Worksheet B Part I

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KNOLLWOOD-ARMY DISTAFF FOUNDATION
WASHINGTON DC, DC  20015

Medicare Provider Number: 095026
Cost report status: Settled Without Audit
[Record Code 1330229 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 095026
PERIOD:
FROM 01/01/2021
TO 12/31/2021
 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 3,298,034 ###                                     1
2 Capital-Related Costs - Moveable Equipment 126,386 ###                                   2
3 Employee Benefits 2,194,582 ###                               3
4 Administrative and General 5,016,666 ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 3,191,237 ### ### ### ###                           5
6 Laundry and Linen Service 220,842 ### ### ### ###                         6
7 Housekeeping 1,025,879 ### ### ### ###                       7
8 Dietary 3,403,456 ### ### ### ### ### ###                     8
9 Nursing Administration 415,155 ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy 5,525 ### ### ###               11
12 Medical Records and Library             12
13 Social Service 134,281 ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 791,572 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,052,641 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 1,092,545 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 40
41 Laboratory 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 10,906 ### ### ### ### 43
44 Physical Therapy 287,821 ### ### ### ### 44
45 Occupational Therapy 268,468 ### ### ### ### 45
46 Speech Pathology 125,369 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 184,166 ### ### ### ### 48
49 Drugs Charged to Patients 115,879 ### ### ### ### 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 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 443,546 ### ### ### ### ### ### ### ### 84
89 Subtotals 25,404,956 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 57,159 ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 357,349 ### ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 25,819,464 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7