Worksheet B Part I

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MANOR CARE OF RENO NV LLC D.B.A. M
RENO, NV  89509

Medicare Provider Number: 295043
Cost report status: Settled Without Audit
[Record Code 1109514 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 295043
PERIOD:
FROM 06/01/2013
TO 05/31/2014
 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 669,298 ###                                     1
2 Capital-Related Costs - Moveable Equipment 242,653 ###                                   2
3 Employee Benefits 1,543,013 ### ### ###                               3
4 Administrative and General 2,955,575 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 529,971 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 93,210 ### ### ### ### ### ### ###                         6
7 Housekeeping 286,283 ### ### ### ### ### ### ###                       7
8 Dietary 802,978 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 436,294 ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 38,976 ### ### ### ###             12
13 Social Service 283,437 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,493,330 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 106,715 ### ### ### ### 40
41 Laboratory 48,778 ### ### ### ### 41
42 Intravenous Therapy 140,869 ### ### ### 42
43 Oxygen (Inhalation) Therapy 3,692 ### ### ### ### 43
44 Physical Therapy 890,496 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 454,163 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 176,107 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 54 ### ### ### ### 47
48 Medical Supplies Charged to Patients 179,676 ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 539,249 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 11,007 ### ### ### ### 51
52 Other Ancillary Service Cost 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 13,925,824 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 258 ### ### ### ### ### ### ### ### 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 13,926,082 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7