Worksheet B Part I

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GOLDEN YEARS NURSING HOME
FALCON, NC  28342

Medicare Provider Number: 345367
Cost report status: Settled Without Audit
[Record Code 1118180 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 345367
PERIOD:
FROM 10/01/2013
TO 09/30/2014
 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 190,766 ###                                     1
2 Capital-Related Costs - Moveable Equipment 41,227 ###                                   2
3 Employee Benefits 328,586 ###                               3
4 Administrative and General 508,450 ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 171,525 ### ### ### ###                           5
6 Laundry and Linen Service 51,826 ### ### ### ###                         6
7 Housekeeping 51,125 ### ### ### ###                       7
8 Dietary 247,607 ### ### ### ###                     8
9 Nursing Administration 153,164 ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library 12,874 ### ### ### ###             12
13 Social Service 32,974 ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 30,318 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 939,465 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 687 ### ### ### ### 40
41 Laboratory 1,250 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 4,324 ### ### ### ### 43
44 Physical Therapy 73,970 ### ### ### ### ### 44
45 Occupational Therapy 49,231 ### ### ### ### ### 45
46 Speech Pathology 61,418 ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 36,407 ### ### ### ### 48
49 Drugs Charged to Patients 93,270 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 43,091 ### ### ### ### ### 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 3,123,555 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 523 ### ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 82 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 3,124,160 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7