Worksheet A

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CLARK RETIREMENT COMMUNITY
GRAND RAPIDS, MI  49506

Medicare Provider Number: 235401
Cost report status: Settled Without Audit
[Record Code 336553 - 1996]
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RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
PROVIDER NO:
235401
PERIOD:
FROM 05/01/2007
TO 04/30/2008
 WORKSHEET A
COST CENTER (Omit Cents) SALARIES OTHER
TOTAL
(Col 1 + Col 2)
RECLASSI-
FICATIONS
Increase /
Decrease
(Fr Wkst A-6)
 RECLASSIFIED TRIAL BALANCE (Col 3 +/- Col 4) ADJUSTMENTS TO EXPENSES Increase/Decrease (Fr Wkst A-8) NET EXPENSES FOR COST ALLOC (Col 5 +/- Col 6)  
A B C D 1 2 3 4 5 6 7
GENERAL SERVICE COST CENTERS
1 0100 x Capital-Related Costs - Building & Fixture ### ### ### ### ### ### 1
2 0200 x Capital-Related Costs - Movable Equipment 2
3 0300 x Employee Benefits ### ### ### ### ### ### 3
4 0400 x Administrative and General ### ### ### ### ### ### ### 4
5 0500 x Plant Operation, Maintenance and Repairs ### ### ### ### ### ### 5
6 0600 x Laundry and Linen Service ### ### ### ### ### ### 6
7 0700 x Housekeeping ### ### ### ### ### ### 7
8 0800 x Dietary ### ### ### ### ### ### 8
9 0900 x Nursing Administration ### ### ### ### ### 9
10 1000   Central Services and Supply 10
11 1100   Pharmacy 11
12 1200   Medical Records and Library ### ### ### ### 12
13 1300   Social Service ### ### ### ### ### ### 13
14 1400   Intern & Residents (Apprvd Teaching Prog.) 14
15     Other General Service Cost ### ### ### ### ### ### ### 15
INPATIENT ROUTINE SERVICE COST CENTERS
16 1600 x Skilled Nursing Facility ### ### ### ### ### ### 16
17         17
18 1800 x Nursing Facility 18
18.01 1810   Intermediate Care Facility - Mentally Retarded 18.01
19 1900 x Other Long Term Care ### ### ### ### ### ### ### 19
20     Other Inpatient Routine Cost 20
ANCILLARY SERVICE COST CENTERS
21 2100 x Radiology 21
22 2200 x Laboratory ### ### ### ### 22
23 2300 x Intravenous Therapy 23
24 2400 x Oxygen (Inhalation) Therapy ### ### ### 24
25 2500 x Physical Therapy ### ### ### ### 25
26 2600 x Occupational Therapy 26
27 2700 x Speech Pathology 27
28 2800 x Electrocardiology 28
29 2900 x Medical Supplies Charged to Patients ### ### ### 29
30 3000 x Drugs Charged to Patients ### ### ### ### 30
31 3100 x Dental Care - Title XIX only 31
32 3200 x Support Surfaces 32
33   x Other Ancillary Service Cost Center 33
OUTPATIENT SERVICE COST CENTERS
34 3400   Clinic 34
35 3500   Rural Health Clinic (RHC) 35
36     Other Outpatient Service Cost 36
OTHER REIMBURSABLE COST CENTERS
37 3700   Administrative and General - HHA 37
38 3800   Skilled Nursing Care - HHA 38
39 3900   Physical Therapy - HHA 39
40 4000   Occupational Therapy - HHA 40
41 4100   Speech Pathology - HHA 41
42 4200   Medical Social Services - HHA 42
43 4300   Home Health Aide - HHA 43
44 4400   Durable Medical Equipment - Rented - HHA 44
45 4500   Durable Medical Equipment - Sold - HHA 45
46 4600   Home Delivered Meals - HHA 46
47 4700   Other Home Health Services - HHA 47
48 4800   Ambulance 48
49 4900   Intern and Resident (Not Apprvd Teaching Prog) 49
50 5000   Outpatient Rehabilitation Provider 50}
51     Other Reimbursable Cost 51
SPECIAL PURPOSE COST CENTERS
52 5200   Malpractice Premiums & Paid Losses 52
53 5300   Interest Expense   53
54 5400 x Utilization Review -- SNF 54
55 5500   Hospice 55
56   x Other Special Purpose Cost 56
57 5700   Subtotals ### ### ### ### ### ### ### 57
NON REIMBURSABLE COST CENTERS
58 5800   Gift, Flower, Coffee Shops and Canteen ### ### ### ### 58
59 5900 x Barber and Beauty Shop 59
60 6000   Physicians' Private Offices 60
61 6100   Nonpaid Workers 61
62 6200   Patients Laundry 62
63   x Other Non Reimbursable Cost ### ### ### ### ### ### ### 63
75   x TOTAL ### ### ### ### ### ### 75