Worksheet B Part I

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CARMEL RICHMOND NURSING HOME
STATEN ISLAND, NY  10304

Medicare Provider Number: 335455
Cost report status: Settled Without Audit
[Record Code 1273343 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 335455
PERIOD:
FROM 01/01/2019
TO 12/31/2019
 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 1,836,273 ###                                     1
2 Capital-Related Costs - Moveable Equipment 198,297 ###                                   2
3 Employee Benefits 8,496,834 ### ### ###                               3
4 Administrative and General 6,445,887 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 2,225,832 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 929,982 ### ### ### ### ### ### ###                         6
7 Housekeeping 1,231,081 ### ### ### ### ### ### ### ###                       7
8 Dietary 2,866,475 ### ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 1,442,111 ### ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 497,016 ### ### ### ### ### ### ###                 10
11 Pharmacy 1,192,460 ### ### ###               11
12 Medical Records and Library 110,051 ### ### ### ### ### ### ### ### ###             12
13 Social Service 517,903 ### ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 414,827 ### ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 11,278,966 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 138,359 ### ### ### ### 40
41 Laboratory 101,488 ### ### ### ### ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 1,520,977 ### ### ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 1,198,808 ### ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 96,145 ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 48
49 Drugs Charged to Patients ### ### ### 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 42,739,772 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 122,362 ### ### ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 29,982 ### ### ### ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 16,610 ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 42,908,726 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7