Worksheet B Part I

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409 KND NRSG & REHAB-MOUNTAIN VALLEY
KELLOGG, ID  83837

Medicare Provider Number: 135065
Cost report status: Settled Without Audit
[Record Code 1046741 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 135065
PERIOD:
FROM 07/01/2011
TO 06/30/2012
 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 518,587 ###                                     1
2 Capital-Related Costs - Moveable Equipment 109,804 ###                                   2
3 Employee Benefits 610,436 ### ### ###                               3
4 Administrative and General 722,582 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 238,227 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 69,200 ### ### ### ### ### ###                         6
7 Housekeeping 91,809 ### ### ### ### ### ###                       7
8 Dietary 347,260 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 170,690 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 2,902 ### ### ### ### ### ### ### ###                 10
11 Pharmacy 30,121 ### ### ###               11
12 Medical Records and Library 41,561 ### ### ### ### ### ### ### ###             12
13 Social Service 98,500 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,261,765 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 3,946 ### ### ### 40
41 Laboratory 20,230 ### ### ### 41
42 Intravenous Therapy 856 ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 151,282 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 96,269 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 44,132 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 39 ### ### ### 47
48 Medical Supplies Charged to Patients 21,173 ### ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 117,605 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 18,014 ### ### ### ### ### 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 4,786,990 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 5,319 ### ### ### ### ### ### ### ### 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 4,792,309 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7