Worksheet B Part I
- Return to Cost Report Summary
- Form B001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3524, REV 6
STURGEON BAY HEALTH SERVICES
STURGEON BAY, WI 54235
STURGEON BAY, WI 54235
Medicare Provider Number: 525306
Cost report status: Settled Without Audit
[Record Code 1242872 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS | Provider CCN: 525306 | 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 | 410,614 | ### | 1 | ||||||||||||||||||
2 | Capital-Related Costs - Moveable Equipment | 46,232 | ### | 2 | ||||||||||||||||||
3 | Employee Benefits | 295,397 | ### | 3 | ||||||||||||||||||
4 | Administrative and General | 1,161,554 | ### | ### | ### | ### | ### | 4 | ||||||||||||||
5 | Plant Operation, Maintenance and Repairs | 245,913 | ### | ### | ### | ### | ### | ### | 5 | |||||||||||||
6 | Laundry and Linen Service | 100,860 | ### | ### | ### | ### | ### | ### | 6 | |||||||||||||
7 | Housekeeping | 162,609 | ### | ### | ### | ### | ### | ### | 7 | |||||||||||||
8 | Dietary | 433,200 | ### | ### | ### | ### | ### | ### | 8 | |||||||||||||
9 | Nursing Administration | 163,583 | ### | ### | ### | ### | ### | ### | ### | ### | 9 | |||||||||||
10 | Central Services and Supply | 40,790 | ### | ### | ### | ### | ### | ### | ### | ### | 10 | |||||||||||
11 | Pharmacy | 11 | ||||||||||||||||||||
12 | Medical Records and Library | 8,712 | ### | ### | ### | ### | ### | ### | ### | ### | 12 | |||||||||||
13 | Social Service | 55,464 | ### | ### | ### | ### | ### | ### | ### | ### | 13 | |||||||||||
14 | Nursing and Allied Health Education | 14 | ||||||||||||||||||||
15 | Other General Service Cost | 99,056 | ### | ### | ### | ### | ### | ### | ### | ### | 15 | |||||||||||
INPATIENT ROUTINE SERVICE COST CENTERS | ||||||||||||||||||||||
30 | Skilled Nursing Facility | 1,554,229 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 30 | |||
31 | Nursing Facility | ### | ### | ### | 31 | |||||||||||||||||
32 | ICF/IID | 32 | ||||||||||||||||||||
33 | Other Long Term Care | 33 | ||||||||||||||||||||
ANCILLARY SERVICE COST CENTERS | ||||||||||||||||||||||
40 | Radiology | 1,467 | ### | ### | ### | ### | 40 | |||||||||||||||
41 | Laboratory | 7,133 | ### | ### | ### | ### | 41 | |||||||||||||||
42 | Intravenous Therapy | 42 | ||||||||||||||||||||
43 | Oxygen (Inhalation) Therapy | 8,655 | ### | ### | ### | ### | 43 | |||||||||||||||
44 | Physical Therapy | 276,292 | ### | ### | ### | ### | ### | ### | ### | ### | 44 | |||||||||||
45 | Occupational Therapy | 199,412 | ### | ### | ### | ### | ### | ### | ### | ### | 45 | |||||||||||
46 | Speech Pathology | 90,312 | ### | ### | ### | ### | ### | ### | ### | ### | 46 | |||||||||||
47 | Electrocardiology | 47 | ||||||||||||||||||||
48 | Medical Supplies Charged to Patients | ### | ### | ### | ### | ### | ### | ### | ### | 48 | ||||||||||||
49 | Drugs Charged to Patients | 108,402 | ### | ### | ### | ### | ### | ### | ### | ### | 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 | 3,986 | ### | ### | ### | ### | 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 | 5,473,872 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 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 | 11,750 | ### | ### | ### | ### | ### | ### | ### | ### | ### | 95 | ||||||||||
98 | Cross Foot Adjustments | 98 | ||||||||||||||||||||
99 | Negative Cost Center | 99 | ||||||||||||||||||||
100 | Total | 5,485,622 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 100 | |||
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120) | ||||||||||||||||||||||
08-16 | Rev. 7 |