Worksheet B Part I

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WANAQUE CENTER FOR NURSING & REHAB
HASKELL, NJ  07420

Medicare Provider Number: 315229
Cost report status: Settled Without Audit
[Record Code 1143095 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 315229
PERIOD:
FROM 01/01/2014
TO 06/17/2014
 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 799,547 ###                                     1
2 Capital-Related Costs - Moveable Equipment 90,892 ###                                   2
3 Employee Benefits 855,785 ###                               3
4 Administrative and General 937,007 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 294,780 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 97,372 ### ### ### ### ### ###                         6
7 Housekeeping 58,852 ### ### ### ### ### ###                       7
8 Dietary 314,216 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 161,907 ### ### ### ###                   9
10 Central Services and Supply 62,288 ### ### ### ### ### ### ### ###                 10
11 Pharmacy 11,841 ### ### ###               11
12 Medical Records and Library 9,346 ### ### ### ###             12
13 Social Service 50,159 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 89,918 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,541,018 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 8,265,012 ### ### ### ### ### ### ### ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 4,905 ### ### ### ### 40
41 Laboratory 5,243 ### ### ### ### 41
42 Intravenous Therapy 11,280 ### ### ### ### ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 51,444 ### ### ### ### ### 43
44 Physical Therapy 121,698 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 40,233 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 9,894 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 41,939 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 168,955 ### ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 1,273 ### ### ### ### 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 5,914 ### ### ### ### 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 14,102,718 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 14,102,718 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7