Worksheet B Part I

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WILLIS NURSING & REHABILITATION L.P
WILLIS, TX  77378

Medicare Provider Number: 675274
Cost report status: Settled Without Audit
[Record Code 1283335 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 675274
PERIOD:
FROM 01/01/2020
TO 09/30/2020
 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 365,465 ###                                     1
2 Capital-Related Costs - Moveable Equipment 7,205 ###                                   2
3 Employee Benefits 195,207 ###                               3
4 Administrative and General 366,272 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 140,745 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 15,883 ### ### ### ### ### ### ###                         6
7 Housekeeping 86,900 ### ### ### ### ### ### ###                       7
8 Dietary 186,387 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 182,011 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ### ###                 10
11 Pharmacy 3,954 ### ### ### ### ### ### ###               11
12 Medical Records and Library 4,448 ### ### ### ### ### ### ### ###             12
13 Social Service 38,677 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 27,217 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 731,521 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 42,214 ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 1,151 ### ### ### ### 40
41 Laboratory 1,415 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 726 ### ### ### ### ### ### ### ### 43
44 Physical Therapy 66,511 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 69,875 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 13,674 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 6,557 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 22,436 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 21,520 ### ### ### ### 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 2,597,971 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 400 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 2,598,371 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7