Preview
FILED: NEW YORK COUNTY CLERK 06/28/2023 03:21 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 06/28/2023
O'LEARY EXHIBIT 35
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -1- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
1
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -2- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
2
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -3- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) Proprietary & Not-For-Profit Corporation Identify Stockholders
or Board of Directors on next Schedule
(2) Enter 1 for each Operator
(3) Must Total 100%
3
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -4- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) Enter 1 for each person listed
(2) Must Total 100%
4
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -5- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) If owner is a corporation, identify the stockholder(s) on the next schedule
5
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -6- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) Enter 1 for each stockholder
(2) Identify type of property:
1 = Land
2 = Building
3 = Moveable Equipment
6
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -7- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) % owned by Operators of reporting RHCF
(2) State facility located in
Realty = Realty Co.
C.O./Mang. = Central Office Management
EDP/Acct. = Electronic Data Processing / Accounting
Other = Specify type
7
FILED: NEW YORK COUNTY CLERK 06/28/2023 03:21 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 06/28/2023
8
FILED: NEW YORK COUNTY CLERK 06/28/2023 03:21 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 06/28/2023
9
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -8- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
PATIENT SERVICES PROVIDED: ENTER 1 OR 2 FOR EACH SERVICE
PROVIDED BY YOUR FACILITY ON LAST DAY OF COST REPORT PERIOD, LEAVE
BLANK IF NOT PROVIDED.
10
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 -9- 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
11
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 10 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
12
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 11 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
13
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 12 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
14
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 13 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
NUMBER OF PATIENTS AS OF LAST DAY OF REPORT PERIOD:
NOTE: IF AGE IS UNKNOWN APPROXIMATE. TOTALS MUST AGREE WITH
CC/LINE 0011/024 (CENSUS MIDNIGHT OF LAST DAY OF REPORT PERIOD)
15
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 14 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
NOTE: *TOTALS MUST AGREE WITH CC/LINE, 0011/024
**MEDICAID PATIENTS (INCLUDED IN LINE 013 ABOVE)
THAT WERE PREVIOUS PRIVATE PAY
16
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 15 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
*TOTAL NEW ADMISSIONS IS DEFINED AS ALL ADMISSIONS (CC/LINE,
0011/012) EXCLUDING READMISSIONS (CC/LINE, 0011/027) AND, FOR
MULTILEVEL FACILITIES, ADMISSIONS FROM OTHER COLUMN OF FACILITY
(CC/LINE, 0011/011).
17
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 16 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
18
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 17 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
A. PATIENT ORIGIN BY COUNTY, RESIDENTIAL HEALTH CARE PATIENTS ONLY.
ENTER THE NUMBER OF PATIENTS UNDER CARE AS OF THE LAST DAY OF
THE REPORT PERIOD BY COUNTY OF RESIDENCE AT THE TIME OF MOST
RECENT ADMISSION AND BY SOURCE OF PAYMENT. DESIGNATE THE
COUNTY OF ORIGIN BY ENTERING THE FOLLOWING APPROPRIATE CODE
NUMBERS IN COLUMN A.
01 ALBANY 19 GREENE 39 PUTNAM 59 WESTCHESTER
02 ALLEGANY 20 HAMILTON 41 RENSSELAER 60 WYOMING
03 BROOME 21 HERKIMER 43 ROCKLAND 61 YATES
04 CATTARAUGUS 22 JEFFERSON 44 ST. LAWRENCE 70 BRONX
05 CAYUGA 24 LEWIS 45 SARATOGA 71 KINGS
06 CHAUTAUGUA 25 LIVINGSTON 46 SCHENECTADY 72 MANHATTAN
07 CHEMUNG 26 MADISON 47 SCHOHARIE 73 QUEENS
08 CHENANGO 27 MONROE 48 SCHUYLER 74 RICHMOND
09 CLINTON 28 MONTGOMERY 49 SENECA
10 COLUMBIA 29 NASSAU 50 STEUBEN
11 CORTLAND 31 NIAGARA 51 SUFFOLK
12 DELAWARE 32 ONEIDA 52 SULLIVAN
13 DUTCHESS 33 ONONDAGA 53 TIOGA
14 ERIE 34 ONTARIO 54 TOMPKINS
15 ESSEX 35 ORANGE 55 ULSTER
16 FRANKLIN 36 ORLEANS 56 WARREN
17 FULTON 37 OSWEGO 57 WASHINGTON
18 GENESEE 38 OTSEGO 58 WAYNE
19
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 18 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
NOTE: COLUMN TOTALS MUST AGREE WITH CORRESPONDING TOTALS ON CC/LINE
0413/018. PLEASE USE ONLY ONE LINE FOR EACH COUNTY OF ORIGIN,
STARTING WITH LINE 1.
