Worksheet B Part I

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PRINCE GEORGE HEALTHCARE CENTER
GEORGETOWN, SC  29440

Medicare Provider Number: 425295
Cost report status: Settled Without Audit
[Record Code 1333876 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 425295
PERIOD:
FROM 01/01/2021
TO 12/31/2021
 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 945,187 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 821,698 ###                               3
4 Administrative and General 1,529,299 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 505,972 ### ### ### ### ###                           5
6 Laundry and Linen Service 123,091 ### ### ### ### ### ###                         6
7 Housekeeping 439,436 ### ### ### ### ### ###                       7
8 Dietary 838,163 ### ### ### ### ### ###                     8
9 Nursing Administration 573,170 ### ### ### ###                   9
10 Central Services and Supply 31,983 ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 32,329 ### ### ### ### ### ### ###             12
13 Social Service 118,661 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 89,469 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,617,186 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 9,425 ### ### ### ### 40
41 Laboratory 19,128 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 3,791 ### ### ### ### 43
44 Physical Therapy 208,516 ### ### ### ### ### ### ### 44
45 Occupational Therapy 216,286 ### ### ### ### ### ### ### 45
46 Speech Pathology 84,518 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 67,522 ### ### ### ### ### 48
49 Drugs Charged to Patients 277,805 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 6,981 ### ### ### ### 51
52 Other Ancillary Service Cost 21,501 ### ### ### ### 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 11,581,117 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 17,042 ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 11,598,159 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7