Worksheet B Part I

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ROSEGATE VILLAGE
INDIANAPOLIS, IN  46237

Medicare Provider Number: 155757
Cost report status: As Submitted
[Record Code 1356264 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 155757
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 753,367 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 1,140,370 ###                               3
4 Administrative and General 1,443,872 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 542,144 ### ### ### ### ###                           5
6 Laundry and Linen Service 118,752 ### ### ### ### ### ###                         6
7 Housekeeping 264,774 ### ### ### ### ### ###                       7
8 Dietary 896,284 ### ### ### ### ### ### ###                     8
9 Nursing Administration 710,313 ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library 36,023 ### ### ### ###             12
13 Social Service 169,489 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 212,131 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,696,224 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 40,602 ### ### ### 40
41 Laboratory 59,470 ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 2,470 ### ### ### ### ### 43
44 Physical Therapy 346,454 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 308,872 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 164,567 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 136,311 ### ### ### ### 48
49 Drugs Charged to Patients 277,523 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 21,439 ### ### ### 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 12,341,451 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 8,860 ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 679,103 ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 13,029,414 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7