Worksheet S-3 Part V
- Return to Cost Report Summary
- Form S305
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
PLEASANT VIEW CENTER
CONCORD, NH 03301
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 |
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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) |
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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 |