Worksheet B Part I

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CARLISLE MANOR
CARLISLE, OH  45005

Medicare Provider Number: 366043
Cost report status: Settled Without Audit
[Record Code 1328269 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 366043
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 510,505 ###                                     1
2 Capital-Related Costs - Moveable Equipment 43,164 ###                                   2
3 Employee Benefits 277,631 ### ### ###                               3
4 Administrative and General 683,685 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 145,263 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 33,304 ### ### ### ### ### ### ###                         6
7 Housekeeping 54,189 ### ### ### ### ### ### ###                       7
8 Dietary 302,374 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 84,335 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 41,526 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library ### ### ### ### ### ### ###             12
13 Social Service 122,041 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,362,765 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 2,726 ### ### ### 40
41 Laboratory 15,819 ### ### ### 41
42 Intravenous Therapy 63 ### ### ### 42
43 Oxygen (Inhalation) Therapy 11,342 ### ### ### ### ### ### ### 43
44 Physical Therapy 84,002 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 79,331 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 17,172 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 440 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 147,593 ### ### ### ### ### ### ### 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 4,019,270 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 4,019,270 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7