Worksheet B Part I

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HERITAGE PARK REHABILITATION AND HEA
ROY, UT  84067

Medicare Provider Number: 465003
Cost report status: Settled Without Audit
[Record Code 1172396 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 465003
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 553,657 ###                                     1
2 Capital-Related Costs - Moveable Equipment 60,905 ###                                   2
3 Employee Benefits 414,839 ###                               3
4 Administrative and General 1,845,987 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 568,545 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 145,569 ### ### ### ### ### ###                         6
7 Housekeeping 217,525 ### ### ### ### ### ###                       7
8 Dietary 736,655 ### ### ### ### ### ### ###                     8
9 Nursing Administration 813,893 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 194,231 ### ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 85,981 ### ### ### ### ### ### ### ###             12
13 Social Service 146,526 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 150,496 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,748,859 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 27,244 ### ### ### ### 40
41 Laboratory 69,025 ### ### ### ### 41
42 Intravenous Therapy 56,509 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 259,826 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 316,785 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 181,099 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 50,979 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 473,165 ### ### ### 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 11,118,300 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 6,574 ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 11,124,874 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7