]
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["25.",{"$f":"+'WS 3 Direct All'!B37:D37","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I37","v":0},0]
["26.",{"$f":"+'WS 3 Direct All'!B38:D38","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I38","v":0},0]
["27.",{"$f":"+'WS 3 Direct All'!B39:D39","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I39","v":0},0]
["28.",{"$f":"+'WS 3 Direct All'!B40:D40","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I40","v":0},0]
["29.",{"$f":"+'WS 3 Direct All'!B41:D41","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I41","v":0},0]
["30.",{"$f":"+'WS 3 Direct All'!B42:D42","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I42","v":0},0]
["31.",{"$f":"+'WS 3 Direct All'!B43:D43","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I43","v":0},0]
["32.",{"$f":"+'WS 3 Direct All'!B44:D44","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I44","v":0},0]
["33.",{"$f":"+'WS 3 Direct All'!B45:D45","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I45","v":0},0]
["34.",{"$f":"+'WS 3 Direct All'!B46:D46","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I46","v":0},0]
["35.",{"$f":"+'WS 3 Direct All'!B47:D47","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I47","v":0},0]
["36.",{"$f":"+'WS 3 Direct All'!B48:D48","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I48","v":0},0]
["37.",{"$f":"+'WS 3 Direct All'!B49:D49","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I49","v":0},0]
["38.",{"$f":"+'WS 3 Direct All'!B50:D50","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I50","v":0},0]
["39.",{"$f":"+'WS 3 Direct All'!B51:D51","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I51","v":0},0]
["40.",{"$f":"+'WS 3 Direct All'!B52:D52","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I52","v":0},0]
["41.",{"$f":"+'WS 3 Direct All'!B53:D53","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I53","v":0},0]
["42.",{"$f":"+'WS 3 Direct All'!B54:D54","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I54","v":0},0]
["43.",{"$f":"+'WS 3 Direct All'!B55:D55","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I55","v":0},0]
["44.",{"$f":"+'WS 3 Direct All'!B56:D56","v":0},null,null,null,{"$f":"IFERROR(ROUND(+E56/$E$87,6),0)","v":0},{"$f":"+F56*$G$87","v":0},{"$f":"+'WS 3 Direct All'!I56","v":0},0]
["45.",{"$f":"+'WS 3 Direct All'!B57:D57","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I57","v":0},0]
["46.",{"$f":"+'WS 3 Direct All'!B58:D58","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I58","v":0},0]
["47.",{"$f":"+'WS 3 Direct All'!B59:D59","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I59","v":0},0]
["48.",{"$f":"+'WS 3 Direct All'!B60:D60","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I60","v":0},0]
["49.",{"$f":"+'WS 3 Direct All'!B61:D61","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I61","v":0},0]
