Worksheet B Part I

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GRACE CARE CTR
WICHITA FALLS, TX  76301

Medicare Provider Number: 455901
Cost report status: Settled Without Audit
[Record Code 1059388 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 455901
PERIOD:
FROM 06/01/2012
TO 05/31/2013
 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 446,333 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 320,679 ### ###                               3
4 Administrative and General 430,370 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 161,040 ### ### ### ### ###                           5
6 Laundry and Linen Service 27,733 ### ### ### ### ### ###                         6
7 Housekeeping 44,587 ### ### ### ### ### ### ###                       7
8 Dietary 304,794 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 216,291 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 11,108 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 11,740 ### ### ### ### ### ### ###             12
13 Social Service 26,344 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 24,725 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 865,819 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 3,123 ### ### ### ### 40
41 Laboratory 22,143 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 2,061 ### ### ### ### 43
44 Physical Therapy 159,845 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 156,918 ### ### ### ### ### ### ### 45
46 Speech Pathology 91,891 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 26,082 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 71,338 ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 5,621 ### ### ### ### 51
52 Other Ancillary Service Cost 756 ### ### ### ### 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 3,431,341 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 32,466 ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 3,463,807 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7