Worksheet B Part I

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PATRIOTS COLONY INC
WILLIAMSBURG, VA  23188

Medicare Provider Number: 495369
Cost report status: Settled Without Audit
[Record Code 1326553 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 495369
PERIOD:
FROM 01/01/2021
TO 12/31/2021
 WORKSHEET B PART I
Cost Center Description Net Expenses for Cost Allocation (from Wkst. A, col. 7) Cap. Rel Buildings & Fixtures Cap. Rel Movable Equipment Employee Benefits Subtotal (Sum of cols. 0 - 3) Administrative & General Plant Oper. Maintenance & Repairs Laundry & Linen Service House Keeping Dietary Nursing Administration Central Services & Supply Pharmacy Medical Records & Library Social Service Nursing & Allied Health Education Other General Service Cost Subtotal Post Step-down Adjustments Total  
0 1 2 3 3 A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS                                          
1 Capital-Related Costs - Buildings & Fixtures 365,354 ###                                     1
2 Capital-Related Costs - Moveable Equipment 935,632 ###                                   2
3 Employee Benefits 1,157,833 ###                               3
4 Administrative and General 2,748,400 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,535,673 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 83,076 ### ### ### ### ### ###                         6
7 Housekeeping 916,272 ### ### ### ### ### ### ###                       7
8 Dietary 3,920,931 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 1,180,457 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library ### ### ### ### ### ### ###             12
13 Social Service 92,842 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 1,001,448 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 328,219 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 2,212,638 ### ### ### ### 31
32 ICF/IID ### ### ### ### ### ### ### ### 32
33 Other Long Term Care 6,907,937 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 4,965 ### ### ### ### 40
41 Laboratory 13,234 ### ### ### ### 41
42 Intravenous Therapy 88,639 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 622,027 ### ### ### ### 44
45 Occupational Therapy 552,620 ### ### ### ### 45
46 Speech Pathology 157,315 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients -6,940 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 323,337 ### ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 3,823 ### ### ### ### 52
OUTPATIENT SERVICE COST CENTERS                                          
60 Clinic ### ### ### ### ### ### ### ### 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 63
OTHER REIMBURSABLE COST CENTERS                                          
70 Home Health Agency Cost 70
71 Ambulance 71
72 Outpatient Rehabilitation (specify) 72
73 CMHC 73
74 Other Reimbursable Cost 18,218 ### ### ### ### 74
SPECIAL PURPOSE COST CENTERS                                          
83 Hospice 83
84 Other Special Purpose Cost 84
89 Subtotals 25,163,950 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 50,928 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 184,634 ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 25,399,512 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7