Worksheet B Part I

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PRESTIGE CARE & REHAB - PARKSIDE
UNION GAP, WA  98903

Medicare Provider Number: 505401
Cost report status: Settled Without Audit
[Record Code 1059059 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 505401
PERIOD:
FROM 11/28/2012
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 18,154 ###                                     1
2 Capital-Related Costs - Moveable Equipment 497 ###                                   2
3 Employee Benefits 45,113 ### ### ###                               3
4 Administrative and General 38,858 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 15,843 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 6,840 ### ### ### ### ### ### ###                         6
7 Housekeeping 5,648 ### ### ### ### ### ### ###                       7
8 Dietary 27,219 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 17,756 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 8,884 ### ### ### ### ### ### ###                 10
11 Pharmacy ### ### ### ### ### ### ###               11
12 Medical Records and Library 6,768 ### ### ### ### ### ### ### ###             12
13 Social Service 8,849 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 115,663 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 139 ### ### ### 40
41 Laboratory 1,669 ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 11,416 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 4,913 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 360 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 48
49 Drugs Charged to Patients 16,795 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 6,787 ### ### ### 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 358,171 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 334 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 6,811 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 365,316 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7