Worksheet B Part I

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ARCADIA CARE AUBURN
AUBURN, IL  62615

Medicare Provider Number: 145136
Cost report status: Settled Without Audit
[Record Code 1332686 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 145136
PERIOD:
FROM 11/01/2021
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 43,489 ###                                     1
2 Capital-Related Costs - Moveable Equipment 4,029 ###                                   2
3 Employee Benefits 67,796 ###                               3
4 Administrative and General 118,202 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 30,281 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 2,507 ### ### ### ### ### ### ###                         6
7 Housekeeping 14,966 ### ### ### ###                       7
8 Dietary 59,130 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 40,561 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 14,753 ### ### ### ### ### ### ###                 10
11 Pharmacy 660 ### ### ###               11
12 Medical Records and Library 6,399 ### ### ### ###             12
13 Social Service 19,990 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 11,312 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 321,248 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 1,174 ### ### ### ### 40
41 Laboratory 3,536 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 3,144 ### ### ### ### 43
44 Physical Therapy 25,371 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 31,320 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 3,868 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 733 ### ### ### ### 48
49 Drugs Charged to Patients 16,772 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 220 ### ### ### ### 51
52 Other Ancillary Service Cost 1,000 ### ### ### ### 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 9,509 ### ### ### ### 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 851,970 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 6,405 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 858,375 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7