Worksheet B Part I

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HICKORY CREEK AT HICKSVILLE
HICKSVILLE, OH  46526

Medicare Provider Number: 365680
Cost report status: Settled Without Audit
[Record Code 1145258 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 365680
PERIOD:
FROM 01/01/2015
TO 12/31/2015
 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 308,157 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 224,919 ###                               3
4 Administrative and General 658,072 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 151,033 ### ### ### ### ###                           5
6 Laundry and Linen Service 43,320 ### ### ### ###                         6
7 Housekeeping 60,376 ### ### ### ### ### ###                       7
8 Dietary 277,539 ### ### ### ### ### ### ###                     8
9 Nursing Administration 181,099 ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library 4,633 ### ### ### ###             12
13 Social Service 86,154 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 895,776 ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 40
41 Laboratory 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 83,385 ### ### ### ### ### ### ### 44
45 Occupational Therapy 73,238 ### ### ### ### 45
46 Speech Pathology 4,960 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 30,224 ### ### ### ### 48
49 Drugs Charged to Patients 50,843 ### ### ### 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 502 ### ### ### ### 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 3,134,230 ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 86 ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 277,660 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 3,411,976 ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7