["50.",{"$f":"+'WS 3 Direct All'!B62:D62","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I62","v":0},0]
["SUBTOTAL",null,null,null,{"$f":"SUM(E13:E62)","v":0},{"$f":"SUM(F13:F62)","v":0},{"$f":"SUM(G13:G62)","v":0},{"$f":"SUM(H13:H62)","v":0},{"$f":"SUM(I13:I62)","v":0}]
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["NON-RELATED"]
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["54.",{"$f":"+'WS 3 Direct All'!B69:D69","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I69","v":0},0]
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["61.",{"$f":"+'WS 3 Direct All'!B76:D76","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I76","v":0},0]
["62.",{"$f":"+'WS 3 Direct All'!B77:D77","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I77","v":0},0]
["63.",{"$f":"+'WS 3 Direct All'!B78:D78","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I78","v":0},0]
["64.",{"$f":"+'WS 3 Direct All'!B79:D79","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I79","v":0},0]
["65.",{"$f":"+'WS 3 Direct All'!B80:D80","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I80","v":0},0]
["66.",{"$f":"+'WS 3 Direct All'!B81:D81","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I81","v":0},0]
["67.",{"$f":"+'WS 3 Direct All'!B82:D82","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I82","v":0},0]
["68.",{"$f":"+'WS 3 Direct All'!B83:D83","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I83","v":0},0]
["69.",{"$f":"+'WS 3 Direct All'!B84:D84","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I84","v":0},0]
["70.",{"$f":"+'WS 3 Direct All'!B85:D85","v":0},null,null,null,0,0,{"$f":"+'WS 3 Direct All'!I85","v":0},0]
["SUBTOTAL",null,null,null,{"$f":"SUM(E66:E85)","v":0},{"$f":"SUM(F66:F85)","v":0},{"$f":"SUM(G66:G85)","v":0},{"$f":"SUM(H66:H85)","v":0},{"$f":"SUM(I66:I85)","v":0}]
["71.","TOTAL",null,null,{"$f":"+E86+E63","v":0},{"$f":"+F86+F63","v":0},{"$f":"+'WS 3 Pg 2'!I67","v":0},{"$f":"+H86+H63","v":0},{"$f":"+I86+I63","v":0}]

{"sheet":"WS 3 BS AssetLiabeq","index":36,"n_rows":77,"n_cols":9,"rows_kept":77,"cut":false,"hidden":false,"merged":[[0,3,0,8],[4,0,4,8],[8,0,8,6],[68,3,68,6],[58,3,58,6],[47,0,47,6],[5,0,5,8]]}
["HOME OFFICE NAME:",null,null,{"$f":"+'WS 3 Front Page'!E9","v":0}]
[]
["PERIOD OF REPORT:",null,null,"FROM",{"$f":"+'WS 3 Front Page'!E15","v":"00:00:00"},null,"TO",{"$f":"+'WS 3 Front Page'!H15","v":"00:00:00"}]
[]
["WORKSHEET 3"]
["BALANCE SHEET"]
[]
[null,null,null,null,null,null,null,"BALANCE AT END OF"]
["ASSETS",null,null,null,null,null,null,"Current Year","Prior Year"]
["CURRENT ASSETS:"]
[null,"Cash on hand or in bank"]
[null,"Savings deposits or certificates of deposit"]
[null,"Short-term investments"]
[null,"Accounts and notes receivables"]
[null,"A/R & N/A - Employees and owners"]
[null,"A/R & N/A - Intercompany"]
[null,"Less: Allowance for doubtful accounts"]
[null,"Interest Receivable"]
[null,"Inventories"]
[null,"Prepaid expenses"]
