Worksheet B Part I

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CANTERBURY ON THE LAKE
WATERFORD, MI  48329

Medicare Provider Number: 235555
Cost report status: Settled Without Audit
[Record Code 1146987 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 235555
PERIOD:
FROM 07/01/2014
TO 06/30/2015
 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 1,130,692 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 1,276,308 ### ###                               3
4 Administrative and General 2,027,882 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,478,071 ### ### ### ### ###                           5
6 Laundry and Linen Service 70,698 ### ### ### ### ### ###                         6
7 Housekeeping 465,736 ### ### ### ### ### ###                       7
8 Dietary 2,504,316 ### ### ### ### ### ###                     8
9 Nursing Administration 554,824 ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 226,863 ### ### ### ### ### ### ###             12
13 Social Service 121,911 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 151,000 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,858,776 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 2,177,149 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 315,717 ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 44,012 ### ### ### 40
41 Laboratory 34,361 ### ### ### 41
42 Intravenous Therapy ### ### ### 42
43 Oxygen (Inhalation) Therapy 35,084 ### ### ### ### ### ### ### 43
44 Physical Therapy 1,000,608 ### ### ### ### ### ### ### 44
45 Occupational Therapy 921,091 ### ### ### ### ### ### ### 45
46 Speech Pathology 259,191 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 22,586 ### ### ### ### ### 48
49 Drugs Charged to Patients 487,338 ### ### ### 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 17,164,214 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 83,447 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices ### ### ### ### ### ### ### 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 962,137 ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 18,209,798 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7