Worksheet B Part I

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EPCOH ON BLACKSTONE BOULEVARD LLC
PROVIDENCE, RI  02906

Medicare Provider Number: 415126
Cost report status: Settled Without Audit
[Record Code 1150862 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 415126
PERIOD:
FROM 01/01/2016
TO 05/14/2016
 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 840,719 ###                                     1
2 Capital-Related Costs - Moveable Equipment 69,001 ###                                   2
3 Employee Benefits 434,755 ### ### ###                               3
4 Administrative and General 551,986 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 269,686 ### ### ### ### ### ###                           5
6 Laundry and Linen Service ### ### ### ### ### ###                         6
7 Housekeeping 113,426 ### ### ### ### ### ###                       7
8 Dietary 383,248 ### ### ### ### ### ### ###                     8
9 Nursing Administration 40,049 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 40,996 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 27,564 ### ### ### ###             12
13 Social Service 32,578 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 98,476 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 591,683 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 15,731 ### ### ### ### 40
41 Laboratory 43,426 ### ### ### ### 41
42 Intravenous Therapy 27,116 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 4,871 ### ### ### ### 43
44 Physical Therapy 204,373 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 196,125 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 11,408 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 5,445 ### ### ### ### 48
49 Drugs Charged to Patients 158,719 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 14,160 ### ### ### ### 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 4,175,541 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 434,520 ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 4,610,061 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7