Worksheet B Part I

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RETAMA MANOR NURSING CTR-JOURDANTON
JOURDANTON, TX  78026

Medicare Provider Number: 455549
Cost report status: Settled Without Audit
[Record Code 1151770 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 455549
PERIOD:
FROM 10/01/2014
TO 05/31/2015
 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 185,770 ###                                     1
2 Capital-Related Costs - Moveable Equipment 30,317 ###                                   2
3 Employee Benefits 201,456 ### ### ###                               3
4 Administrative and General 370,013 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 112,798 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 21,724 ### ### ### ### ### ###                         6
7 Housekeeping 52,408 ### ### ### ### ### ###                       7
8 Dietary 154,592 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 129,763 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 66,045 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 9,178 ### ### ### ### ### ### ### ###             12
13 Social Service 49,957 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 56,330 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 510,454 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 2,187 ### ### ### ### 40
41 Laboratory 1,210 ### ### ### ### 41
42 Intravenous Therapy 527 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 55,750 ### ### ### ### ### ### 44
45 Occupational Therapy 22,618 ### ### ### ### ### ### 45
46 Speech Pathology 28,697 ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 11,687 ### ### ### ### 48
49 Drugs Charged to Patients 31,671 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 6,691 ### ### ### ### 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 2,111,843 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 2,111,843 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7