Worksheet B Part I

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HIGHLAND MANOR INC
NEW ULM, MN  56073

Medicare Provider Number: 245490
Cost report status: Settled Without Audit
[Record Code 1078726 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 245490
PERIOD:
FROM 10/01/2011
TO 09/30/2012
 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 839,226 ###                                     1
2 Capital-Related Costs - Moveable Equipment 289,243 ###                                   2
3 Employee Benefits 861,664 ### ### ###                               3
4 Administrative and General 935,704 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 448,626 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 79,873 ### ### ### ### ### ### ###                         6
7 Housekeeping 298,143 ### ### ### ### ### ### ###                       7
8 Dietary 326,431 ### ### ### ### ### ### ###                     8
9 Nursing Administration 99,122 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library 103,484 ### ### ### ### ### ### ### ###             12
13 Social Service 67,622 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 132,808 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,589,055 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 17,452 ### ### ### ### 40
41 Laboratory 7,366 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 4,610 ### ### ### ### 43
44 Physical Therapy 240,653 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 166,392 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 18,399 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 10,946 ### ### ### ### 48
49 Drugs Charged to Patients 135,668 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 130,285 ### ### ### ### 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 138,098 ### ### ### ### ### 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 7,940,870 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 43 ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 610,949 ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 8,551,862 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7