Worksheet B Part I

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WESLEY HEALTH CARE CENTER INC.
SARATOGA SPRINGS, NY  12866

Medicare Provider Number: 335394
Cost report status: Settled Without Audit
[Record Code 1055471 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 335394
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 1,156,633 ###                                     1
2 Capital-Related Costs - Moveable Equipment 358,941 ###                                   2
3 Employee Benefits 3,969,163 ###                               3
4 Administrative and General 5,819,300 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,847,673 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 431,775 ### ### ### ### ### ### ###                         6
7 Housekeeping 626,132 ### ### ### ### ### ### ### ###                       7
8 Dietary 2,676,312 ### ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 1,070,015 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 655,224 ### ### ### ### ### ### ### ###                 10
11 Pharmacy 1,900,957 ### ### ### ### ### ### ### ###               11
12 Medical Records and Library 56,154 ### ### ### ### ### ### ### ###             12
13 Social Service 343,524 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 10,767,801 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 40
41 Laboratory 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 1,556,914 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 611,685 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 148,025 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 48
49 Drugs Charged to Patients 7,090 ### ### ### ### 49
50 Dental Care - Title XIX only ### ### ### ### ### ### ### ### 50
51 Support Surfaces 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 34,003,318 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 26,469 ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 340,266 ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 34,370,053 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7