BENNETT HILLS CENTER
GOODING, ID  83330

Medicare Provider Number: 135134
Cost report status: Settled Without Audit
[Record Code 1256366 - 2010]

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SNF REPORTING OF DIRECT CARE EXPENDITURES Provider CCN: 135134
PERIOD:
FROM 01/01/2018
TO 10/31/2018
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