SNFData - 185333 - 12/2019 - Worksheet S-3 Part V

KLONDIKE CENTER
LOUISVILLE, KY 40218

Medicare Provider Number: 185333

Cost report status: Settled Without Audit

[Record Code 1275636 - 2010]

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SNF REPORTING OF DIRECT CARE EXPENDITURES				Provider CCN: 185333	PERIOD: FROM 01/01/2019 TO 12/31/2019	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)
OCCUPATIONAL CATEGORY		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