Worksheet B Part I

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FRIENDSHIP VILLAGE OF COLUMBUS
COLUMBUS, OH  43231

Medicare Provider Number: 365399
Cost report status: Settled Without Audit
[Record Code 1248905 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 365399
PERIOD:
FROM 07/01/2018
TO 06/30/2019
 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 251,727 ###                                     1
2 Capital-Related Costs - Moveable Equipment 67,212 ###                                   2
3 Employee Benefits 896,571 ###                               3
4 Administrative and General 1,145,661 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 237,546 ### ### ### ###                           5
6 Laundry and Linen Service 68,133 ### ### ### ###                         6
7 Housekeeping 40,844 ### ### ### ###                       7
8 Dietary 675,336 ### ### ### ###                     8
9 Nursing Administration 349,310 ### ### ### ###                   9
10 Central Services and Supply 98,210 ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 64,215 ### ### ### ###             12
13 Social Service 33,787 ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 133,407 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,709,020 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 21,041 ### ### ### 40
41 Laboratory 32,354 ### ### ### 41
42 Intravenous Therapy 12,757 ### ### ### 42
43 Oxygen (Inhalation) Therapy 34,348 ### ### ### 43
44 Physical Therapy 380,006 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 342,169 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 137,117 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 87,407 ### ### ### ### 48
49 Drugs Charged to Patients 309,660 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 39,707 ### ### ### 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 7,167,545 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 -1 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 7,167,544 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7