Worksheet B Part I

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HERITAGE MANOR CARLINVILLE LLC
CARLINVILLE, IL  62626

Medicare Provider Number: 145456
Cost report status: Settled Without Audit
[Record Code 1319284 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 145456
PERIOD:
FROM 01/01/2020
TO 12/31/2020
 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 423,254 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 486,367 ###                               3
4 Administrative and General 734,314 ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 305,292 ### ### ### ###                           5
6 Laundry and Linen Service 84,142 ### ### ### ###                         6
7 Housekeeping 100,049 ### ### ### ###                       7
8 Dietary 391,645 ### ### ### ###                     8
9 Nursing Administration 173,487 ### ### ### ###                   9
10 Central Services and Supply 53,649 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library             12
13 Social Service 111,521 ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,673,090 ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 6,678 ### ### ### ### 40
41 Laboratory 32,823 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 218,945 ### ### ### ### ### ### ### 44
45 Occupational Therapy 255,020 ### ### ### ### ### ### ### 45
46 Speech Pathology 38,400 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 57,547 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 294,379 ### ### ### ### 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 842 ### ### ### ### 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 5,441,444 ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 39 ### ### ### ### ### ### ### 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 5,441,483 ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7