Worksheet B Part I

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BAYPOINTE REHAB CENTER
BROCKTON, MA  02401

Medicare Provider Number: 225690
Cost report status: Settled Without Audit
[Record Code 1396265 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 225690
PERIOD:
FROM 01/01/2023
TO 12/31/2023
 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 1,169,211 ###                                     1
2 Capital-Related Costs - Moveable Equipment 22,023 ###                                   2
3 Employee Benefits 1,274,245 ### ### ###                               3
4 Administrative and General 4,593,426 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 969,895 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 190,700 ### ### ### ### ### ### ###                         6
7 Housekeeping 335,339 ### ### ### ### ### ### ###                       7
8 Dietary 1,143,615 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 1,038,991 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 38,111 ### ### ### ### ### ### ###                 10
11 Pharmacy 5,810 ### ### ###               11
12 Medical Records and Library 87,978 ### ### ### ### ### ### ### ###             12
13 Social Service 318,129 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 284,807 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 5,102,418 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 51,985 ### ### ### ### 40
41 Laboratory 84,236 ### ### ### ### 41
42 Intravenous Therapy 7,698 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 136,317 ### ### ### ### ### 43
44 Physical Therapy 327,707 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 348,530 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 27,603 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 2,025 ### ### ### ### 47
48 Medical Supplies Charged to Patients 2,841 ### ### ### ### 48
49 Drugs Charged to Patients 165,466 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 13,104 ### ### ### ### 51
52 Other Ancillary Service Cost 2,970 ### ### ### ### 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 88,857 ### ### ### ### 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 17,834,037 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 17,834,037 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7