Worksheet B Part I

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AVALON WEST HEALTH & REHABILITATION
SALT LAKE CITY, UT  84123

Medicare Provider Number: 465066
Cost report status: Settled Without Audit
[Record Code 1236023 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 465066
PERIOD:
FROM 07/01/2016
TO 06/30/2017
 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 980,458 ###                                     1
2 Capital-Related Costs - Moveable Equipment 83,604 ###                                   2
3 Employee Benefits 552,781 ### ### ###                               3
4 Administrative and General 1,461,571 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 259,395 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 101,775 ### ### ### ### ### ###                         6
7 Housekeeping 158,824 ### ### ### ### ### ###                       7
8 Dietary 589,835 ### ### ### ### ### ###                     8
9 Nursing Administration 437,346 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 58,263 ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 44,535 ### ### ### ### ### ### ###             12
13 Social Service 61,894 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 187,799 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,096,943 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 22,324 ### ### ### 40
41 Laboratory 88,430 ### ### ### 41
42 Intravenous Therapy 142,349 ### ### ### 42
43 Oxygen (Inhalation) Therapy 7,919 ### ### ### 43
44 Physical Therapy 462,658 ### ### ### ### ### ### ### 44
45 Occupational Therapy 366,079 ### ### ### ### ### ### ### 45
46 Speech Pathology 175,457 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 58,641 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 417,516 ### ### ### 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 8,816,396 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 8,816,396 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7