Worksheet B Part I

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MYRTLE BEACH MANOR
MYRTLE BEACH, SC  29572

Medicare Provider Number: 425070
Cost report status: Settled Without Audit
[Record Code 1016790 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 425070
PERIOD:
FROM 01/01/2011
TO 12/31/2011
 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 996,987 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 921,795 ### ###                               3
4 Administrative and General 1,047,256 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 549,686 ### ### ### ### ###                           5
6 Laundry and Linen Service 90,606 ### ### ### ### ### ###                         6
7 Housekeeping 229,121 ### ### ### ### ### ###                       7
8 Dietary 717,552 ### ### ### ### ### ### ###                     8
9 Nursing Administration 351,675 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 31,305 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 36,339 ### ### ### ###             12
13 Social Service 84,620 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 137,779 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,316,666 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 329,167 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 568,748 ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 11,847 ### ### ### ### 40
41 Laboratory 27,535 ### ### ### ### 41
42 Intravenous Therapy 3,012 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 1,701 ### ### ### ### 43
44 Physical Therapy 239,336 ### ### ### ### ### ### ### 44
45 Occupational Therapy 177,471 ### ### ### ### ### ### ### 45
46 Speech Pathology 89,996 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 104,193 ### ### ### ### ### 48
49 Drugs Charged to Patients 281,910 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 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 650 ### ### ### ### 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 8,346,953 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 8,346,953 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7