[null,"Other current assets"]
[null,"    TOTAL CURRENT ASSETS",null,null,null,null,null,{"$f":"SUM(H11:H21)","v":0},{"$f":"SUM(I11:I21)","v":0}]
["FIXED ASSETS:"]
[null,"Land"]
[null,"Land Improvements"]
[null,"    Less accumulated depreciation"]
[null,"Buildings and fixed equipment"]
[null,"    Less accumulated depreciation"]
[null,"Movable Equipment"]
[null,"    Less accumulated depreciation"]
[null,"Leasehold Improvements"]
[null,"    Less accumulated depreciation"]
[null,"A/R & N/R - Home Office"]
[null,"A/R & N/R - Nursing Homes"]
[null,"    TOTAL FIXED ASSETS",null,null,null,null,null,{"$f":"SUM(H24:H34)","v":0},{"$f":"SUM(I24:I34)","v":0}]
["NONCURRENT ASSETS:"]
[null,"Long-term investments"]
[null,"Investments in subsidiaries"]
[null,"Deposits and advances"]
[null,"Deferred loan costs and finance charges"]
[null,"Deferred taxes"]
[null,"Organization cost"]
[null,"Goodwill"]
[null,"Escrow funds"]
[null,"Other"]
[null,"    TOTAL NONCURRENT ASSETS:",null,null,null,null,null,{"$f":"SUM(H37:H45)","v":0},{"$f":"SUM(I37:I45)","v":0}]
["TOTAL ASSETS",null,null,null,null,null,null,{"$f":"+H46+H35+H22","v":0},{"$f":"+I46+I35+I22","v":0}]
["LIABILITIES"]
["CURRENT LIABILITIES:"]
[null,"Accounts and notes payable"]
[null,"A/P & N/P - Intercompany"]
[null,"A/P & N/P - Employees and owners"]
[null,"Current portion of long-term debt"]
[null,"Accrued salaries and bonuses"]
[null,"Accrued employee benefits"]
[null,"Accrued income taxes"]
[null,"Accrued other taxes"]
[null,"Dividends payable"]
[null,"Other (describe)"]
[null,"    TOTAL CURRENT LIABILITIES",null,null,null,null,null,{"$f":"SUM(H49:H59)","v":0},{"$f":"SUM(I49:I59)","v":0}]
["LONG-TERM LIABILITIES:"]
[null,"Notes Payable"]
[null,"Mortgage Payable"]
[null,"A/P & N/P - On home office"]
[null,"A/P & N/P - On nursing home properties"]
[null,"Capitalized lease obligations"]
[null,"Loans from owners"]
[null,"Unsecured loans"]
[null,"Other (describe)"]
[null,"    TOTAL LONG-TERM LIABILITIES",null,null,null,null,null,{"$f":"SUM(H61:H69)","v":0},{"$f":"SUM(I61:I69)","v":0}]
["EQUITY:"]
[" ","Capital stock"]
[null,"Paid-in capital"]
[null,"Retain Earnings"]
[null,"Other"]
[null,"    TOTAL EQUITY",null,null,null,null,null,{"$f":"SUM(H71:H75)","v":0},{"$f":"SUM(I71:I75)","v":0}]
["TOTAL LIABILITIES AND EQUITY",null,null,null,null,null,null,{"$f":"+H76+H70+H60","v":0},{"$f":"+I76+I70+I60","v":0}]

{"sheet":"WS 3 Owner Comp","index":37,"n_rows":82,"n_cols":17,"rows_kept":82,"cut":false,"hidden":false,"merged":[[70,13,74,13],[70,12,74,12],[65,10,69,10],[65,13,69,13],[65,11,69,11],[70,3,74,3],[65,3,69,3],[60,16,64,16],[65,14,69,14],[65,15,69,15],[65,12,69,12],[65,16,69,16],[70,16,74,16],[70,11,74,11],[70,14,74,14],[70,15,74,15],[60,15,64,15],[60,14,64,14],[60,13,64,13],[60,9,64,9],[60,12,64,12],[60,3,64,3],[70,4,74,4],[70,10,74,10],[65,9,69,9],[70,9,74,9],[60,11,64,11],[60,10,64,10],[70,7,74,7],[70,8,74,8],[65,8,69,8],[70,1,74,1],[70,2,74,2],[60