PLEASANT VIEW CENTER
CONCORD, NH  03301

Medicare Provider Number: 305045
Cost report status: Settled Without Audit
[Record Code 1155610 - 2010]

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SNF REPORTING OF DIRECT CARE EXPENDITURES Provider CCN: 305045
PERIOD:
FROM 10/01/2015
TO 09/30/2016
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