State of California Fiscal Period JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 _part2

STATE OF CALIFORNIA RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS Page 1 Provider Number: ZZT05617J 1619979754 206190263 NPI: OSHPD Facility Number: Fiscal Period: JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 Schedule 8A-2 Provider Name: EISENHOWER NURSING AND CONVALESCENT HOSPITAL TOTAL ADJ (Page 1 ) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 4 5 6 7 8 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ Line Sub No. No. 005 1 Plant Operations and. | STATE OF CALIFORNIA RECLASSIFICATIONS AND OR ADJUSTMENTS TO REPORTED COSTS Provider Name EISENHOWER NURSING AND CONVALESCENT HOSPITAL Provider Number ZZT05617J NPI 1619979754 Schedule 8A-2 Page 1 OSHPD Facility Number Fiscal Period 206190263 JANUARY 1 2009 THROUGH DECEMBER 31 2009 Line Sub No. No. 005 005 005 005 010 1 Plant Operations and Maintenance - Salaries and Wages 2 Plant Operations and Maintenance - Fringe Benefits 3 Plant Operations and Maintenance - Agency staff 4 Plant Operations and Maintenance - other - Nonlabor 1 Housekeeping - Salaries and Wages TOTAL ADJ 4 ousekeeping - Fringe Benefits ousekeeping - Agency staff Jjjousekeeping - other - Nonlabor Depreciation Buildings and Improvements Bepreciation Leasehold Improvements C 0 Depreciation Equipment 4 Depreciation and Amortization - other Peases and Rentals UD Property Taxes Property Insurance 4j Interest-Property Plant and Equipment 4Ồ Interest-Other Paundry and Linen - Salaries and Wages Laundry and Linen - Fringe Benefits ndry and Linen - Agency staff 077 Laundry and Linen - other - Nonlabor Dietary - Salaries and Wages Dietary - Fringe Benefits Dietary - Agency staff Dietary - other - Nonlabor Provision for Bad Debts Patient Supplies - Salaries and Wages Patient Supplies - Fringe Benefits Patient Supplies - Agency staff Patient Supplies - other - Nonlabor Specialized Support Surfaces - Salaries and Wages 077 077 077 080 080 080 080 081 081 081 081 082 082 082 082 2 Specialized Support Surfaces - Fringe Benefits 3 Specialized Support Surfaces - Agency staff 4 Specialized Support Surfaces - other - Nonlabor 1 Physical Therapy - Salaries and Wages 2 Physical Therapy - Fringe Benefits 3 Physical Therapy - Agency staff 4 Physical Therapy - Other - Nonlabor 1 Respiratory Therapy - Salaries and Wages 2 Respiratory Therapy - Fringe Benefits 3 Respiratory Therapy - Agency Staff 4 Respiratory Therapy - other - Nonlabor 1 Occupational Therapy - Salaries and Wages 2 Occupational Therapy - Fringe Benefits 3 .