Worksheet B Part I

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GRACE HEALTHCARE OF PLEASANT HILL
PLEASANT HILL, CA  94523

Medicare Provider Number: 055049
Cost report status: Settled Without Audit
[Record Code 1174308 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 055049
PERIOD:
FROM 01/01/2016
TO 12/31/2016
 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 465,842 ###                                     1
2 Capital-Related Costs - Moveable Equipment 14,470 ###                                   2
3 Employee Benefits 430,167 ### ### ###                               3
4 Administrative and General 1,088,782 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 246,568 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 70,978 ### ### ### ### ### ### ###                         6
7 Housekeeping 134,718 ### ### ### ### ### ### ###                       7
8 Dietary 373,904 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 165,820 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 302 ### ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 31,150 ### ### ### ### ### ### ### ###             12
13 Social Service 151,228 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,776,897 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 17,174 ### ### ### ### 40
41 Laboratory 26,405 ### ### ### ### 41
42 Intravenous Therapy 166 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 3,799 ### ### ### ### ### 43
44 Physical Therapy 257,735 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 228,749 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 16,783 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 9,170 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 221,971 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 7,524 ### ### ### ### 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 565 ### ### ### ### 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 5,740,867 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 1,935 ### ### ### ### 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 5,742,802 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7