Worksheet B Part I

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MIRABELLA PORTLAND
PORTLAND, OR  97239

Medicare Provider Number: 385274
Cost report status: Settled Without Audit
[Record Code 1283944 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 385274
PERIOD:
FROM 10/01/2019
TO 09/30/2020
 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 9,289,004 ###                                     1
2 Capital-Related Costs - Moveable Equipment 665,085 ###                                   2
3 Employee Benefits                               3
4 Administrative and General 4,095,986 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 2,361,859 ### ### ### ### ###                           5
6 Laundry and Linen Service                         6
7 Housekeeping 732,198 ### ### ### ### ### ###                       7
8 Dietary 3,893,260 ### ### ### ### ### ### ###                     8
9 Nursing Administration 261,819 ### ### ### ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library 68,392 ### ### ###             12
13 Social Service 355,643 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,115,593 ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 416,230 ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 2,433 ### ### ### ### ### 40
41 Laboratory 9,417 ### ### ### ### ### 41
42 Intravenous Therapy 12,182 ### ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 187,104 ### ### ### ### ### 44
45 Occupational Therapy 102,229 ### ### ### ### ### 45
46 Speech Pathology 21,791 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 18,454 ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 101,309 ### ### ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 13,227 ### ### ### ### ### 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 152 ### ### ### ### 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 26,723,367 ### ### ### ### ### ### ### ### ### ### ### ### 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 450,555 ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 27,173,922 ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7