Worksheet B Part I

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NEW CASTLE HEALTH AND REHABILITATION
NEW CASTLE, DE  19720

Medicare Provider Number: 085039
Cost report status: Settled Without Audit
[Record Code 1189319 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 085039
PERIOD:
FROM 07/01/2016
TO 06/30/2017
 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 3,828,117 ###                                     1
2 Capital-Related Costs - Moveable Equipment 10,247 ###                                   2
3 Employee Benefits 795,702 ###                               3
4 Administrative and General 1,429,884 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 338,920 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 98,808 ### ### ### ### ### ### ###                         6
7 Housekeeping 160,636 ### ### ### ### ### ### ###                       7
8 Dietary 638,423 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 921,119 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 245,896 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 18,784 ### ### ### ### ### ### ### ###             12
13 Social Service 106,709 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 91,312 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,187,469 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 36,572 ### ### ### ### 40
41 Laboratory 28,906 ### ### ### ### 41
42 Intravenous Therapy 16,750 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 752,702 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 505,362 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 138,101 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 794 ### ### ### ### 48
49 Drugs Charged to Patients 443,939 ### ### ### 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 13,795,152 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 109,151 ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 13,904,303 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7