,1,64,1],[60,2,64,2],[65,1,69,1],[65,2,69,2],[60,8,64,8],[60,6,64,6],[60,7,64,7],[65,4,69,4],[65,5,69,5],[60,4,64,4],[70,6,74,6],[70,5,74,5],[65,6,69,6],[65,7,69,7],[60,5,64,5],[40,2,44,2],[30,1,34,1],[40,1,44,1],[30,2,34,2],[35,1,39,1],[35,2,39,2],[45,2,49,2],[55,1,59,1],[55,4,59,4],[50,3,54,3],[45,1,49,1],[50,1,54,1],[50,2,54,2],[55,2,59,2],[50,4,54,4],[45,4,49,4],[55,16,59,16],[50,7,54,7],[50,16,54,16],[30,5,34,5],[55,3,59,3],[55,6,59,6],[55,5,59,5],[50,6,54,6],[30,3,34,3],[45,6,49,6],[35,3,39,3],[30,4,34,4],[35,4,39,4],[40,3,44,3],[40,4,44,4],[45,3,49,3],[35,5,39,5],[45,7,49,7],[55,8,59,8],[45,5,49,5],[50,5,54,5],[55,7,59,7],[50,8,54,8],[50,15,54,15],[45,15,49,15],[50,13,54,13],[50,14,54,14],[50,12,54,12],[45,13,49,13],[45,12,49,12],[50,10,54,10],[45,9,49,9],[55,10,59,10],[55,12,59,12],[55,15,59,15],[55,13,59,13],[55,14,59,14],[50,9,54,9],[55,9,59,9],[55,11,59,11],[50,11,54,11],[30,16,34,16],[35,16,39,16],[45,16,49,16],[30,15,34,15],[30,11,34,11],[40,16,44,16],[45,8,49,8],[45,10,49,10],[40,10,44,10],[40,12,44,12],[45,14,49,14],[40,13,44,13],[40,9,44,9],[45,11,49,11],[30,10,34,10],[30,12,34,12],[40,15,44,15],[35,15,39,15],[40,14,44,14],[35,11,39,11],[40,11,44,11],[30,14,34,14],[30,13,34,13],[35,13,39,13],[35,14,39,14],[35,12,39,12],[40,5,44,5],[35,6,39,6],[30,9,34,9],[25,8,29,8],[25,6,29,6],[30,7,34,7],[25,5,29,5],[35,9,39,9],[40,6,44,6],[40,8,44,8],[40,7,44,7],[35,8,39,8],[35,7,39,7],[25,7,29,7],[30,6,34,6],[25,10,29,10],[30,8,34,8],[35,10,39,10],[15,11,19,11],[15,15,19,15],[15,5,19,5],[15,10,19,10],[15,1,19,1],[25,16,29,16],[20,16,24,16],[25,11,29,11],[25,13,29,13],[25,14,29,14],[25,15,29,15],[25,12,29,12],[20,6,24,6],[25,9,29,9],[20,15,24,15],[20,13,24,13],[20,8,24,8],[20,10,24,10],[20,14,24,14],[20,11,24,11],[20,12,24,12],[20,9,24,9],[20,7,24,7],[25,4,29,4],[20,4,24,4],[20,5,24,5],[25,2,29,2],[25,3,29,3],[20,1,24,1],[20,2,24,2],[20,3,24,3],[25,1,29,1],[0,2,0,8],[2,2,2,3],[2,5,2,6],[15,6,19,6],[15,7,19,7],[4,1,4,16],[15,9,19,9],[15,14,19,14],[15,13,19,13],[6,1,6,16],[15,2,19,2],[15,16,19,16],[15,4,19,4],[15,12,19,12],[15,3,19,3],[15,8,19,8]]}
[null,"HOME OFFICE NAME:",{"$f":"+'WS 3 Front Page'!E9","v":0}]
[]
[null,"PERIOD OF REPORT: FROM",{"$f":"+'WS 3 Front Page'!E15","v":"00:00:00"},null,"TO",{"$f":"+'WS 3 Front Page'!H15","v":"00:00:00"}]
[]
[null,"WORKSHEET 3"]
[]
[null,"STATEMENT OF OWNERS/DIRECTORS COMPENSATION "]
[]
[]
[null,null,null,null,null,"ESTIMATED",null,null,null,"(1)",null,"(2)","(1-2)","(3)",null,"(3)","(3-4)"]
[null,null,null,null,"ESTIMATED","HOURS PER",null,null,null,null,null," ","COMPENSATION",null,null,"MAXIMUM","DIRECTOR'S FEES"]
[null,null,null,null,"HOURS PER","WEEK DEVOTED",null,null,null," ","Line","MAXIMUM","IN EXCESS"," ","Reported","ALLOWABLE","IN EXCESS"]
[null," "," ","DESCRIPTION OF","WEEK DEVOTED","TO OTHER","PERCENTAGE",null,null,null,"Number","ALLOWABLE","MAXIMUM",null,"On","DIRECTOR'S","OF MAXIMUM"]
