Worksheet B Part I

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LIFE CARE CENTER OF BOISE
BOISE, ID  83706

Medicare Provider Number: 135038
Cost report status: Settled Without Audit
[Record Code 1214257 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 135038
PERIOD:
FROM 10/01/2016
TO 12/31/2016
 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 77,238 ###                                     1
2 Capital-Related Costs - Moveable Equipment 27,363 ###                                   2
3 Employee Benefits 181,691 ### ### ###                               3
4 Administrative and General 194,735 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 53,532 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 19,586 ### ### ### ### ### ### ###                         6
7 Housekeeping 36,179 ### ### ### ### ### ### ###                       7
8 Dietary 106,301 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 105,335 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 7,109 ### ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 19,574 ### ### ### ### ### ### ### ###             12
13 Social Service 20,973 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 38,961 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 573,381 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 858 ### ### ### 40
41 Laboratory 3,154 ### ### ### 41
42 Intravenous Therapy 740 ### ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 105 ### ### ### ### 43
44 Physical Therapy 88,027 ### ### ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 53,738 ### ### ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 16,141 ### ### ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 12,889 ### ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 43,814 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 553 ### ### ### 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 1,681,977 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 151 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 16,716 ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 1,698,844 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7