Worksheet B Part I

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MEADOWOOD
BLOOMINGTON, IN  47408

Medicare Provider Number: 155253
Cost report status: Settled Without Audit
[Record Code 1035976 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 155253
PERIOD:
FROM 01/01/2012
TO 12/31/2012
 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 3,491,604 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 894,454 ### ###                               3
4 Administrative and General 1,243,596 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,407,156 ### ### ### ### ###                           5
6 Laundry and Linen Service 52,949 ### ### ### ### ### ###                         6
7 Housekeeping 282,127 ### ### ### ### ### ###                       7
8 Dietary 1,307,819 ### ### ### ### ### ### ###                     8
9 Nursing Administration 204,162 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 38,981 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 37,569 ### ### ### ### ### ### ###             12
13 Social Service 80,291 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 300,415 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 587,840 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 964,057 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 369,172 ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 5,226 ### ### ### ### 40
41 Laboratory 17,191 ### ### ### ### 41
42 Intravenous Therapy 13,619 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 8,260 ### ### ### ### 43
44 Physical Therapy 324,447 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 229,921 ### ### ### ### ### 45
46 Speech Pathology 91,028 ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 10,852 ### ### ### ### 48
49 Drugs Charged to Patients 170,593 ### ### ### ### 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 19,028 ### ### ### ### 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 12,152,357 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 12,152,357 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7