Worksheet B Part I

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MEADOWBROOK CARE CENTER
FREEPORT, NY  11520

Medicare Provider Number: 335796
Cost report status: Settled Without Audit
[Record Code 1230257 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 335796
PERIOD:
FROM 01/01/2017
TO 12/31/2017
 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 2,893,667 ###                                     1
2 Capital-Related Costs - Moveable Equipment 653,446 ###                                   2
3 Employee Benefits 5,414,981 ###                               3
4 Administrative and General 4,029,966 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,178,342 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 466,298 ### ### ### ### ### ###                         6
7 Housekeeping 1,050,830 ### ### ### ### ### ### ###                       7
8 Dietary 2,382,649 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 860,819 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 597,950 ### ### ### ### ### ### ### ###                 10
11 Pharmacy 58,094 ### ### ###               11
12 Medical Records and Library 28,325 ### ### ### ### ### ### ### ###             12
13 Social Service 421,380 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 446,702 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 10,235,067 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 112,654 ### ### ### ### 40
41 Laboratory 55,861 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 1,216,770 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 943,943 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 300,075 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 9,109 ### ### ### ### 48
49 Drugs Charged to Patients 615,852 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 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 28,710 ### ### ### ### 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 34,001,490 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 56,400 ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 34,057,890 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7