Worksheet B-1

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ADMIRALS POINTE
HURON, OH  44839

Medicare Provider Number: 365968
Cost report status: Settled Without Audit
[Record Code 1176223 - 2010]
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COST ALLOCATION - STATISTICAL BASIS Provider CCN: 365968
PERIOD:
FROM 01/01/2016
TO 12/31/2016
 WORKSHEET B - 1
Cost Center Description   Cap. Rel. Buildings & Fixtures (Sq. Feet) Cap. Rel. Movable Equipment (Dollar Value or Sq. Feet) Employee Benefits (Gross Salaries) Reconciliation Administrative & General (Accumulated Cost) Plant Oper. Maintenance & Repairs (Sq. Feet) Laundry & Linen Service (Pounds of Laundry) House Keeping (Hours of Service) Dietary (Meals Served) Nursing Administration (Direct Nursing Hrs.) Central Services & Supply (Costed Requisitions) Pharmacy (Costed Requisitions) Medical Records & Library (Time Spent) Social Service (Time Spent) Nursing & Allied Health Education (Assigned Time) Other General Service Cost Subtotal Post Step-down Adjustments Total  
0 1 2 3 4 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   ###                                   1
2 Capital-Related Costs - Moveable Equipment     ###                                 2
3 Employee Benefits   ###                                 3
4 Administrative and General   ### ### ### ### ###                       4
5 Plant Operation, Maintenance and Repairs   ### ### ### ### ###                         5
6 Laundry and Linen Service   ### ### ### ### ###                       6
7 Housekeeping   ### ### ### ### ### ###                       7
8 Dietary   ### ### ### ### ### ### ###                     8
9 Nursing Administration   ### ### ### ### ### ### ###                 9
10 Central Services and Supply   ### ### ### ### ### ###                 10
11 Pharmacy                 11
12 Medical Records and Library   ### ### ### ### ### ### ###           12
13 Social Service   ### ### ###         13
14 Nursing and Allied Health Education           14
15 Other General Service Cost         15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility   ### ### ### ### ### ### ### ### ### ### ### ###       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   ### ### ### ### ###       44
45 Occupational Therapy   ### ### ### ### ###       45
46 Speech Pathology   ### ### ### ### ###       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   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   ### ### ### ### ### ### ### ### ### ### ### ### ###       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 Adjustment                                         98
99 Negative Cost Center                                         99
102 Cost to be allocated (Per Wkst. B, Pt I.)   ### ### ###   ### ### ### ### ### ### ### ### ###       102
103 Unit Cost Multiplier (Wkst. B, Pt I.)   ### ### ###   ### ### ### ### ### ### ### ### ###       103
104 Cost to be allocated (Per Wkst. B, Pt. II)         ### ### ### ### ### ### ### ### ###       104
105 Unit Cost Multiplier (Wkst B, Pt. II)         ### ### ### ### ### ### ### ### ###       105
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16     Rev 7