Worksheet B Part I

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CARE ONE AT JACKSON
JACKSON, NJ  08527

Medicare Provider Number: 315240
Cost report status: Settled Without Audit
[Record Code 1273478 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 315240
PERIOD:
FROM 01/01/2018
TO 12/31/2018
 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 835,338 ###                                     1
2 Capital-Related Costs - Moveable Equipment 258,280 ###                                   2
3 Employee Benefits 1,896,554 ### ### ###                               3
4 Administrative and General 2,380,550 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 582,522 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 40,351 ### ### ### ### ### ### ###                         6
7 Housekeeping 295,897 ### ### ### ### ### ### ###                       7
8 Dietary 863,205 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 685,529 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 94,797 ### ### ### ### ### ### ### ###                 10
11 Pharmacy 55,380 ### ### ###               11
12 Medical Records and Library 32,111 ### ### ### ### ### ### ### ###             12
13 Social Service 92,195 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 263,631 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,287,466 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 942,827 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 48,072 ### ### ### ### 40
41 Laboratory 52,865 ### ### ### ### 41
42 Intravenous Therapy 123,786 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 23,280 ### ### ### ### 43
44 Physical Therapy 802,536 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 612,835 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 151,938 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 156,794 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 477,383 ### ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 19,474 ### ### ### ### 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 15,075,596 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 15 ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 20,143 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 15,095,754 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7