20
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 19 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
21
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 20 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
A. LABOR ORGANIZATION:
1. ARE ANY RESIDENTIAL HEALTH CARE FACILITY EMPLOYEES
REPRESENTED BY A LABOR ORGANIZATION ENTER ?
2. IF ANSWER TO A1 IS YES, SUPPLY APPROPRIATE INFORMATION BELOW
USING THE CODE NUMBER IN COLUMN B TO INDICATE UNION AFFILIATION
FOR EACH UNIT AS DEFINED IN THE RECOGNITION CLAUSE OF THE LABOR
AGREEMENT. IF THE RECOGNITION CLAUSE COVERS MORE THAN ONE UNIT,
DATA FOR EACH UNIT MUST BE PROVIDED.
EX: RECOGNITION CLAUSE COVERS NON-PROFESSIONAL EMPLOYEES INCLUDING
HOUSEKEEPING, DIETARY, AIDES, ORDERLIES, MAINTENANCE AND CLERICAL.
THE HOUSEKEEPING, DIETARY AND ORDERLIES WOULD BE REPORTED ON THE
'SERVICE' LINE 01, THE MAINTENANCE EMPLOYEES ON LINE 02, AND THE
CLERICAL EMPLOYEES ON LINE 05.
COLUMN B - UNION CODE
01 DISTRICT 1199, NATIONAL UNION OF HOSPITAL AND HEALTH CARE
EMPLOYEES
02 LOCAL 144, HOTEL, HOSP., NURSING HOME AND ALLIED SERVICES-SEIU
03 LOCAL 200, HOTEL, HOSP., NURSING HOME AND ALLIED SERVICES-SEIU
04 LOCAL 721, LICENSED PRACTICAL NURSES OF NYC, AFFIL. WITH
HOTEL, HOSP., ETC. - SEIU
05 LOCAL 1115, JOINT BOARD OF NURSING AND HOSPITAL EMPLOYEES
06 LOCAL 4, MEDICAL AND HEALTH EMPLOYEES UNION
07 LOCAL 810, INTERNATIONAL BROTHERHOOD OF TEAMSTERS
08 LOCAL 30, INTERNATIONAL UNION OF OPERATING ENGINEERS
09 LOCAL 907, INTERNATIONAL UNION OF OPERATING ENGINEERS
10 BUFFALO & WESTERN NEW YORK HOSPITAL AND NURSING HOME COUNCIL
11 SNA - NEW YORK STATE NURSES ASSOCIATION
12 CSEA - CIVIL SERVICE EMPLOYEES ASSOCIATION
13 COUNCIL 66, AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL
EMPLOYEES
14 DISTRICT COUNCIL 37, AMERICAN FEDERATION OF STATE, COUNTY &
MUNICIPAL EMPLOYEES
15 OTHER UNION - PLEASE SPECIFY ON NOTEPAD:
22
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 21 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
NOTE: LEAVE ANY 'BARGAINING UNIT' LINE BLANK FOR ANY GROUP OF
WORKERS WHO ARE EITHER: 1) NOT REPRESENTED BY A UNION OR 2) NOT
ON THE FACILITY PAYROLL.
COUNT EACH PERSON EMPLOYED AND EACH CATEGORY. (I.E. ONE PERSON
COULD BE COUNTED TWICE IF THEY WERE EMPLOYED BOTH FULL AND PART
TIME) CASUAL SHALL BE DEFINED AS: ANY PERSON EMPLOYED BY THE
NURSING HOME ON A PER DIEM BASIS OR THROUGH A CONTRACT WITH A NON-
RELATED AGENCY, SERVING IN A CAPACITY NORMALLY FILLED BY A FULL
TIME OR PART TIME STAFF INDIVIDUAL. ALL EMPLOYEES HIRED THROUGH
A RELATED COMPANY SHALL BE CLASSIFIED AS IF THEY ARE STAFF OF THE
NURSING HOME.
