SNFData - 366028 - 12/2012

WOODSIDE VILLAGE CARE CENTER
MT. GILEAD, OH 43338-1038

Medicare Provider Number: 366028

Cost report status: Settled Without Audit

[Record Code 1078408 - 2010]

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POST STEP DOWN ADJUSTMENTS		Provider CCN: 366028	PERIOD: FROM 01/01/2012 TO 12/31/2012	WORKSHEET B-2
	Description	Worksheet B		Amount
	Description	Part No.	Line No.	Amount
	1	2	3	4
1	###	###	###	###	1
2	###	###	###	###	2
3	###	###	###	###	3
4	###	###	###	###	4
5					5
6					6
7					7
8					8
9					9
10					10
11					11
12					12
13					13
14					14
15					15
16					16
17					17
18					18
19					19
20					20
21					21
22					22
23					23
24					24
25					25
26					26
27					27
28					28
29					29
30					30
31					31
32					32
33					33
34					34
35					35
36					36
37					37
38					38
39					39
40					40
41					41
42					42
43					43
44					44
45					45
46					46
47					47
48					48
49					49
50					50
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4122)
08-16				Rev. 7

Worksheet B-2