Worksheet B Part I

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PEAK RESOURCES - BROOKSHIRE INC.
HILLSBOROUGH, NC  27278

Medicare Provider Number: 345439
Cost report status: Settled Without Audit
[Record Code 1285478 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 345439
PERIOD:
FROM 10/01/2019
TO 09/30/2020
 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 792,979 ###                                     1
2 Capital-Related Costs - Moveable Equipment 104,582 ###                                   2
3 Employee Benefits 578,723 ###                               3
4 Administrative and General 1,084,733 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 255,902 ### ### ### ### ###                           5
6 Laundry and Linen Service 132,503 ### ### ### ### ### ###                         6
7 Housekeeping 171,218 ### ### ### ### ### ###                       7
8 Dietary 805,292 ### ### ### ### ### ### ###                     8
9 Nursing Administration 339,713 ### ### ### ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library 26,326 ### ### ### ### ### ### ###             12
13 Social Service 73,808 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 77,046 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,519,614 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 164,637 ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 19,707 ### ### ### ### 40
41 Laboratory 17,543 ### ### ### ### 41
42 Intravenous Therapy 48,369 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 8,997 ### ### ### ### 43
44 Physical Therapy 266,015 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 208,741 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 165,752 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 218,539 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 69,469 ### ### ### ### 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 8,150,208 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 72,709 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 8,222,917 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7