Worksheet B Part I

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STERLING HEIGHTS OPCO LLC
STERLING HEIGHTS, MI  48312

Medicare Provider Number: 235263
Cost report status: Settled Without Audit
[Record Code 1260986 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 235263
PERIOD:
FROM 01/01/2018
TO 12/31/2018
 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 325,694 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 1,893,183 ### ###                               3
4 Administrative and General 1,969,504 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,158,001 ### ### ### ### ###                           5
6 Laundry and Linen Service 514,504 ### ### ### ### ### ###                         6
7 Housekeeping 773,654 ### ### ### ### ### ###                       7
8 Dietary 1,965,949 ### ### ### ### ### ### ###                     8
9 Nursing Administration 1,810,062 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 628,602 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 178,109 ### ### ### ### ### ### ###             12
13 Social Service 302,716 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 327,268 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 5,748,515 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 38,775 ### ### ### ### 40
41 Laboratory 64,012 ### ### ### ### 41
42 Intravenous Therapy 102,189 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 72,646 ### ### ### ### ### ### ### 43
44 Physical Therapy 609,813 ### ### ### ### ### ### ### 44
45 Occupational Therapy 502,267 ### ### ### ### ### ### ### 45
46 Speech Pathology 205,397 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 40,408 ### ### ### ### 48
49 Drugs Charged to Patients 434,489 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 24,341 ### ### ### ### 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 19,690,098 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 48,438 ### ### ### ### 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 19,738,536 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7