Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
MIRABELLA SEATTLE
SEATTLE, WA 98109
SEATTLE, WA 98109
Medicare Provider Number: 505520
Cost report status: Settled Without Audit
[Record Code 1335621 - 2010]
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| ADJUSTMENTS TO EXPENSES | Provider CCN: 505520 | PERIOD: FROM 10/01/2019 TO 09/30/2020 |
WORKSHEET A-8 | |||
| Description (1) | Basis for Adjustment (2) | Amount | Expense Classification on Wkst. A to/from which the amount is to be adjusted |
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| 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 - ADMINISTRATIVE REVENUE | ### | ### | ### | ### | 25 |
| 26.00 | GUEST ROOM REVENUE | ### | ### | ### | ### | 26.00 |
| 27.00 | CHANGE INTEREST IN FOUNDAT. | ### | ### | ### | ### | 27.00 |
| 28.00 | ADMIN - BAD DEBT EXPENSE | ### | ### | ### | ### | 28.00 |
| 29.00 | ADMIN - CASH OVER / SHORT | ### | ### | ### | ### | 29.00 |
| 30.00 | SALARIES - MARKETING DIRECTOR | ### | ### | ### | ### | 30.00 |
| 31.00 | MARKETING - PAYROLL TAXES | ### | ### | ### | ### | 31.00 |
| 32.00 | MARKETING - ADMINISTRATIVE EXPENSE | ### | ### | ### | ### | 32.00 |
| 33.00 | DINING - ADDNL. RESIDENT MEALS | ### | ### | ### | ### | 33.00 |
| 34.00 | DINING - ALCOHOL | ### | ### | ### | ### | 34.00 |
| 35.00 | DINING - DELI / BISTRO | ### | ### | ### | ### | 35.00 |
| 36.00 | DINING - TRAY SERVICES | ### | ### | ### | ### | 36.00 |
| 37.00 | REPLACEMENT OF LOST/DAMAGED ITEMS | ### | ### | ### | ### | 37.00 |
| 38.00 | RESIDENT SVC - DEPARTMENTAL REVENUE | ### | ### | ### | ### | 38.00 |
| 39.00 | CATERING - FOOD | ### | ### | ### | ### | 39.00 |
| 40.00 | ACTIVITES - DEPART REVE- RECREATION | ### | ### | ### | ### | 40.00 |
| 41.00 | DEPART REVE- HOUSEKEEPING | ### | ### | ### | ### | 41.00 |
| 42.00 | DEPART REV - MAINTENANCE | ### | ### | ### | ### | 42.00 |
| 43.00 | DEPART REVE- RENOVATIONS | ### | ### | ### | ### | 43.00 |
| 44.00 | SECURITY - DEPARTMENTAL REVENUE | ### | ### | ### | ### | 44.00 |
| 45.00 | DEPART REVENUE - TRANSPORTATION | ### | ### | ### | ### | 45.00 |
| 46.00 | N/O INCOME - RENTAL | ### | ### | ### | ### | 46.00 |
| 47.00 | GENERAL REVENUE - LATE PAYMENT FEE | ### | ### | ### | ### | 47.00 |
| 48.00 | DONATIONS C/Y - EMPLOYEE CHRISTMAS | ### | ### | ### | ### | 48.00 |
| 49.00 | DINING - TAXES - SALES | ### | ### | ### | ### | 49.00 |
| 50.00 | CONTRIBUTED SVCS - PROFESSIONAL | ### | ### | ### | ### | 50.00 |
| 51.00 | ADMIN - DONATIONS - NON-CASH | ### | ### | ### | ### | 51.00 |
| 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) |
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A. Costs - if cost, including applicable overhead, can be determined B. Amount Received - if cost cannot be determined |
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| FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116) | ||||||
| 41-320 | Rev. 1 | |||||