Worksheet B Part I

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LORIEN NRSG & REHAB CTR- BEL AIR
BEL AIR, MD  21015

Medicare Provider Number: 215341
Cost report status: Settled Without Audit
[Record Code 1170098 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 215341
PERIOD:
FROM 01/01/2016
TO 12/31/2016
 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 410,527 ###                                     1
2 Capital-Related Costs - Moveable Equipment 56,277 ###                                   2
3 Employee Benefits 934,326 ###                               3
4 Administrative and General 1,884,988 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 538,127 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 129,172 ### ### ### ### ### ### ###                         6
7 Housekeeping 198,549 ### ### ### ### ### ### ###                       7
8 Dietary 914,836 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 718,791 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ### ###                 10
11 Pharmacy 1,751 ### ### ###               11
12 Medical Records and Library 22,304 ### ### ### ### ### ### ### ###             12
13 Social Service 84,436 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 233,599 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,176,805 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 792,867 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 40
41 Laboratory 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 31,096 ### ### ### ### 43
44 Physical Therapy 813,237 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 514,391 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 176,441 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 313,423 ### ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 11,005 ### ### ### ### 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 10,956,948 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 36,572 ### ### ### ### ### ### ### ### 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 10,993,520 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7