Worksheet B, Part II

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MONADNOCK LODGE - RIVERWOODS
EXETER, NH  03833-

Medicare Provider Number: 305049
Cost report status: Settled Without Audit
[Record Code 127543 - 1996]
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ALLOCATION OF CAPITAL - RELATED COSTS
PROVIDER NO:
305049
PERIOD:
FROM 07/01/2000
TO 06/30/2001
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