Worksheet B, Part II

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BELFOREST NURSING & REHAB. CENTER
FOREST HILL, MD  21050

Medicare Provider Number: 215194
Cost report status: Settled Without Audit
[Record Code 88300 - 1996]
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ALLOCATION OF CAPITAL - RELATED COSTS
PROVIDER NO:
215194
PERIOD:
FROM 01/01/1997
TO 08/31/1997
WORKSHEET B Part II
  
COST CENTER
DIRECTLY
ASSIGNED
CAPITAL
RELATED COSTS
CAP. REL.
BUILDINGS
& FIXTURES
CAP. REL.
MOVABLE
EQUIPMENT
 SUBTOTAL
EMPLOYEE
BENEFITS
ADMINIS-
TRATIVE
& GENERAL
PLANT OPER.
MAINTENANCE
& REPAIRS
LAUNDRY
& LINEN
SERVICE
HOUSE
KEEPING
 DIETARY
NURSING
ADMINIS-
TRATION
CENTRAL
SERVICES
& SUPPLY
 PHARMACY MEDICAL RECORDS AND LIBRARY SOCIAL SERVICE INTERNS & RESIDENTS OTHER GENERAL SERVICE COST SUBTOTAL POST STEPDOWN ADJUSTMENTS TOTAL  
    0 1 2 2A 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
  GENERAL SERVICE COST CENTERS                                      
1 Capital-Related Costs - Building & Fixture                                   1
2 Capital-Related Costs - Movable Equipment                                   2
3 Employee Benefits ### ###                               3
4 Administrative and General ### ### ###                             4
5 Plant Operation, Maintenance and Repairs ### ### ### ###                           5
6 Laundry and Linen Service ### ### ### ### ###                         6
7 Housekeeping ### ### ### ### ###                       7
8 Dietary ### ### ### ### ### ###                     8
9 Nursing Administration ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library ### ### ### ### ### ###             12
13 Social Service ### ### ### ### ### ###           13
14 Intern & Residents (Approved Teaching Program)         14
15 Other General Service cost       15
  INPATIENT ROUTINE SERVICE COST CENTERS                                      
16 Skilled Nursing Facility ### ### ### ### ### ### ### ### ### ### ### ### ### 16
17                                           17
18 Nursing Facility ### ### ### ### ### ### ### ### ### ### ### ### ### 18
18.1 Intermediate Care Facility/Mentally Retarded 18.1
19 Other Long Term Care 19
20 Other Inpatient Routine Service Cost 20
  ANCILLARY SERVICE COST CENTER                                      
21 Radiology 21
22 Laboratory 22
23 Intravenous Therapy ### ### ### 23
24 Oxygen (Inhalation) Therapy ### ### ### ### 24
25 Physical Therapy ### ### ### ### ### ### ### ### ### ### 25
26 Occupational Therapy ### ### ### ### ### ### ### ### 26
27 Speech Pathology ### ### ### ### ### ### ### 27
28 Electrocardiology 28
29 Medical Supplies Charged to Patients ### ### ### 29
30 Drugs Charged to Patients ### ### ### ### 30
31 Dental Care - Title XIX only 31
32 Support Surfaces ### ### ### 32
33 Other Ancillary Service Cost 33
  OUTPATIENT SERVICE COST CENTERS                                      
34 Clinic 34
35 R H C 35
36 Other Outpatient Service Cost 36
  OTHER REIMBURSABLE COST CENTERS                                      
37 Administrative and General - HHA 37
38 Skilled Nursing Care - HHA 38
39 Physical Therapy - HHA 39
40 Occupational Therapy - HHA 40
41 Speech Pathology - HHA 41
42 Medical Social Services - HHA 42
43 Home Health Aide - HHA 43
44 Durable Medical Equipment - Rented - HHA 44
45 Durable Medical Equipment - Sold - HHA 45
46 Home Delivered Meals - HHA 46
47 Other Home Health Services - HHA 47
48 Ambulance 48
49 Interns and Residents (Not An Approved Teaching Program) 49
50 Outpatient Rehabilitation Provider 50
51 Other Reimbursable Cost 51
  SPECIAL PURPOSE COST CENTERS                                      
55 Hospice 55
56 Other Special Purpose Cost 56
57 Subtotals 57
  NON REIMBURSABLE COST CENTERS                                      
58 Gift, Flower, Coffee Shops and Canteen 58
59 Barber and Beauty Shop 59
60 Physicians' Private Offices 60
61 Nonpaid Workers 61
62 Patients Laundry 62
63 Other Non Reimbursable Cost 63
64 Cross Foot Adjustments               64
65 Negative Cost Center   65
75 Total ### ### ### ### ### ### ### ### ### ### ### ### ### 75