23
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023 03:21 PMReport
RHCF-4 Cost INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 22 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
24
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 23 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
*Line 0015 Column 00160 would be used for reporting revenue
for all other operating revenue centers.
25
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 24 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
26
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 25 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
*Location on Part IV refers to the column line where an item is actually reported or the column and
line affected if the item would not be properly included on the part IV, ie. prepared in accordance
with generally accepted accounting principles.
(1) Do not include: (1) Interest paid to NYSDSS on recovery determinations.
(2) Interest paid on funds borrowed to repay NYSDSS recovery determinations.
(3) Interest paid to related parties.
27
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 26 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
28
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 27 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
29
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 28 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) Do not include maintenance equipment such as
lawn mowers, snow blowers, etc.
30
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 29 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) All revenue received in the rate from the Health Recruitment and Retention adjustment.
(2) All revenue received in the rate from the Nursing Home Quality Improvement Demonstration
Program Grant Awards pursuant to Section 2808-d.
31
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 30 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
*Must agree with sum of ccln's (0025/024 & 0025/025 on schedule 8).
32
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 31 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
33
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 32 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
34
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 33 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
35
FILED: NEW YORK COUNTY CLERK 06/28/2023 03:21 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 06/28/2023
36
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023 03:21 PMReport
RHCF-4 Cost INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 34 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) If any of the Equipment is leased as part of a Non-Arms Length Arrangement (See Part II, Schedule 16, Section B) explain on Notepad.
(2) Does Facility have the option to purchase the equipment leased? Enter 1 for YES, 2 for NO in Column 0280.
(3) If lease payment has expired or depreciation and/or interest is fully booked or paid, enter 1 for YES, 2 for NO in column 0288
37
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023 03:21 PMReport
RHCF-4 Cost INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 35 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
Instructions for Facilities Financed Pursuant to
Article 28A of the Public Health Law:
The first line of each Capital Cost Category of Schedule 10 entitled
"Article 28A Financed Costs" is to be used to report the total cost
of all assets purchased with 28A mortgage loan funds and/or operating
escrow funds regardless of amount. The remaining lines in each Capital
Cost Category are to be used to report only the cost of assets acquired
with non-28A funds.
38
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023 03:21 PMReport
RHCF-4 Cost INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 36 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) Have these expenditures received CON or Administrative Review Approval?
(Enter 1 for Yes, 2 for No in Col. 0294)
(2) Are any of these expenditures of a related nature which in their aggregate would result in a
total project cost of over $1,000,000? (Enter 1 for Yes, 2 for No in Col. 0295)
(3) Depreciation methods accepable are: (Indicate by using 1, 2, or 3 in Col. 0187)
1. Straight-line.
2. Declining Balance
3. Sum of the Year's Digits
39
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023 03:21 PMReport
RHCF-4 Cost INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 37 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) Have these expenditures received CON or Administrative Review Approval?
(Enter 1 for Yes, 2 for No in Col. 0294)
(2) Are any of these expenditures of a related nature which in their aggregate would result in a
total project cost of over $1,000,000? (Enter 1 for Yes, 2 for No in Col. 0295)
(3) Depreciation methods accepable are: (Indicate by using 1, 2, or 3 in Col. 0187)
1. Straight-line.
2. Declining Balance
3. Sum of the Year's Digits
40
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023 03:21 PMReport
RHCF-4 Cost INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 38 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
(1) Have these expenditures received CON or Administrative Review Approval?
(Enter 1 for Yes, 2 for No in Col. 0294)
(2) Are any of these expenditures of a related nature which in their aggregate would result in a
total project cost of over $1,000,000? (Enter 1 for Yes, 2 for No in Col. 0295)
(3) Depreciation methods accepable are: (Indicate by using 1, 2, or 3 in Col. 0187)
