Worksheet B Part I

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MICHIGAN VETERAN HOMES AT CHESTERFIE
CHESTERFIELD TOWNSHIP, MI  48047

Medicare Provider Number: 235728
Cost report status: Settled Without Audit
[Record Code 1345964 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 235728
PERIOD:
FROM 10/01/2021
TO 09/30/2022
 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                                     1
2 Capital-Related Costs - Moveable Equipment 126,336 ###                                   2
3 Employee Benefits 2,679,155 ###                               3
4 Administrative and General 745,569 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,300,584 ### ### ### ### ###                           5
6 Laundry and Linen Service -82,434 ### ### ### ###                         6
7 Housekeeping 536,542 ### ### ### ### ###                       7
8 Dietary 1,478,180 ### ### ### ### ### ###                     8
9 Nursing Administration 621,136 ### ### ### ### ### ###                   9
10 Central Services and Supply 301,501 ### ### ### ### ###                 10
11 Pharmacy 618,684 ### ### ### ### ### ###               11
12 Medical Records and Library             12
13 Social Service 556,741 ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 10,210,841 ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 4,490 ### ### ### ### 40
41 Laboratory 619 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 3,785 ### ### ### ### 43
44 Physical Therapy 164,064 ### ### ### ### ### ### 44
45 Occupational Therapy 147,241 ### ### ### ### 45
46 Speech Pathology 55,532 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 48
49 Drugs Charged to Patients 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 1,187 ### ### ### ### 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 19,469,753 ### ### ### ### ### ### ### ### ### ### ### ### ### 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 10,143 ### ### ### ### 94
95 Other Nonreimbursable Cost 95
98 Cross Foot Adjustments       98
99 Negative Cost Center ### ### ### 99
100 Total 19,479,896 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7