[null,null,null,"DUTIES PERFORMED","TO THE","NURSING","OF OWNERSHIP","SALARIES ","OTHER","TOTAL","Reported","COMPENSATION","ALLOWABLE","DIRECTOR'S","Line","FEES","ALLOWABLE"]
[null,"NAME","TITLE",null,"HOME OFFICE","FACILITIES","IN BUSINESS","AND WAGES","COMPENSATION","COMPENSATION","On","(a)","(b)","FEES","Number","(a)","(b)"]
[null,null,null,null,null,null,null,null,null,{"$f":"+I16+H16","v":0},null,null,{"$f":"IF(J16<L16,0,+J16-L16)","v":0},null,null,null,{"$f":"IF(N16<P16,0,+N16-P16)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I21+H21","v":0},null,null,{"$f":"IF(J21<L21,0,+J21-L21)","v":0},null,null,null,{"$f":"IF(N21<P21,0,+N21-P21)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I26+H26","v":0},null,null,{"$f":"IF(J26<L26,0,+J26-L26)","v":0},null,null,null,{"$f":"IF(N26<P26,0,+N26-P26)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I31+H31","v":0},null,null,{"$f":"IF(J31<L31,0,+J31-L31)","v":0},null,null,null,{"$f":"IF(N31<P31,0,+N31-P31)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I36+H36","v":0},null,null,{"$f":"IF(J36<L36,0,+J36-L36)","v":0},null,null,null,{"$f":"IF(N36<P36,0,+N36-P36)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I41+H41","v":0},null,null,{"$f":"IF(J41<L41,0,+J41-L41)","v":0},null,null,null,{"$f":"IF(N41<P41,0,+N41-P41)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I46+H46","v":0},null,null,{"$f":"IF(J46<L46,0,+J46-L46)","v":0},null,null,null,{"$f":"IF(N46<P46,0,+N46-P46)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I51+H51","v":0},null,null,{"$f":"IF(J51<L51,0,+J51-L51)","v":0},null,null,null,{"$f":"IF(N51<P51,0,+N51-P51)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I56+H56","v":0},null,null,{"$f":"IF(J56<L56,0,+J56-L56)","v":0},null,null,null,{"$f":"IF(N56<P56,0,+N56-P56)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I61+H61","v":0},null,null,{"$f":"IF(J61<L61,0,+J61-L61)","v":0},null,null,null,{"$f":"IF(N61<P61,0,+N61-P61)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I66+H66","v":0},null,null,{"$f":"IF(J66<L66,0,+J66-L66)","v":0},null,null,null,{"$f":"IF(N66<P66,0,+N66-P66)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,{"$f":"+I71+H71","v":0},null,null,{"$f":"IF(J71<L71,0,+J71-L71)","v":0},null,null,null,{"$f":"IF(N71<P71,0,+N71-P71)","v":0}]
[]
[]
[]
[]
[null,null,null,null,null,null,"Totals",{"$f":"SUM(H16:H71)","v":0},{"$f":"SUM(I16:I71)","v":0},{"$f":"SUM(J16:J71)","v":0},null,{"$f":"SUM(L16:L71)","v":0},{"$f":"SUM(M16:M71)","v":0},{"$f":"SUM(N16:N71)","v":0},null,{"$f":"SUM(P16:P71)","v":0},{"$f":"SUM(Q16:Q71)","v":0}]
[]
[]
[null,"(a) See cost report instructions and reimbursement regulations as to calculation of maximum allowable compensation."]
[null,"(b) The compensation in excess of the allowable maximum should be recorded as a non-allowable cost adjustment."]
[]
[null,"   NOTE: ALL owners and their relatives who receive any type of compensation from this home must be listed on this schedule."]