1. Straight-line.
2. Declining Balance
3. Sum of the Year's Digits
41
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
12311539
Report
NYSCEFPeriod:
DOC.01/01/20 - 12/31/20
NO. 251 - 39 - 19-Aug-21,
RECEIVED NYSCEF:04:0906/28/2023
PM
42
FILED:
1401341N NEW
Buffalo YORK
Center COUNTY
For rehabilitatio CLERK 06/28/2023
RHCF-4 Cost Report03:21 PM INDEX
DCN: NO. 451549/2023
Preview
FILED: NEW YORK COUNTY CLERK 06/28/2023 03:21 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 06/28/2023 O'LEARY EXHIBIT 35 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -1- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 1 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -2- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 2 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -3- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) Proprietary & Not-For-Profit Corporation Identify Stockholders or Board of Directors on next Schedule (2) Enter 1 for each Operator (3) Must Total 100% 3 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -4- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) Enter 1 for each person listed (2) Must Total 100% 4 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -5- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) If owner is a corporation, identify the stockholder(s) on the next schedule 5 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -6- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) Enter 1 for each stockholder (2) Identify type of property: 1 = Land 2 = Building 3 = Moveable Equipment 6 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -7- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) % owned by Operators of reporting RHCF (2) State facility located in Realty = Realty Co. C.O./Mang. = Central Office Management EDP/Acct. = Electronic Data Processing / Accounting Other = Specify type 7 FILED: NEW YORK COUNTY CLERK 06/28/2023 03:21 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 06/28/2023 8 FILED: NEW YORK COUNTY CLERK 06/28/2023 03:21 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 06/28/2023 9 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -8- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM PATIENT SERVICES PROVIDED: ENTER 1 OR 2 FOR EACH SERVICE PROVIDED BY YOUR FACILITY ON LAST DAY OF COST REPORT PERIOD, LEAVE BLANK IF NOT PROVIDED. 10 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 -9- 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 11 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 10 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 12 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 11 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 13 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 12 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 14 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 13 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM NUMBER OF PATIENTS AS OF LAST DAY OF REPORT PERIOD: NOTE: IF AGE IS UNKNOWN APPROXIMATE. TOTALS MUST AGREE WITH CC/LINE 0011/024 (CENSUS MIDNIGHT OF LAST DAY OF REPORT PERIOD) 15 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 14 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM NOTE: *TOTALS MUST AGREE WITH CC/LINE, 0011/024 **MEDICAID PATIENTS (INCLUDED IN LINE 013 ABOVE) THAT WERE PREVIOUS PRIVATE PAY 16 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 15 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM *TOTAL NEW ADMISSIONS IS DEFINED AS ALL ADMISSIONS (CC/LINE, 0011/012) EXCLUDING READMISSIONS (CC/LINE, 0011/027) AND, FOR MULTILEVEL FACILITIES, ADMISSIONS FROM OTHER COLUMN OF FACILITY (CC/LINE, 0011/011). 17 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 16 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 18 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 17 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM A. PATIENT ORIGIN BY COUNTY, RESIDENTIAL HEALTH CARE PATIENTS ONLY. ENTER THE NUMBER OF PATIENTS UNDER CARE AS OF THE LAST DAY OF THE REPORT PERIOD BY COUNTY OF RESIDENCE AT THE TIME OF MOST RECENT ADMISSION AND BY SOURCE OF PAYMENT. DESIGNATE THE COUNTY OF ORIGIN BY ENTERING THE FOLLOWING APPROPRIATE CODE NUMBERS IN COLUMN A. 01 ALBANY 19 GREENE 39 PUTNAM 59 WESTCHESTER 02 ALLEGANY 20 HAMILTON 41 RENSSELAER 60 WYOMING 03 BROOME 21 HERKIMER 43 ROCKLAND 61 YATES 04 CATTARAUGUS 22 JEFFERSON 44 ST. LAWRENCE 70 BRONX 05 CAYUGA 24 LEWIS 45 SARATOGA 71 KINGS 06 CHAUTAUGUA 25 LIVINGSTON 46 SCHENECTADY 72 MANHATTAN 07 CHEMUNG 26 MADISON 47 SCHOHARIE 73 QUEENS 08 CHENANGO 27 MONROE 48 SCHUYLER 74 RICHMOND 09 CLINTON 28 MONTGOMERY 49 SENECA 10 COLUMBIA 29 NASSAU 50 STEUBEN 11 CORTLAND 31 NIAGARA 51 SUFFOLK 12 DELAWARE 32 ONEIDA 52 SULLIVAN 13 DUTCHESS 33 ONONDAGA 53 TIOGA 14 ERIE 34 ONTARIO 54 TOMPKINS 15 ESSEX 35 ORANGE 55 ULSTER 16 FRANKLIN 36 ORLEANS 56 WARREN 17 FULTON 37 OSWEGO 57 WASHINGTON 18 GENESEE 38 OTSEGO 58 WAYNE 19 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 18 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM NOTE: COLUMN TOTALS MUST AGREE WITH CORRESPONDING TOTALS ON CC/LINE 0413/018. PLEASE USE ONLY ONE LINE FOR EACH COUNTY OF ORIGIN, STARTING WITH LINE 1. 