Worksheet B Part I

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MANOR CARE OF LAURELDALE PA LLC
LAURELDALE, PA  19605

Medicare Provider Number: 395477
Cost report status: As Submitted
[Record Code 1363634 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 395477
PERIOD:
FROM 06/01/2022
TO 01/31/2023
 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 245,892 ###                                     1
2 Capital-Related Costs - Moveable Equipment 126,371 ###                                   2
3 Employee Benefits 846,258 ### ### ###                               3
4 Administrative and General 2,212,715 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 316,465 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 93,694 ### ### ### ### ### ###                         6
7 Housekeeping 148,032 ### ### ### ### ### ###                       7
8 Dietary 754,137 ### ### ### ### ### ### ###                     8
9 Nursing Administration 254,895 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 31,938 ### ### ### ###             12
13 Social Service 156,767 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,563,152 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 14 ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 1,507 ### ### ### ### 40
41 Laboratory 41
42 Intravenous Therapy 17,864 ### ### ### 42
43 Oxygen (Inhalation) Therapy 25,088 ### ### ### ### 43
44 Physical Therapy 180,745 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 117,451 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 59,619 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 116,119 ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 149,095 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 10,421 ### ### ### ### 51
52 Other Ancillary Service Cost 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 74
SPECIAL PURPOSE COST CENTERS                                          
83 Hospice 83
84 Other Special Purpose Cost 84
89 Subtotals 9,428,239 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 9,897 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 65,531 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 9,503,667 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7