SNFData - 366016 - 12/2004 - Worksheet B, Part II

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Form B002
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3525, REV 6

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MAIN ST TERRACE CARE CEN
LANCASTER, OH 43130-

Medicare Provider Number: 366016

Cost report status: Settled Without Audit

[Record Code 241084 - 1996]

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ALLOCATION OF CAPITAL - RELATED COSTS						PROVIDER NO: 366016		PERIOD: FROM 01/01/2004 TO 12/31/2004		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