MC-BELDEN VILLAGE OF CANTON OH LLC
CANTON, OH  44718

Medicare Provider Number: 365324
Cost report status: Settled Without Audit
[Record Code 1193967 - 2010]

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SNF REPORTING OF DIRECT CARE EXPENDITURES Provider CCN: 365324
PERIOD:
FROM 06/01/2016
TO 05/31/2017
WORKSHEET S-3
PART V
OCCUPATIONAL CATEGORY Amount Reported Fringe Benefits
Adjusted Salaries
(col. 1 + col. 2)
Paid Hours Related to
Salary in col. 3
Average Hourly Wage
(col. 3 ÷ col. 4)
 
1 2 3 4 5
Direct Salaries          
  Nursing Occupations            
1 Registered Nurses (RNs) ### ### ### ### ### 1
2 Licensed Practical Nurses (LPNs) ### ### ### ### ### 2
3 Certified Nursing Assistants/Nursing Assistants/Aides ### ### ### ### ### 3
4 Total Nursing (sum of lines 1 through 3) ### ### ### ### ### 4
5 Physical Therapists ### ### ### ### ### 5
6 Physical Therapy Assistants ### ### ### ### ### 6
7 Physical Therapy Aides ### ### ### ### ### 7
8 Occupational Therapists ### ### ### ### ### 8
9 Occupational Therapy Assistants ### ### ### ### ### 9
10 Occupational Therapy Aides 10
11 Speech Therapists ### ### ### ### ### 11
12 Respiratory Therapists 12
13 Other Medical Staff ### ### ### ### ### 13
Contract Labor          
  Nursing Occupations            
14 Registered Nurses (RNs)   14
15 Licensed Practical Nurses (LPNs)   15
16 Certified Nursing Assistants/Nursing Assistants/Aides   16
17 Total Nursing (sum of lines 14 through 16)   17
18 Physical Therapists ###   ### ### ### 18
19 Physical Therapy Assistants   19
20 Physical Therapy Aides   20
21 Occupational Therapists   21
22 Occupational Therapy Assistants   22
23 Occupational Therapy Aides   23
24 Speech Therapists ###   ### ### ### 24
25 Respiratory Therapists   25
26 Other Medical Staff   26
 
FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.4)
 
08-16   Rev. 7