Worksheet B Part I

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MOUNT PLEASANT MANOR LLC
MOUNT PLEASANT, SC  29464

Medicare Provider Number: 425110
Cost report status: Settled Without Audit
[Record Code 1048588 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 425110
PERIOD:
FROM 10/01/2011
TO 09/30/2012
 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 809,263 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 616,021 ###                               3
4 Administrative and General 1,012,336 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 376,304 ### ### ### ### ###                           5
6 Laundry and Linen Service 80,679 ### ### ### ### ### ###                         6
7 Housekeeping 234,445 ### ### ### ### ### ###                       7
8 Dietary 648,550 ### ### ### ### ### ### ###                     8
9 Nursing Administration 535,928 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 105,805 ### ### ### ### ### ### ###                 10
11 Pharmacy 19,550 ### ### ###               11
12 Medical Records and Library 137,901 ### ### ### ### ### ### ###             12
13 Social Service 122,507 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 110,328 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,288,109 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 2,701 ### ### ### ### 40
41 Laboratory 7,194 ### ### ### ### 41
42 Intravenous Therapy 404 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 6,292 ### ### ### ### 43
44 Physical Therapy 135,224 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 184,283 ### ### ### ### ### 45
46 Speech Pathology 86,305 ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 159,498 ### ### ### ### 48
49 Drugs Charged to Patients 295,194 ### ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 55,725 ### ### ### ### 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 4,329 ### ### ### ### 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 8,034,875 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 823 ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 8,035,698 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7