State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 28 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 15 10.1(4) 165 14 8A-1 165.00 Administration * ($286) $55,635 $55,349 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 666,312 (55,635) 610,677 * To reclassify the provider's elimination of public relations/ marketing expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 16 10.1(4) 165 14 8A-1 165.00 Administration * $55,349 $469,722 $525,071 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 610,677 (469,722) 140,955 * To reclassify the provider's elimination of management fees expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 17 10.1(4) 165 14 8A-1 165.00 Administration * $525,071 ($525,071) $0 Not Reported 8A-1 165.11 Administration - Other - Nonlabor * 140,955 525,071 666,026 * To reclassify the provider's home office expense adjustment for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 28 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 18 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $666,026 ($1,754) $664,272 * 10.1(4) 35 14 8A-2 35.00 Leases and Rentals 522,000 1,754 523,754 * To reclassify lease and rental expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 19 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $664,272 ($4,469) $659,803 * 10.1(4) 35 14 8A-2 35.00 Leases and Rentals * 523,754 4,469 528,223 * To reclassify lease and rental expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 28 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 20 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $288,407 ($61,420) $226,987 Not Reported 8A-2 165.02 Administration - Fringe Benefits * 62,829 (10,278) 52,551 To adjust administrator compensation based on Department of Health Care Services guidelines. 42 CFR 413.102 / CMS Pub. 15-1, Chapter 9 SPA, Section (III)(J) W&I, Section 14126.023(f) Medi-Cal Bulletin 371 21 10.1(4) 35 14 8A-2 35.00 Leases and Rentals * $528,223 ($522,000) $6,223 To eliminate rental expenses applicable to a related facility. 42 CFR 413.17 and 413.134(h) / CMS Pub. 15-1, Section 1011.5 22 10.1(4) 40 14 8A-2 40.00 Property Taxes $1,070 $65,154 $66,224 Not Reported 8A-2 45.00 Property Insurance 0 20,240 20,240 Not Reported 8A-2 50.00 Interest - Property, Plant, and Equipment 0 166,994 166,994 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 659,803 15,831 675,634 * To include cost of ownership in lieu of related party lease expense. 42 CFR 413.17, 413.20 and 413.24 / CMS Pub. 15-1, Section 1011.5 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $675,634 23 To eliminate dues and subscriptions expense for lobby fees. ($682) 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2139 24 To eliminate the reported theft and losses expenses not (1,945) reimbursable by Medi-Cal. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304 and 2160.3 25 To adjust the reported Medical Director Fees expense to agree (1,060) with the provider's invoices. ($3,687) $671,947 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 28 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 26 Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * $98,862 ($475) $98,387 To eliminate Housekeeping expense not applicable to period under review. 42 CFR 413.20, 413.24 and 413.5 CMS Pub. 15-1, Sections 2300, 2302.1 and 2304 27 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $387,337 $924 $388,261 To adjust the Skilled Nursing Care expense to agree with the provider's invoices and check payments. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 28 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENT TO REPORTED STATISTICS 28 Not Reported 7 5 Plant Operations and Maintenance (Square Feet) 0 435 435 Not Reported 7 10 Housekeeping 0 105 105 Not Reported 7 60 Laundry and Linen 0 1,524 1,524 Not Reported 7 65 Dietary 0 4,325 4,325 Not Reported 7 155 Social Services 0 171 171 Not Reported 7 160 Activities 08080 Not Reported 7 165 Administration 0 680 680 Not Reported 7 170 Inservice Education - Nursing 0 154 154 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 12,192 7,474 19,666 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 12,192 7,039 19,231 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 12,192 6,934 19,126 To adjust square footage statistics to agree with the prior year's audit findings in order to properly allocate indirect costs. 42 CFR 413.24 and 413.50 CMS Pub. 15-1, Sections 2300, 2304 and 2306 Page 8 This is trial version www.adultpdf.com . Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 26 Not Reported 8A-2 10.04 Housekeeping - Other - Nonlabor * $98,862 ($475) $98,387 To eliminate Housekeeping expense not applicable to period. Adjustments RECONCILIATION OF THE PROVIDER'S ADJUSTMENTS TO THE AUDIT REPORT 15 10.1(4) 165 14 8A-1 165.00 Administration * ($286) $55,635 $55,349 * Not Reported 8A-1 165.11 Administration - Other - Nonlabor. Adjusted Adjustments NEW VISTA NURSING & REHABILITATION CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06031H Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS