Worksheet B, Part I

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RICHLAND MANOR
BLUFFTON, OH  45817

Medicare Provider Number: 365405
Cost report status: Settled Without Audit
[Record Code 363821 - 1996]
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COST ALLOCATION - GENERAL SERVICE COSTS
PROVIDER NO:
365405
PERIOD:
FROM 01/01/2008
TO 12/31/2008
 WORKSHEET B Part I  
COST CENTER (Omit Cents) NET EXPENSES FOR COST ALLOCATION Fr. Wkst A, Col 7
CAP. REL.
BUILDINGS
& FIXTURES
CAP. REL.
MOVABLE
EQUIPMENT
EMPLOYEE
BENEFITS
SUBTOTAL
(Sum of
Columns 0 - 3)
ADMINIS-
TRATIVE
& GENERAL
PLANT OPER.
MAINTENANCE
& REPAIRS
LAUNDRY
& LINEN
SERVICE
HOUSE
KEEPING
 DIETARY NURSING
CENTRAL
SERVICES
& SUPPLY
 PHARMACY
MEDICAL
RECORDS
& LIBRARY
SOCIAL
SERVICE
INTERNS &
RESIDENTS
OTHER
GENERAL
SERVICE
COST
 SUBTOTAL
POST
STEPDOWN
ADJUSTMENTS
 TOTAL  
    0 1 2 3 3A 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 Services                           20
  ANCILLARY SERVICE COST CENTERS
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 in 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