Worksheet B Part I
- Return to Cost Report Summary
- Form B001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3524, REV 6
CORN HERITAGE VILLAGE & REHAB
CORN, OK 73024
CORN, OK 73024
Medicare Provider Number: 375409
Cost report status: Settled Without Audit
[Record Code 1278869 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS | Provider CCN: 375409 | PERIOD: FROM 07/01/2019 TO 06/30/2020 |
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 | 181,498 | ### | 1 | ||||||||||||||||||
2 | Capital-Related Costs - Moveable Equipment | 5,689 | ### | 2 | ||||||||||||||||||
3 | Employee Benefits | 461,228 | ### | ### | ### | 3 | ||||||||||||||||
4 | Administrative and General | 981,348 | ### | ### | ### | ### | ### | 4 | ||||||||||||||
5 | Plant Operation, Maintenance and Repairs | 311,080 | ### | ### | ### | ### | ### | ### | 5 | |||||||||||||
6 | Laundry and Linen Service | 101,822 | ### | ### | ### | ### | ### | ### | ### | 6 | ||||||||||||
7 | Housekeeping | 124,221 | ### | ### | ### | ### | ### | ### | ### | 7 | ||||||||||||
8 | Dietary | 662,736 | ### | ### | ### | ### | ### | ### | ### | ### | 8 | |||||||||||
9 | Nursing Administration | 121,702 | ### | ### | ### | ### | 9 | |||||||||||||||
10 | Central Services and Supply | 10 | ||||||||||||||||||||
11 | Pharmacy | 8,550 | ### | ### | ### | 11 | ||||||||||||||||
12 | Medical Records and Library | 12 | ||||||||||||||||||||
13 | Social Service | 129,871 | ### | ### | ### | ### | ### | ### | ### | ### | 13 | |||||||||||
14 | Nursing and Allied Health Education | 14 | ||||||||||||||||||||
15 | Other General Service Cost | 15 | ||||||||||||||||||||
INPATIENT ROUTINE SERVICE COST CENTERS | ||||||||||||||||||||||
30 | Skilled Nursing Facility | 2,036,980 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 30 | ||||||
31 | Nursing Facility | 31 | ||||||||||||||||||||
32 | ICF/IID | 32 | ||||||||||||||||||||
33 | Other Long Term Care | 33 | ||||||||||||||||||||
ANCILLARY SERVICE COST CENTERS | ||||||||||||||||||||||
40 | Radiology | 2,618 | ### | ### | ### | ### | 40 | |||||||||||||||
41 | Laboratory | 3,335 | ### | ### | ### | ### | 41 | |||||||||||||||
42 | Intravenous Therapy | 42 | ||||||||||||||||||||
43 | Oxygen (Inhalation) Therapy | 43 | ||||||||||||||||||||
44 | Physical Therapy | 190,718 | ### | ### | ### | ### | ### | ### | ### | ### | 44 | |||||||||||
45 | Occupational Therapy | 220,020 | ### | ### | ### | ### | ### | ### | ### | ### | 45 | |||||||||||
46 | Speech Pathology | 46,096 | ### | ### | ### | ### | ### | ### | ### | ### | 46 | |||||||||||
47 | Electrocardiology | 47 | ||||||||||||||||||||
48 | Medical Supplies Charged to Patients | 48 | ||||||||||||||||||||
49 | Drugs Charged to Patients | 41,570 | ### | ### | ### | ### | ### | 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 | 5,631,082 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 89 | |||||
NON REIMBURSABLE COST CENTERS | ||||||||||||||||||||||
90 | Gift, Flower, Coffee Shops and Canteen | 90 | ||||||||||||||||||||
91 | Barber and Beauty Shop | 21,834 | ### | ### | ### | ### | ### | ### | ### | ### | ### | 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 | 5,652,916 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 100 | |||||
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120) | ||||||||||||||||||||||
08-16 | Rev. 7 |