Worksheet A

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SPRINGPOINT AT MONROE VILLAGE
JAMESBURG, NJ  08831

Medicare Provider Number: 315269
Cost report status: Settled Without Audit
[Record Code 1112981 - 2010]
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RECLASSIFICATION AND ADJUSTMENT
OF TRIAL BALANCE OF EXPENSES-
 Provider CCN: 315269
PERIOD:
FROM 01/01/2014
TO 12/31/2014
 WORKSHEET A
Cost Center Description SALARIES OTHER TOTAL (col. 1 + col. 2) RECLASSIFICATIONS Increase/Decrease (from Wkst. A-6) RECLASSIFIED TRIAL BALANCE (col. 3 +/- col. 4) ADJUSTMENTS TO EXPENSES Increase/Decrease (from Wkst. A-8) NET EXPENSES FOR COST ALLOCATION (col. 5 +/- col. 6)  
A B C 1 2 3 4 5 6 7 A
GENERAL SERVICE COST CENTERS                
1 0100 Capital-Related Costs - Buildings & Fixtures   ### ### ### ### ### ### 1
2 0200 Capital-Related Costs - Moveable Equipment   ### ### ### ### ### ### 2
3 0300 Employee Benefits ### ### ### ### 3
4 0400 Administrative and General ### ### ### ### ### ### ### 4
5 0500 Plant Operation, Maintenance and Repairs ### ### ### ### ### ### 5
6 0600 Laundry and Linen Service ### ### ### ### ### ### 6
7 0700 Housekeeping ### ### ### ### ### ### 7
8 0800 Dietary ### ### ### ### ### ### 8
9 0900 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 Nursing and Allied Health Education 14
15   Other General Service Cost ### ### ### ### ### 15
INPATIENT ROUTINE SERVICE COST CENTERS                
30 3000 Skilled Nursing Facility ### ### ### ### ### 30
31 3100 Nursing Facility 31
32 3200 ICF/IID 32
33 3300 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                
40 4000 Radiology ### ### ### ### ### 40
41 4100 Laboratory ### ### ### ### 41
42 4200 Intravenous Therapy ### ### ### ### 42
43 4300 Oxygen (Inhalation) Therapy 43
44 4400 Physical Therapy ### ### ### ### 44
45 4500 Occupational Therapy ### ### ### ### 45
46 4600 Speech Pathology ### ### ### ### 46
47 4700 Electrocardiology ### ### ### 47
48 4800 Medical Supplies Charged to Patients ### ### ### 48
49 4900 Drugs Charged to Patients ### ### ### ### 49
50 5000 Dental Care - Title XIX only 50
51 5100 Support Surfaces 51
52   Other Ancillary Service Cost 52
OUTPATIENT SERVICE COST CENTERS                
60 6000 Clinic ### ### ### ### ### 60
61 6100 Rural Health Clinic (RHC) 61
62 6200 FQHC 62
63   Other Outpatient Service Cost 63
OTHER REIMBURSABLE COST CENTERS                
70 7000 Home Health Agency Cost 70
71 7100 Ambulance ### ### ### ### 71
72   Outpatient Rehabilitation (specify) 72
73 7300 CMHC 73
74   Other Reimbursable Cost 74
SPECIAL PURPOSE COST CENTERS                
80 8000 Malpractice Premiums & Paid Losses   - 0 - 80
81 8100 Interest Expense   - 0 - 81
82 8200 Utilization Review - 0 - 82
83 8300 Hospice 83
84   Other Special Purpose Cost 84
89   SUBTOTALS (sum of lines 1 through 84) ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                
90 9000 Gift, Flower, Coffee Shops and Canteen ### ### ### ### 90
91 9100 Barber and Beauty Shop ### ### ### ### 91
92 9200 Physicians' Private Offices 92
93 9300 Nonpaid Workers 93
94 9400 Patients' Laundry 94
95   Other Nonreimbursable Cost ### ### ### ### ### 95
100   TOTAL ### ### ### ### ### ### 100
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4113)
Rev. 7   41-317