Worksheet B Part I
- Return to Cost Report Summary
- Form B001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3524, REV 6
CONTINENTAL MANOR
BLANCHESTER, OH 45107
BLANCHESTER, OH 45107
Medicare Provider Number: 365592
Cost report status: Settled Without Audit
[Record Code 1062136 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS | Provider CCN: 365592 | 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 | 282,458 | ### | 1 | ||||||||||||||||||
2 | Capital-Related Costs - Moveable Equipment | 2 | ||||||||||||||||||||
3 | Employee Benefits | 975,818 | ### | ### | 3 | |||||||||||||||||
4 | Administrative and General | 596,491 | ### | ### | ### | ### | 4 | |||||||||||||||
5 | Plant Operation, Maintenance and Repairs | 212,281 | ### | ### | ### | ### | ### | 5 | ||||||||||||||
6 | Laundry and Linen Service | 83,093 | ### | ### | ### | ### | ### | ### | 6 | |||||||||||||
7 | Housekeeping | 100,318 | ### | ### | ### | ### | ### | ### | 7 | |||||||||||||
8 | Dietary | 380,632 | ### | ### | ### | ### | ### | ### | ### | 8 | ||||||||||||
9 | Nursing Administration | 145,856 | ### | ### | ### | ### | ### | ### | ### | 9 | ||||||||||||
10 | Central Services and Supply | ### | ### | ### | ### | ### | ### | 10 | ||||||||||||||
11 | Pharmacy | 11 | ||||||||||||||||||||
12 | Medical Records and Library | 21,993 | ### | ### | ### | ### | ### | ### | ### | 12 | ||||||||||||
13 | Social Service | 111,313 | ### | ### | ### | ### | ### | ### | ### | 13 | ||||||||||||
14 | Nursing and Allied Health Education | 14 | ||||||||||||||||||||
15 | Other General Service Cost | 15 | ||||||||||||||||||||
INPATIENT ROUTINE SERVICE COST CENTERS | ||||||||||||||||||||||
30 | Skilled Nursing Facility | 1,435,413 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 30 | |||||
31 | Nursing Facility | 31 | ||||||||||||||||||||
32 | ICF/IID | 32 | ||||||||||||||||||||
33 | Other Long Term Care | 33 | ||||||||||||||||||||
ANCILLARY SERVICE COST CENTERS | ||||||||||||||||||||||
40 | Radiology | 3,956 | ### | ### | ### | ### | 40 | |||||||||||||||
41 | Laboratory | 10,668 | ### | ### | ### | ### | 41 | |||||||||||||||
42 | Intravenous Therapy | 15,197 | ### | ### | ### | ### | 42 | |||||||||||||||
43 | Oxygen (Inhalation) Therapy | 43 | ||||||||||||||||||||
44 | Physical Therapy | 138,199 | ### | ### | ### | ### | ### | ### | ### | 44 | ||||||||||||
45 | Occupational Therapy | 123,392 | ### | ### | ### | ### | 45 | |||||||||||||||
46 | Speech Pathology | 81,308 | ### | ### | ### | ### | 46 | |||||||||||||||
47 | Electrocardiology | 47 | ||||||||||||||||||||
48 | Medical Supplies Charged to Patients | 40,287 | ### | ### | ### | ### | 48 | |||||||||||||||
49 | Drugs Charged to Patients | 62,420 | ### | ### | ### | 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 | 21,215 | ### | ### | ### | ### | 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 | 4,842,308 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 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 | 406,055 | ### | ### | ### | ### | ### | ### | ### | ### | 95 | |||||||||||
98 | Cross Foot Adjustments | 98 | ||||||||||||||||||||
99 | Negative Cost Center | 99 | ||||||||||||||||||||
100 | Total | 5,248,363 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 100 | |||||
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120) | ||||||||||||||||||||||
08-16 | Rev. 7 |