Worksheet B Part I

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THE OAKS AT BYRON CENTER
BYRON CENTER, MI  49315-7817

Medicare Provider Number: 235639
Cost report status: Settled Without Audit
[Record Code 1329514 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 235639
PERIOD:
FROM 01/01/2021
TO 12/31/2021
 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 998,065 ###                                     1
2 Capital-Related Costs - Moveable Equipment 611,289 ###                                   2
3 Employee Benefits 1,589,169 ### ### ###                               3
4 Administrative and General 1,119,046 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 446,317 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 9,474 ### ### ### ### ### ###                         6
7 Housekeeping 275,249 ### ### ### ### ### ### ###                       7
8 Dietary 734,073 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 375,351 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 175,144 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library ### ### ### ### ### ### ###             12
13 Social Service 128,548 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 234,933 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,247,851 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 449,914 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 3,355 ### ### ### 40
41 Laboratory 7,074 ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 8,036 ### ### ### ### ### ### ### 43
44 Physical Therapy 206,837 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 148,659 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 16,437 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 5,658 ### ### ### 48
49 Drugs Charged to Patients 205,700 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 14,642 ### ### ### 51
52 Other Ancillary Service Cost 34,117 ### ### ### 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 10,044,938 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 19,434 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 82,866 ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 10,147,238 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7