SNFData - 255326 - 12/2012

COTTAGE GROVE NURSING HOME LP
JACKSON, MS 39206

Medicare Provider Number: 255326

Cost report status: Settled Without Audit

[Record Code 1081823 - 2010]

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ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES				Provider CCN: 255326		PERIOD: FROM 01/01/2012 TO 12/31/2012		WORKSHEET A-7
Description		Beginning Balances	Acquisitions			Disposals and Retirements	Ending Balance	Fully Depreciated Assets
		Beginning Balances	Purchases	Donation	Total	Disposals and Retirements	Ending Balance	Fully Depreciated Assets
		1	2	3	4	5	6	7
1	Land								1
2	Land Improvements								2
3	Buildings and Fixtures								3
4	Building Improvements	###					###		4
5	Fixed Equipment								5
6	Movable Equipment	###	###		###		###		6
7	Subtotal (sum of lines 1-6)	###	###		###		###		7
8	Reconciling Items								8
9	Total (line 7 minus line 8)	###	###		###		###		9
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4115)
Rev. 1								41-319

Worksheet A-7