Worksheet B Part I
- Return to Cost Report Summary
- Form B001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3524, REV 6
EAST RIDGE RETIREMENT VILLAGE
CUTLER BAY, FL 33157
CUTLER BAY, FL 33157
Medicare Provider Number: 105508
Cost report status: Settled Without Audit
[Record Code 1043412 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS | Provider CCN: 105508 | PERIOD: FROM 01/01/2012 TO 12/31/2012 |
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 | 2,506,048 | ### | 1 | ||||||||||||||||||
2 | Capital-Related Costs - Moveable Equipment | 40,273 | ### | 2 | ||||||||||||||||||
3 | Employee Benefits | 1,276,869 | ### | ### | ### | 3 | ||||||||||||||||
4 | Administrative and General | 2,429,988 | ### | ### | ### | ### | ### | 4 | ||||||||||||||
5 | Plant Operation, Maintenance and Repairs | 1,950,261 | ### | ### | ### | ### | ### | ### | 5 | |||||||||||||
6 | Laundry and Linen Service | 22,637 | ### | ### | ### | ### | ### | ### | ### | 6 | ||||||||||||
7 | Housekeeping | 654,050 | ### | ### | ### | ### | ### | ### | ### | 7 | ||||||||||||
8 | Dietary | 1,458,669 | ### | ### | ### | ### | ### | ### | ### | ### | 8 | |||||||||||
9 | Nursing Administration | 197,129 | ### | ### | ### | ### | ### | ### | ### | ### | 9 | |||||||||||
10 | Central Services and Supply | 80,569 | ### | ### | ### | ### | 10 | |||||||||||||||
11 | Pharmacy | 11 | ||||||||||||||||||||
12 | Medical Records and Library | 41,027 | ### | ### | ### | ### | ### | ### | ### | ### | 12 | |||||||||||
13 | Social Service | 52,192 | ### | ### | ### | ### | ### | ### | ### | ### | 13 | |||||||||||
14 | Nursing and Allied Health Education | 14 | ||||||||||||||||||||
15 | Other General Service Cost | 87,879 | ### | ### | ### | ### | ### | ### | ### | ### | 15 | |||||||||||
INPATIENT ROUTINE SERVICE COST CENTERS | ||||||||||||||||||||||
30 | Skilled Nursing Facility | 1,903,305 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 30 | |||
31 | Nursing Facility | 31 | ||||||||||||||||||||
32 | ICF/IID | 32 | ||||||||||||||||||||
33 | Other Long Term Care | 33 | ||||||||||||||||||||
ANCILLARY SERVICE COST CENTERS | ||||||||||||||||||||||
40 | Radiology | 4,760 | ### | ### | ### | ### | 40 | |||||||||||||||
41 | Laboratory | 11,952 | ### | ### | ### | ### | 41 | |||||||||||||||
42 | Intravenous Therapy | 42 | ||||||||||||||||||||
43 | Oxygen (Inhalation) Therapy | 43 | ||||||||||||||||||||
44 | Physical Therapy | 370,143 | ### | ### | ### | ### | ### | ### | ### | ### | 44 | |||||||||||
45 | Occupational Therapy | 282,846 | ### | ### | ### | ### | ### | ### | ### | ### | 45 | |||||||||||
46 | Speech Pathology | 8,020 | ### | ### | ### | ### | ### | ### | ### | ### | 46 | |||||||||||
47 | Electrocardiology | 47 | ||||||||||||||||||||
48 | Medical Supplies Charged to Patients | 52,840 | ### | ### | ### | ### | ### | ### | ### | ### | 48 | |||||||||||
49 | Drugs Charged to Patients | 116,398 | ### | ### | ### | ### | 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 | 13,547,855 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 89 | |||
NON REIMBURSABLE COST CENTERS | ||||||||||||||||||||||
90 | Gift, Flower, Coffee Shops and Canteen | ### | ### | ### | ### | ### | ### | ### | ### | 90 | ||||||||||||
91 | Barber and Beauty Shop | 52,903 | ### | ### | ### | ### | ### | ### | ### | ### | ### | 91 | ||||||||||
92 | Physicians' Private Offices | 92 | ||||||||||||||||||||
93 | Nonpaid Workers | 93 | ||||||||||||||||||||
94 | Patients' Laundry | 94 | ||||||||||||||||||||
95 | Other Nonreimbursable Cost | 2,990,500 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 95 | |||
98 | Cross Foot Adjustments | 98 | ||||||||||||||||||||
99 | Negative Cost Center | 99 | ||||||||||||||||||||
100 | Total | 16,591,258 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 100 | |||
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120) | ||||||||||||||||||||||
08-16 | Rev. 7 |