Worksheet B Part I

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SOUTH COAST POST ACUTE
SANTA ANA, CA  92707

Medicare Provider Number: 055653
Cost report status: Settled Without Audit
[Record Code 1332903 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 055653
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 511,244 ###                                     1
2 Capital-Related Costs - Moveable Equipment 191,958 ###                                   2
3 Employee Benefits 4,235,045 ###                               3
4 Administrative and General 6,002,906 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 777,170 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 459,350 ### ### ### ### ### ### ###                         6
7 Housekeeping 685,899 ### ### ### ### ### ### ###                       7
8 Dietary 2,013,840 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 635,773 ### ### ### ###                   9
10 Central Services and Supply 177,376 ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 342,702 ### ### ### ### ### ### ### ###             12
13 Social Service 1,219,314 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 5,763,155 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 51,353 ### ### ### ### ### 40
41 Laboratory 112,215 ### ### ### ### ### 41
42 Intravenous Therapy 36,339 ### ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 656,341 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 617,166 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 86,919 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 101,573 ### ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 316,518 ### ### ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 8,949 ### ### ### ### 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 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 25,003,105 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 4,434 ### ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 16,475,593 ### ### ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 41,483,132 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7