Worksheet B Part I

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CANON LODGE CARE CENTER
CANON CITY, CO  81212

Medicare Provider Number: 065217
Cost report status: Settled Without Audit
[Record Code 1158477 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 065217
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 95,259 ###                                     1
2 Capital-Related Costs - Moveable Equipment 62,793 ###                                   2
3 Employee Benefits 337,878 ### ### ###                               3
4 Administrative and General 497,618 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 178,422 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 40,162 ### ### ### ### ### ### ###                         6
7 Housekeeping 63,131 ### ### ### ### ### ### ###                       7
8 Dietary 256,204 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 217,136 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 64 ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 26,284 ### ### ### ### ### ### ### ###             12
13 Social Service 37,211 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 52,999 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 950,355 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 874 ### ### ### 40
41 Laboratory 4,409 ### ### ### 41
42 Intravenous Therapy 2,149 ### ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 102,356 ### ### ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 101,450 ### ### ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 15,342 ### ### ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 10,753 ### ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 68,871 ### ### ### 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 3,121,720 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 20,648 ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 3,142,368 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7