Worksheet B Part I

Add to Cart
Add to Cart
back to list
back to list
free profile
free profile
profile
profile
financial & statistical
financial & statistical
financial indicators
financial indicators
RUGs statistics
RUGs statistics
cost reports
cost reports
HERITAGE MANOR NORMAL LLC
NORMAL, IL  61761

Medicare Provider Number: 145732
Cost report status: Settled Without Audit
[Record Code 1331035 - 2010]
Print
Print
Excel
Excel
PDF
PDF

You are not logged in or you have not purchased this report. This report has had its actual values replaced with dummy text ('###').

If you would like to become a subscriber, please look at our subscription details.

If you are already a subscriber, please login.

COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 145732
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 865,696 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 942,019 ### ###                               3
4 Administrative and General 1,484,160 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 580,608 ### ### ### ### ###                           5
6 Laundry and Linen Service 116,055 ### ### ### ### ### ###                         6
7 Housekeeping 313,631 ### ### ### ### ### ###                       7
8 Dietary 836,105 ### ### ### ### ### ### ###                     8
9 Nursing Administration 247,004 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 277,891 ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library             12
13 Social Service 224,422 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,261,467 ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 491,582 ### ### ### ### ### ### ### ### ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 7,097 ### ### ### ### 40
41 Laboratory 7,978 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 143,004 ### ### ### ### 43
44 Physical Therapy 348,819 ### ### ### ### ### ### ### 44
45 Occupational Therapy 277,504 ### ### ### ### 45
46 Speech Pathology 80,245 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 6,535 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 639,371 ### ### ### ### ### ### ### 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 10,870 ### ### ### ### 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 12,162,063 ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 8,181 ### ### ### ### 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 12,170,244 ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7