{"sheet":"Supplemental Information","index":38,"n_rows":61,"n_cols":11,"rows_kept":61,"cut":false,"hidden":false,"merged":[[50,7,51,7],[52,7,53,7],[54,7,55,7],[56,7,57,7],[50,6,51,6],[52,6,53,6],[54,6,55,6],[56,6,57,6],[50,5,51,5],[52,5,53,5],[54,5,55,5],[56,5,57,5],[50,4,51,4],[52,4,53,4],[54,4,55,4],[56,4,57,4],[0,0,0,10],[2,0,2,10],[23,1,23,8],[5,1,5,7],[15,2,15,7],[19,1,19,7],[21,1,21,7],[16,3,16,7],[17,3,17,7],[8,2,8,7],[13,2,13,7],[14,2,14,7],[9,2,9,7],[10,2,10,7],[11,2,11,7],[12,2,12,7]]}
["Supplement to Title XIX (Medicaid) Nursing Facility Cost Report "]
[]
["This form was developed by MHD to expedite the audit process and minimize additional questions, therefore, it is to be completed and submitted with the Medicaid cost report.  The questions contained in this document are considered requests for additional information and will not be asked again during the course of the audit.  Therefore, any information requested in this supplemental form that is not provided may be adjusted by the Division as undocumented."]
[]
[]
[1,"Please indicate what your facility’s federal fiscal year end for income tax reporting is.  Each provider shall adopt the same 12 month fiscal period for completing its cost report as is used for federal income tax reporting.  If it is not the same, please stop here and contact MHD at (573)751-5663."]
[]
[2,"Have the following required documents been included with the cost report?  If no, please indicate why in the space provided.",null,null,null,null,null,null,"Yes/No",null,"Reasoning\n(Complete if No is Selected)"]
[null,1,"Original copy of page 1 of the Title XIX cost report signed by the authorized facility representative and notarized."]
[null,2,"Working trial balance used to prepare the cost report."]
[null,3,"Title VIII (Medicare) Cost Report.  If the Medicare cost report is not complete at the time the Medicaid Cost Report is due, please indicate the estimated time of completion."]
[null,4,"Copies of all new or renewed management, consultant, lease agreements, or other contracts must be filed with the cost report if they have not been previously provided."]
[null,5,"Copy of the Certified Public Accountant Independent Audit Report and Management Letter if performed during the cost report period.  If the audit is not complete at the time the Medicaid Cost Report is due, please indicate the estimated time of completion.  Please note, facilities new to the MO HealthNet program must have an independent audit performed on the first two full years."]
[null,6,"Schedule H, Statement of Owner/Directors Compensation has been completed and reports all facility owners, Board of Directors, employees that serve in a capacity of a director at the nursing facility (i.e. Director of Finance, CFO, Director of Human Resources, etc.), related party individuals, and family members that receive compensation from the facility."]
[null,7,"If the facility has a lease with a related party, a Worksheet 2, Related Party Lease has been completed and reports all costs incurred by the related party."]
[null,8,"If the facility reports expenses related to a home office, the following documents have been completed and submitted with the cost report:"]
[null,null,"a","A Worksheet 3, Home Office Cost Report or Medicare Home Office Cost Report and"]
[null,null,"b","Worksheet 3, Statement of Owners’ Directors Compensation must be completed for all owners including:  direct and indirect ownership, officers, directors, and family members to the fourth degree."]
[]
[3,"A copy of the real estate tax receipt(s) or detailed documentation to support the expense reported on Schedule B, line 108 has been included.  If no, please indicate why in the space provided."]
[]
[4,"A copy of the personal property tax receipt(s) or documentation to support the expense reported on Schedule B, line 109 has been included.  If no, please indicate why in the space provided."]
[]
[5,"Please indicate if the amounts reported for Payroll Taxes, Employee Benefits, Workers’ Compensation are allocated or actual."]
