Worksheet B Part I

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FOREST HILL HEALTH AND REHAB CENTER
FOREST HILL, MD  21050

Medicare Provider Number: 215194
Cost report status: Settled Without Audit
[Record Code 1105866 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 215194
PERIOD:
FROM 10/01/2012
TO 09/30/2013
 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 1,688,518 ###                                     1
2 Capital-Related Costs - Moveable Equipment 137,041 ###                                   2
3 Employee Benefits 898,538 ###                               3
4 Administrative and General 2,197,917 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 406,157 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 197,367 ### ### ### ### ### ###                         6
7 Housekeeping 269,922 ### ### ### ### ### ###                       7
8 Dietary 808,251 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 563,616 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 234,179 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 44,962 ### ### ### ### ### ### ### ###             12
13 Social Service 216,590 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 109,002 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,312,249 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 47,736 ### ### ### ### 40
41 Laboratory 32,575 ### ### ### ### 41
42 Intravenous Therapy 26,966 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 26,955 ### ### ### ### ### 43
44 Physical Therapy 551,115 ### ### ### ### ### ### 44
45 Occupational Therapy 476,356 ### ### ### ### ### ### 45
46 Speech Pathology 200,176 ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 62,847 ### ### ### ### 48
49 Drugs Charged to Patients 364,494 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 10,409 ### ### ### ### 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 13,883,938 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 13,883,938 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7