Worksheet B Part I

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MAPLE HILLS HEALTHCARE INC.
OVERLAND PARK, KS  66204

Medicare Provider Number: 175550
Cost report status: Settled Without Audit
[Record Code 1363065 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 175550
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 2,502,254 ###                                     1
2 Capital-Related Costs - Moveable Equipment 60,235 ###                                   2
3 Employee Benefits 294,514 ###                               3
4 Administrative and General 1,740,438 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 492,196 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 66,993 ### ### ### ### ### ### ###                         6
7 Housekeeping 176,672 ### ### ### ### ### ### ###                       7
8 Dietary 931,383 ### ### ### ### ### ### ###                     8
9 Nursing Administration 272,614 ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 43,889 ### ### ### ###             12
13 Social Service 427,144 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,724,612 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 411,327 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 6,459 ### ### ### ### ### 40
41 Laboratory 19,550 ### ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 381,299 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 356,136 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 135,806 ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 15,211 ### ### ### ### ### 48
49 Drugs Charged to Patients 174,984 ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 58,096 ### ### ### ### 51
52 Other Ancillary Service Cost 422 ### ### ### ### 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 13,292,234 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 13,292,234 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7