Worksheet B Part I

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GRAND STRAND REHAB
MYRTLE BEACH, SC  29588

Medicare Provider Number: 425323
Cost report status: Settled Without Audit
[Record Code 1197983 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 425323
PERIOD:
FROM 10/01/2016
TO 09/30/2017
 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 636,834 ###                                     1
2 Capital-Related Costs - Moveable Equipment 10,754 ###                                   2
3 Employee Benefits 527,324 ###                               3
4 Administrative and General 751,355 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 436,592 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 77,047 ### ### ### ### ### ### ###                         6
7 Housekeeping 286,511 ### ### ### ### ### ### ###                       7
8 Dietary 648,291 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration                   9
10 Central Services and Supply 37,590 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 127,964 ### ### ### ### ### ### ### ###             12
13 Social Service 173,953 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,353,182 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 4,433 ### ### ### ### ### 40
41 Laboratory 1,763 ### ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 6,183 ### ### ### ### ### 43
44 Physical Therapy 233,897 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 334,248 ### ### ### ### ### 45
46 Speech Pathology 136,769 ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 19,153 ### ### ### ### ### 48
49 Drugs Charged to Patients 196,763 ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 4,570 ### ### ### ### ### 51
52 Other Ancillary Service Cost 471 ### ### ### ### ### 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 9,187 ### ### ### ### ### 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 7,014,834 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 7,014,834 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7