Worksheet B-1

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SPRINGPOINT AT MONROE VILLAGE
JAMESBURG, NJ  08831

Medicare Provider Number: 315269
Cost report status: Settled Without Audit
[Record Code 1112981 - 2010]
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COST ALLOCATION - STATISTICAL BASIS Provider CCN: 315269
PERIOD:
FROM 01/01/2014
TO 12/31/2014
 WORKSHEET B - 1
Cost Center Description   Cap. Rel. Buildings & Fixtures (Sq. Feet) Cap. Rel. Movable Equipment (Dollar Value or Sq. Feet) Employee Benefits (Gross Salaries) Reconciliation Administrative & General (Accumulated Cost) Plant Oper. Maintenance & Repairs (Sq. Feet) Laundry & Linen Service (Pounds of Laundry) House Keeping (Hours of Service) Dietary (Meals Served) Nursing Administration (Direct Nursing Hrs.) Central Services & Supply (Costed Requisitions) Pharmacy (Costed Requisitions) Medical Records & Library (Time Spent) Social Service (Time Spent) Nursing & Allied Health Education (Assigned Time) Other General Service Cost Subtotal Post Step-down Adjustments Total  
0 1 2 3 4 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
2 Capital-Related Costs - Moveable Equipment     ###                                 2
3 Employee Benefits   ###                                 3
4 Administrative and General   ### ### ### ### ###                       4
5 Plant Operation, Maintenance and Repairs   ### ### ### ### ###                         5
6 Laundry and Linen Service   ### ### ### ### ### ###                       6
7 Housekeeping   ### ### ### ### ### ###                       7
8 Dietary   ### ### ### ### ### ### ###                     8
9 Nursing Administration   ### ### ### ### ### ### ###                 9
10 Central Services and Supply   ### ### ### ### ### ###                 10
11 Pharmacy   ### ###               11
12 Medical Records and Library   ###           12
13 Social Service   ### ### ### ### ### ### ###         13
14 Nursing and Allied Health Education           14
15 Other General Service Cost   ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility   ### ### ### ### ### ### ### ### ### ### ### ### ### ###       30
31 Nursing Facility         31
32 ICF/IID         32
33 Other Long Term Care         33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology   ###       40
41 Laboratory   ###       41
42 Intravenous Therapy   ###       42
43 Oxygen (Inhalation) Therapy         43
44 Physical Therapy   ### ### ### ### ###       44
45 Occupational Therapy   ### ### ### ### ###       45
46 Speech Pathology   ### ### ### ### ###       46
47 Electrocardiology   ###       47
48 Medical Supplies Charged to Patients   ###       48
49 Drugs Charged to Patients   ###       49
50 Dental Care - Title XIX only         50
51 Support Surfaces         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   ### ### ### ### ### ### ### ### ### ### ### ### ### ### ###       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 Adjustment                                         98
99 Negative Cost Center                                         99
102 Cost to be allocated (Per Wkst. B, Pt I.)   ### ### ###   ### ### ### ### ### ### ### ### ### ###       102
103 Unit Cost Multiplier (Wkst. B, Pt I.)   ### ### ###   ### ### ### ### ### ### ### ### ### ###       103
104 Cost to be allocated (Per Wkst. B, Pt. II)         ### ### ### ### ### ### ### ### ### ###       104
105 Unit Cost Multiplier (Wkst B, Pt. II)         ### ### ### ### ### ### ### ### ### ###       105
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16     Rev 7