Worksheet A

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BROOKSIDE CARE CENTER
KENOSHA, WI  53144

Medicare Provider Number: 525556
Cost report status: Settled Without Audit
[Record Code 354623 - 1996]
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RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES
PROVIDER NO:
525556
PERIOD:
FROM 01/01/2008
TO 12/31/2008
 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