20 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 19 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 21 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 20 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM A. LABOR ORGANIZATION: 1. ARE ANY RESIDENTIAL HEALTH CARE FACILITY EMPLOYEES REPRESENTED BY A LABOR ORGANIZATION ENTER ? 2. IF ANSWER TO A1 IS YES, SUPPLY APPROPRIATE INFORMATION BELOW USING THE CODE NUMBER IN COLUMN B TO INDICATE UNION AFFILIATION FOR EACH UNIT AS DEFINED IN THE RECOGNITION CLAUSE OF THE LABOR AGREEMENT. IF THE RECOGNITION CLAUSE COVERS MORE THAN ONE UNIT, DATA FOR EACH UNIT MUST BE PROVIDED. EX: RECOGNITION CLAUSE COVERS NON-PROFESSIONAL EMPLOYEES INCLUDING HOUSEKEEPING, DIETARY, AIDES, ORDERLIES, MAINTENANCE AND CLERICAL. THE HOUSEKEEPING, DIETARY AND ORDERLIES WOULD BE REPORTED ON THE 'SERVICE' LINE 01, THE MAINTENANCE EMPLOYEES ON LINE 02, AND THE CLERICAL EMPLOYEES ON LINE 05. COLUMN B - UNION CODE 01 DISTRICT 1199, NATIONAL UNION OF HOSPITAL AND HEALTH CARE EMPLOYEES 02 LOCAL 144, HOTEL, HOSP., NURSING HOME AND ALLIED SERVICES-SEIU 03 LOCAL 200, HOTEL, HOSP., NURSING HOME AND ALLIED SERVICES-SEIU 04 LOCAL 721, LICENSED PRACTICAL NURSES OF NYC, AFFIL. WITH HOTEL, HOSP., ETC. - SEIU 05 LOCAL 1115, JOINT BOARD OF NURSING AND HOSPITAL EMPLOYEES 06 LOCAL 4, MEDICAL AND HEALTH EMPLOYEES UNION 07 LOCAL 810, INTERNATIONAL BROTHERHOOD OF TEAMSTERS 08 LOCAL 30, INTERNATIONAL UNION OF OPERATING ENGINEERS 09 LOCAL 907, INTERNATIONAL UNION OF OPERATING ENGINEERS 10 BUFFALO & WESTERN NEW YORK HOSPITAL AND NURSING HOME COUNCIL 11 SNA - NEW YORK STATE NURSES ASSOCIATION 12 CSEA - CIVIL SERVICE EMPLOYEES ASSOCIATION 13 COUNCIL 66, AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL EMPLOYEES 14 DISTRICT COUNCIL 37, AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL EMPLOYEES 15 OTHER UNION - PLEASE SPECIFY ON NOTEPAD: 22 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 21 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM NOTE: LEAVE ANY 'BARGAINING UNIT' LINE BLANK FOR ANY GROUP OF WORKERS WHO ARE EITHER: 1) NOT REPRESENTED BY A UNION OR 2) NOT ON THE FACILITY PAYROLL. COUNT EACH PERSON EMPLOYED AND EACH CATEGORY. (I.E. ONE PERSON COULD BE COUNTED TWICE IF THEY WERE EMPLOYED BOTH FULL AND PART TIME) CASUAL SHALL BE DEFINED AS: ANY PERSON EMPLOYED BY THE NURSING HOME ON A PER DIEM BASIS OR THROUGH A CONTRACT WITH A NON- RELATED AGENCY, SERVING IN A CAPACITY NORMALLY FILLED BY A FULL TIME OR PART TIME STAFF INDIVIDUAL. ALL EMPLOYEES HIRED THROUGH A RELATED COMPANY SHALL BE CLASSIFIED AS IF THEY ARE STAFF OF THE NURSING HOME. 23 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 03:21 PMReport RHCF-4 Cost INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 22 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 24 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 23 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM *Line 0015 Column 00160 would be used for reporting revenue for all other operating revenue centers. 25 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 24 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 26 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 25 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM *Location on Part IV refers to the column line where an item is actually reported or the column and line affected if the item would not be properly included on the part IV, ie. prepared in accordance with generally accepted accounting principles. (1) Do not include: (1) Interest paid to NYSDSS on recovery determinations. (2) Interest paid on funds borrowed to repay NYSDSS recovery determinations. (3) Interest paid to related parties. 