[]
[6,"Breakdowns:  Please complete each of the below tables."]
[]
[null,1,"Please complete the below table for any grant or gift revenue your facility received."]
[null,null,null,"Date the Revenue\nwas Received","Restricted or\nUnrestricted *","Amount of\nRevenue","CR Line # of\nRelated Exp."]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,"*  If restricted also include nature of restriction:  capital, patient care, operating expenditures, etc."]
[]
[null,2,"Please complete the below table for the insurance expenses reported on Schedule B, lines 107 and 136."]
[null,null,null,"Description\nof Insurance","Dates of Coverage","Name of\nInsurance Company","Amount","CR Line #"]
[null,null,null,"Building"]
[null,null,null,"Property"]
[null,null,null,"Equipment"]
[null,null,null,"Liability"]
[null,null,null,"Bond"]
[null,null,null,"Umbrella"]
[null,null,null,"Malpractice"]
[null,null,null,"Other:  Description"]
[]
[null,null,null,"Other:  Description"]
[]
[null,null,null,"Other:  Description"]
[]
[null,null,null,"Other:  Description"]
[]
[]
[null,3,"Please complete the below table for the legal and accounting fees reported on Schedule B, lines 124 and 125."]
[null,null,null,"Date of\nService","Firm Name","Detailed Description\nof the service\nprovided","Amount","CR Line #"]

{"sheet":"Database","index":39,"n_rows":9,"n_cols":321,"rows_kept":9,"cut":false,"hidden":true,"merged":[]}
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A'!F49","v":0},{"$f":"+'Sch A'!F50","v":0},{"$f":"+'Sch A'!F51","v":0},{"$f":"+'Sch A'!F52","v":0},{"$f":"+'Sch A'!F53","v":0},{"$f":"IF(SUM(LB9:LE9)-LF9<>0,SUM(LB9:LE9)-LF9,\"\")","v":""},{"$f":"+'Sch A'!F55","v":0}]

{"sheet":"FRV","index":40,"n_rows":13,"n_cols":156,"rows_kept":13,"cut":false,"hidden":true,"merged":[[5,27,5,37]]}
["FRV Data",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Worksheet 1 :  Non-Certified / Non-Related Info.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Renovations",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Amortization",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Loans",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"End"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"You will need to look each one up to determine what the worksheet 1 is filled out for.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"- Allow renovations related only to nursing facility ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"- Verify all non-allowable \"St Line Amort\" columns are \"0\"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"- Allow debt related only to capital :  building, construction, renovations/improvements",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DB"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Look at ones the have days listed with no wksht 1 indicated ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"       - exclude rcf, assisted living, apts, etc.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"- Allow debt related only to capital :  building, construction, renovations/improvements",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Amort",null,"- Allow debt related only to nursing facility - exclude rcf, assisted living, apts, etc.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Amortization Verification"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2008 CR",null,null,null,"Look at ones where a wksht 1 is indicated but no days are reported",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"- exclude CIP, vehicles, land, farms/cows,  etc.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"- Allow debt related only to nursing facility - exclude rcf, assisted living, apts, etc.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Match?","for",null,"- verify loan is only included 1 time - for ex., refinancing may be in twice",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"If Loan = 0,"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Renovations & Loan",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Amortization",null,null,null,null,null,"- consolidated / HB - disallow all",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"- Check discrepancies between Sch B & Sch D",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Sch D60 -","FRV",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"then"]
[null," ",null,null,null,null,null,null,null,null,null,null,null,null,null,"Beds highlighted in blue need to be changed in database",null,null,null,null,null,null,null,"Non-Related Only",null,null,null,"Wksht-1 Database Calculations",null,null,null,null,null,null,null,null,null,null,null,"Non-Related &/or Non-Cert",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Sch B102","(Pulling from",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Total",null,null,null,null,null,null,"Amort = 0"]
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