Worksheet B Part I

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TERRACE OF ST CLOUD
ST CLOUD, FL  36740

Medicare Provider Number: 105528
Cost report status: As Submitted
[Record Code 1356122 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 105528
PERIOD:
FROM 01/01/2022
TO 12/31/2022
 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 1,447,006 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 236,752 ### ###                               3
4 Administrative and General 2,432,221 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 655,767 ### ### ### ### ###                           5
6 Laundry and Linen Service 120,198 ### ### ### ### ### ###                         6
7 Housekeeping 207,680 ### ### ### ### ### ###                       7
8 Dietary 774,068 ### ### ### ### ### ### ###                     8
9 Nursing Administration 824,557 ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 20,492 ### ### ### ### ### ### ### ###             12
13 Social Service 226,935 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,317,553 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 45,494 ### ### ### ### 40
41 Laboratory 69,329 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 668 ### ### ### ### 43
44 Physical Therapy 306,019 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 351,095 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 101,231 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 978 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 331,985 ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 1,462 ### ### ### ### 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 11,471,490 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 6,957 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 11,478,447 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7