Worksheet B Part I

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THE LAURELS OF UNIVERSITY PARK
RICHMOND, VA  23233

Medicare Provider Number: 495109
Cost report status: Settled Without Audit
[Record Code 1055593 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 495109
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 1,024,593 ###                                     1
2 Capital-Related Costs - Moveable Equipment 269,606 ###                                   2
3 Employee Benefits 1,153,497 ### ### ###                               3
4 Administrative and General 911,181 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 435,037 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 73,909 ### ### ### ### ### ### ###                         6
7 Housekeeping 266,048 ### ### ### ### ### ### ###                       7
8 Dietary 708,996 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 710,395 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 76,950 ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 40,323 ### ### ### ### ### ### ### ###             12
13 Social Service 128,319 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 115,920 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,688,850 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 24,491 ### ### ### ### ### 40
41 Laboratory 40,329 ### ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 39,773 ### ### ### ### ### 43
44 Physical Therapy 662,174 ### ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 394,573 ### ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 121,100 ### ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 108,160 ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 515,448 ### ### ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 10,526 ### ### ### ### ### ### ### ### ### 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 422 ### ### ### ### 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 10,520,620 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 24,500 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 876 ### ### ### ### 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 96 ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 10,546,092 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7