Worksheet B Part I

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CHRISTIN LIVING COMMUNITIES - THE JO
LITTLETON, CO  80122

Medicare Provider Number: 065345
Cost report status: Settled Without Audit
[Record Code 1239843 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 065345
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 1,353,396 ###                                     1
2 Capital-Related Costs - Moveable Equipment 172,286 ###                                   2
3 Employee Benefits 1,259,570 ### ### ###                               3
4 Administrative and General 348,185 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 291,433 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 1,687 ### ### ### ### ### ###                         6
7 Housekeeping 353,395 ### ### ### ### ### ### ###                       7
8 Dietary 2,389,406 ### ### ### ### ### ### ###                     8
9 Nursing Administration 537,503 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 37,308 ### ### ### ### ### ### ###                 10
11 Pharmacy 74,422 ### ### ###               11
12 Medical Records and Library 67,935 ### ### ### ### ### ### ### ###             12
13 Social Service 127,725 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 217,423 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,547,758 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 8,934 ### ### ### ### 40
41 Laboratory 28,304 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 10,458 ### ### ### ### 43
44 Physical Therapy 262,217 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 207,530 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 71,486 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 130,110 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 73,786 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 23,387 ### ### ### ### 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 11,595,644 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 3,693,677 ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 15,289,321 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7