Worksheet A-8

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LIFE CARE CENTER OF MEDINA
MEDINA, OH  44256

Medicare Provider Number: 365085
Cost report status: Settled Without Audit
[Record Code 1145771 - 2010]
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ADJUSTMENTS TO EXPENSES Provider CCN: 365085
PERIOD:
FROM 01/01/2014
TO 12/31/2014
 WORKSHEET A-8
Description (1) Basis for Adjustment (2) Amount
Expense Classification on Wkst. A
to/from which the amount is to be adjusted
  
Cost Center Line No.
  0 1 2 3 4
1 Investment income on restricted funds (Chapter 2) 1
2 Trade, quantity and time discounts on purchases (Chapter 8) 2
3 Refunds and rebates of expenses Chapter 8) 3
4 Rental of provider space by suppliers Chapter 8) 4
5 Telephone services (pay stations excluded) (Chapter 21) 5
6 Television and radio service (Chapter 21) 6
7 Parking lot (Chapter 21) 7
8 Remuneration applicable to provider-based physician adjustment Worksheet A-8-2   8
9 Home office costs (Chapter 21) 9
10 Sale of scrap, waste, etc. (Chapter 23) 10
11 Nonallowable costs related to certain Capital expenditures (Chapter 24) 11
12 Adjustment resulting from transactions with related organizations (Chapter 10) Worksheet A-8-1 ###   12
13 Laundry and Linen service 13
14 Revenue - Employee meals ### ### ### ### 14
15 Cost of meals - Guests 15
16 Sale of medical supplies to other than patients 16
17 Sale of drugs to other than patients 17
18 Sale of medical records and abstracts 18
19 Vending machines ### ### ### ### 19
20 Income from imposition of interest, finance or penalty charges (Chapter 21) 20
21 Interest expense on Medicare overpayments and borrowings to repay Medicare overpayments 21
22 Utilization review--physicians' compensation (Chapter 21) Utilization Review- SNF 82 22
23 Depreciation--buildings and fixtures Capital Related Cost- Building 1 23
24 Depreciation--movable equipment ### ### Capital Related Cost-Movable 2 24
25 Other Adjustment specify - NON ALLOW ADVERT-COMMUNICATIONS ### ### ### ### 25
26.00 NON ALLOW TRAVEL/MEALS-COMMUNICATION ### ### ### ### 26.00
31.00 INTEREST INCOME ### ### ### ### 31.00
31.02 PHYSICIAN CARE C/S ### ### ### ### 31.02
31.03 NON ALLOW AMBULANCE EXPENSE ### ### ### ### 31.03
31.04 INTEREST ADJUSTMENT ### ### ### ### 31.04
31.05 ADMIN & GENERAL ### ### ### ### 31.05
31.06 LOBBY EXPENSE ### ### ### ### 31.06
31.07 NON ALLOW X-RAY ### ### ### ### 31.07
31.08 NON ALLOW TAIL LIAB (GENL LIAB) ### ### ### ### 31.08
31.09 GPO REBATE - DIETARY ### ### ### ### 31.09
31.10 GPO REBATE - HOUSEKEEPING ### ### ### ### 31.10
31.11 GPO REBATE - LAUNDRY/LINEN ### ### ### ### 31.11
31.12 GPO REBATE - PLANT ### ### ### ### 31.12
31.13 GPO REBATE - ADMINISTRATIVE ### ### ### ### 31.13
31.14 GPO REBATE - NURSING SUPPLIES ### ### ### ### 31.14
31.15 RETROSPECTIVE RATE PREMIUM ### ### ### ### 31.15
31.16 NON ALLOW PROVIDER TAX ### ### ### ### 31.16
31.17 NON ALLOW CABLE TV EXPENSE ### ### ### ### 31.17
31.18 NON ALLOW TV DEPRECIATION ### ### ### ### 31.18
100
TOTAL
(sum of lines 1 through 99)
(transfer to Wkst. A, col. 6, line 100)
   ###     100
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1
(2) Basis for adjustment (see instructions)
 
A. Costs - if cost, including applicable overhead, can be determined
B. Amount Received - if cost cannot be determined
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116)
41-320   Rev. 1