Worksheet B Part I

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EDISON CHRISTIAN HEALTH CENTER
GRAND RAPIDS, MI  49504-3999

Medicare Provider Number: 235339
Cost report status: Settled Without Audit
[Record Code 1368079 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 235339
PERIOD:
FROM 06/01/2022
TO 05/31/2023
 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 131,656 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 1,746,984 ### ###                               3
4 Administrative and General 1,209,662 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 632,021 ### ### ### ### ###                           5
6 Laundry and Linen Service 241,777 ### ### ### ### ### ###                         6
7 Housekeeping 260,750 ### ### ### ### ### ### ###                       7
8 Dietary 1,541,381 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 420,713 ### ### ### ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library 8,400 ### ### ###             12
13 Social Service 184,581 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 247,132 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 6,015,279 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 1,583,541 ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 4,888 ### ### ### 40
41 Laboratory 2,656 ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 161,407 ### ### ### ### ### ### ### 44
45 Occupational Therapy 44,819 ### ### ### ### 45
46 Speech Pathology 6,485 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 679 ### ### ### ### 48
49 Drugs Charged to Patients 78,875 ### ### ### 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 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 14,523,686 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 25,099 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices ### ### ### ### ### ### ### 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 250,092 ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 14,798,877 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7