Worksheet B Part I

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COUNTRY OAKS CARE CENTER
POMONA, CA  91768

Medicare Provider Number: 055247
Cost report status: Settled Without Audit
[Record Code 1031508 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 055247
PERIOD:
FROM 01/01/2012
TO 12/31/2012
 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 271,659 ###                                     1
2 Capital-Related Costs - Moveable Equipment 73,821 ###                                   2
3 Employee Benefits 503,507 ###                               3
4 Administrative and General 1,519,371 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 241,157 ### ### ### ### ###                           5
6 Laundry and Linen Service 67,858 ### ### ### ### ### ###                         6
7 Housekeeping 158,414 ### ### ### ### ### ###                       7
8 Dietary 347,091 ### ### ### ### ### ### ###                     8
9 Nursing Administration 222,124 ### ### ### ###                   9
10 Central Services and Supply 16,663 ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 52,680 ### ### ### ### ### ### ### ###             12
13 Social Service 118,066 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 5,080,391 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 18,202 ### ### ### ### ### 40
41 Laboratory 30,205 ### ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 141,165 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 148,231 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 41,728 ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 15,963 ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 180,986 ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 14,577 ### ### ### ### 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 9,263,859 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 4,420 ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 9,268,279 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7