Worksheet B Part I

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PAVILION AT GLACIER VALLEY
SLINGER, WI  53086

Medicare Provider Number: 525461
Cost report status: Settled Without Audit
[Record Code 1369270 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 525461
PERIOD:
FROM 06/01/2022
TO 05/31/2023
 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 1,935,701 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 1,038,049 ### ###                               3
4 Administrative and General 1,101,939 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 387,552 ### ### ### ### ###                           5
6 Laundry and Linen Service 104,733 ### ### ### ### ###                         6
7 Housekeeping 154,209 ### ### ### ### ###                       7
8 Dietary 608,053 ### ### ### ### ### ### ###                     8
9 Nursing Administration 376,334 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 21,914 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 41,060 ### ### ### ### ### ### ###             12
13 Social Service 104,361 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 87,287 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,260,054 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 11,374 ### ### ### ### 40
41 Laboratory 28,636 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 27,819 ### ### ### ### ### ### ### 43
44 Physical Therapy 194,435 ### ### ### ### ### ### ### 44
45 Occupational Therapy 198,209 ### ### ### ### ### ### ### 45
46 Speech Pathology 92,494 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 40,793 ### ### ### ### ### 48
49 Drugs Charged to Patients 249,181 ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 29,335 ### ### ### ### 51
52 Other Ancillary Service Cost 8,916 ### ### ### ### 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 10,102,438 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 125,566 ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 10,228,004 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7