Worksheet B Part I

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AUBURN SENIOR SERVICES INC.
AUBURN, NY  13021

Medicare Provider Number: 335382
Cost report status: Settled Without Audit
[Record Code 1242110 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 335382
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 887,929 ###                                     1
2 Capital-Related Costs - Moveable Equipment 340,236 ###                                   2
3 Employee Benefits 3,924,321 ### ### ###                               3
4 Administrative and General 4,117,265 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 993,153 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 656,660 ### ### ### ### ### ### ###                         6
7 Housekeeping 780,630 ### ### ### ### ### ### ###                       7
8 Dietary 2,915,801 ### ### ### ### ### ### ###                     8
9 Nursing Administration 1,631,775 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 30,787 ### ### ### ### ### ### ###                 10
11 Pharmacy 596,460 ### ### ###               11
12 Medical Records and Library 74,474 ### ### ### ### ### ### ###             12
13 Social Service 396,229 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 348,845 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 9,587,012 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 40
41 Laboratory 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 1,014,988 ### ### ### ### ### ### ### 44
45 Occupational Therapy 723,922 ### ### ### ### ### ### ### 45
46 Speech Pathology 224,440 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 48
49 Drugs Charged to Patients ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 313,559 ### ### ### ### ### ### ### ### 52
OUTPATIENT SERVICE COST CENTERS                                          
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 483,856 ### ### ### ### ### ### ### ### ### 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 30,042,342 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 30,042,342 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7