Worksheet B Part I

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RIVER VALLEY SKILLED NURSING & THERA
CLINTON, OK  73601

Medicare Provider Number: 375141
Cost report status: Settled Without Audit
[Record Code 1342488 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 375141
PERIOD:
FROM 01/01/2020
TO 12/31/2020
 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 225,455 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 279,120 ### ###                               3
4 Administrative and General 1,270,742 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 271,503 ### ### ### ### ###                           5
6 Laundry and Linen Service 64,797 ### ### ### ### ### ###                         6
7 Housekeeping 65,794 ### ### ### ### ### ###                       7
8 Dietary 367,899 ### ### ### ### ### ### ###                     8
9 Nursing Administration 189,463 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 340,627 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 17,442 ### ### ### ### ### ### ###             12
13 Social Service           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 57,557 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,589,315 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 917 ### ### ### ### 40
41 Laboratory 21,390 ### ### ### ### 41
42 Intravenous Therapy 40,170 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 12,272 ### ### ### ### ### ### ### 43
44 Physical Therapy 41,662 ### ### ### ### ### ### ### 44
45 Occupational Therapy 39,059 ### ### ### ### ### ### ### 45
46 Speech Pathology 20,603 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 12,546 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 84,014 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 17,370 ### ### ### ### 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 5,029,717 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 106 ### ### ### ### ### ### ### 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 5,029,823 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7