CARLISLE HEALTH CARE INC.
CARLISLE, OH  45005

Medicare Provider Number: 366043
Cost report status: Settled Without Audit
[Record Code 1143792 - 2010]

You are not logged in or you have not purchased this report. This report has had its actual values replaced with dummy text ('###').

If you would like to become a subscriber, please look at our subscription details.

If you are already a subscriber, please login.

SNF WAGE INDEX INFORMATION PART II - DIRECT SALARIES Provider CCN: 366043
PERIOD:
FROM 01/01/2014
TO 12/31/2014
WORKSHEET S-3
PARTS II & III
  Amount Reported
Reclass. of Salaries from
Wkst. A-6
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
SALARIES            
1 Total salary (see instructions) ### ### ### ### 1
2 Physician salaries-Part A 2
3 Physician salaries-Part B 3
4 Home office personnel 4
5 Sum of lines 2 through 4 5
6 Revised wages (line 1 minus line 5) ### ### ### ### 6
7 Other Long Term Care 7
8 Home Health Agency 8
9 CMHC 9
10 Hospice 10
11 Other excluded areas 11
12 Subtotal excluded salary (sum of lines 7 through 11) 12
13 Total adjusted salaries (line 6 minus line 12) ### ### ### ### 13
OTHER WAGES AND RELATED COSTS            
14 Contract Labor: Patient Related & Mgmt 14
15 Contract Labor: Physician services-Part A 15
16 Home office salaries & wage related costs 16
WAGE RELATED COSTS            
17 Wage related costs core (see Pt. IV) ### ###     17
18 Wage related costs other (see Pt. IV)     18
19 Wage related costs (excluded units)     19
20 Physicians Part A - WRC     20
21 Physicians Part B - WRC     21
22 Total adjusted wage related cost (see instructions) ### ###     22
 
PART III - OVERHEAD COST - DIRECT SALARIES
  Amount Reported
Reclass. of Salaries from
Wkst. A-6
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
1 Employee Benefits 1
2 Administrative & General ### ### ### ### 2
3 Plant Operation, Maintenance & Repairs ### ### ### ### 3
4 Laundry & Linen Service 4
5 Housekeeping 5
6 Dietary 6
7 Nursing Administration ### ### ### ### 7
8 Central Services and Supply 8
9 Pharmacy 9
10 Medical Records & Medical Records Library 10
11 Social Service ### ### ### ### 11
12 Nursing and Allied Health Ed. Act.           12
13 Other General Service (specify _______________) 13
14 Total (sum lines 1 through 13) ### ### ### ### 14
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4105.1 - 4105.2)
41-308   Rev. 7