27 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 26 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 28 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 27 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 29 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 28 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) Do not include maintenance equipment such as lawn mowers, snow blowers, etc. 30 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 29 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) All revenue received in the rate from the Health Recruitment and Retention adjustment. (2) All revenue received in the rate from the Nursing Home Quality Improvement Demonstration Program Grant Awards pursuant to Section 2808-d. 31 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 30 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM *Must agree with sum of ccln's (0025/024 & 0025/025 on schedule 8). 32 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 31 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 33 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 32 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 34 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 33 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 35 FILED: NEW YORK COUNTY CLERK 06/28/2023 03:21 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 251 RECEIVED NYSCEF: 06/28/2023 36 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 03:21 PMReport RHCF-4 Cost INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 34 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) If any of the Equipment is leased as part of a Non-Arms Length Arrangement (See Part II, Schedule 16, Section B) explain on Notepad. (2) Does Facility have the option to purchase the equipment leased? Enter 1 for YES, 2 for NO in Column 0280. (3) If lease payment has expired or depreciation and/or interest is fully booked or paid, enter 1 for YES, 2 for NO in column 0288 37 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 03:21 PMReport RHCF-4 Cost INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 35 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM Instructions for Facilities Financed Pursuant to Article 28A of the Public Health Law: The first line of each Capital Cost Category of Schedule 10 entitled "Article 28A Financed Costs" is to be used to report the total cost of all assets purchased with 28A mortgage loan funds and/or operating escrow funds regardless of amount. The remaining lines in each Capital Cost Category are to be used to report only the cost of assets acquired with non-28A funds. 38 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 03:21 PMReport RHCF-4 Cost INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 36 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) Have these expenditures received CON or Administrative Review Approval? (Enter 1 for Yes, 2 for No in Col. 0294) (2) Are any of these expenditures of a related nature which in their aggregate would result in a total project cost of over $1,000,000? (Enter 1 for Yes, 2 for No in Col. 0295) (3) Depreciation methods accepable are: (Indicate by using 1, 2, or 3 in Col. 0187) 1. Straight-line. 2. Declining Balance 3. Sum of the Year's Digits 39 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 03:21 PMReport RHCF-4 Cost INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 37 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) Have these expenditures received CON or Administrative Review Approval? (Enter 1 for Yes, 2 for No in Col. 0294) (2) Are any of these expenditures of a related nature which in their aggregate would result in a total project cost of over $1,000,000? (Enter 1 for Yes, 2 for No in Col. 0295) (3) Depreciation methods accepable are: (Indicate by using 1, 2, or 3 in Col. 0187) 1. Straight-line. 2. Declining Balance 3. Sum of the Year's Digits 40 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 03:21 PMReport RHCF-4 Cost INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 38 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM (1) Have these expenditures received CON or Administrative Review Approval? (Enter 1 for Yes, 2 for No in Col. 0294) (2) Are any of these expenditures of a related nature which in their aggregate would result in a total project cost of over $1,000,000? (Enter 1 for Yes, 2 for No in Col. 0295) (3) Depreciation methods accepable are: (Indicate by using 1, 2, or 3 in Col. 0187) 1. Straight-line. 2. Declining Balance 3. Sum of the Year's Digits 41 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023 12311539 Report NYSCEFPeriod: DOC.01/01/20 - 12/31/20 NO. 251 - 39 - 19-Aug-21, RECEIVED NYSCEF:04:0906/28/2023 PM 42 FILED: 1401341N NEW Buffalo YORK Center COUNTY For rehabilitatio CLERK 06/28/2023 RHCF-4 Cost Report03:21 PM INDEX DCN: NO. 451549/2023