Worksheet B Part I

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THE ESTATES AT ROSEVILLE LLC
ROSEVILLE, MN  55113

Medicare Provider Number: 245105
Cost report status: Settled Without Audit
[Record Code 1368981 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 245105
PERIOD:
FROM 01/01/2021
TO 12/31/2021
 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 1,171,539 ###                                     1
2 Capital-Related Costs - Moveable Equipment 85,416 ###                                   2
3 Employee Benefits 1,405,378 ###                               3
4 Administrative and General 2,050,635 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 485,008 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 198,721 ### ### ### ### ### ###                         6
7 Housekeeping 362,169 ### ### ### ### ### ###                       7
8 Dietary 1,016,501 ### ### ### ### ### ### ###                     8
9 Nursing Administration 912,510 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 199,909 ### ### ### ### ### ### ### ###             12
13 Social Service 247,167 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 249,670 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 5,182,184 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 15,911 ### ### ### ### 40
41 Laboratory 23,702 ### ### ### ### 41
42 Intravenous Therapy 20,626 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 8,137 ### ### ### ### 43
44 Physical Therapy 374,871 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 391,209 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 99,062 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 27,178 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 356,921 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 12,997 ### ### ### ### 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 14,897,421 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 14,897,421 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7