Worksheet B Part I

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THE MEADOWS OF NAPA VALLEY
NAPA, CA  94559

Medicare Provider Number: 555639
Cost report status: Settled Without Audit
[Record Code 1050685 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 555639
PERIOD:
FROM 04/01/2012
TO 03/31/2013
 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 2,975,392 ###                                     1
2 Capital-Related Costs - Moveable Equipment 456,998 ###                                   2
3 Employee Benefits                               3
4 Administrative and General 2,235,122 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,566,630 ### ### ### ### ###                           5
6 Laundry and Linen Service 159,172 ### ### ### ### ### ###                         6
7 Housekeeping 683,617 ### ### ### ### ### ###                       7
8 Dietary 2,565,489 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 86,809 ### ### ###                   9
10 Central Services and Supply 42,907 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 58,531 ### ### ### ### ### ### ###             12
13 Social Service 302,353 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,086,817 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 15,427 ### ### ### ### ### 40
41 Laboratory 33,989 ### ### ### ### ### 41
42 Intravenous Therapy 36,358 ### ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 539,300 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 444,649 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 98,787 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 122,338 ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 263,397 ### ### ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 1,185 ### ### ### ### ### 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 514 ### ### ### ### 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 15,775,781 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 1,513,302 ### ### ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 17,289,083 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7