Worksheet B Part I

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THE FORUM AT TUCSON
TUCSON, AZ  85712

Medicare Provider Number: 035199
Cost report status: Settled Without Audit
[Record Code 1016832 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 035199
PERIOD:
FROM 01/01/2011
TO 12/31/2011
 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 4,138,473 ###                                     1
2 Capital-Related Costs - Moveable Equipment 36,583 ###                                   2
3 Employee Benefits 828,337 ### ### ###                               3
4 Administrative and General 1,662,266 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,567,783 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 58,963 ### ### ### ### ### ### ###                         6
7 Housekeeping 340,825 ### ### ### ### ### ### ###                       7
8 Dietary 1,772,071 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 259,118 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 67,041 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 41,887 ### ### ### ### ### ### ### ###             12
13 Social Service 86,179 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 168,455 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,370,620 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 887,198 ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 68,490 ### ### ### ### 40
41 Laboratory 26,605 ### ### ### ### 41
42 Intravenous Therapy 2,337 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 10,100 ### ### ### ### 43
44 Physical Therapy 387,163 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 360,394 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 100,425 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 35,851 ### ### ### ### ### 48
49 Drugs Charged to Patients 471,936 ### ### ### ### 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 77 ### ### ### ### 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 14,749,177 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 14,749,177 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7