Worksheet B Part I

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ADDOLORATA VILLA
WHEELING, IL  60090

Medicare Provider Number: 145724
Cost report status: Settled Without Audit
[Record Code 1279461 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 145724
PERIOD:
FROM 07/01/2019
TO 06/30/2020
 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 1,930,466 ###                                     1
2 Capital-Related Costs - Moveable Equipment 186,966 ###                                   2
3 Employee Benefits 2,423,735 ### ### ###                               3
4 Administrative and General 3,082,317 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,800,127 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 151,791 ### ### ### ### ### ### ###                         6
7 Housekeeping 576,653 ### ### ### ### ### ### ###                       7
8 Dietary 2,699,228 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 345,680 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 297,516 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 5,192 ### ### ### ### ### ### ###             12
13 Social Service 197,134 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 224,891 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,112,990 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 335,678 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 507,806 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 5,296 ### ### ### 40
41 Laboratory 11,195 ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 8,063 ### ### ### 43
44 Physical Therapy 188,081 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 140,153 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 52,791 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 435 ### ### ### ### 48
49 Drugs Charged to Patients 105,370 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 4,635 ### ### ### 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 18,394,189 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 828,207 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 19,222,396 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7