Worksheet S-3 Part IV
- Return to Cost Report Summary
- Form S304
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
HAWTHORN GLEN NURSING CENTER
MIDDLETOWN, OH 45044
MIDDLETOWN, OH 45044
Medicare Provider Number: 365813
Cost report status: Settled Without Audit
[Record Code 1090462 - 2010]
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| SNF WAGE RELATED COSTS | Provider CCN: 365813 | PERIOD: FROM 01/01/2013 TO 12/31/2013 |
WORKSHEET S-3 PART IV | |||
| PART IV - Wage Related Cost | ||||||
| Part A - Core List | Amount Reported | |||||
| RETIREMENT COST | ||||||
| 1 | 401k Employer Contributions | ### | 1 | |||
| 2 | Tax Sheltered Annuity (TSA) Employer Contribution | 2 | ||||
| 3 | Qualified and Non-Qualified Pension Plan Cost | 3 | ||||
| 4 | Prior Year Pension Service Cost | 4 | ||||
| PLAN ADMINISTRATIVE COSTS (Paid to External Organizations) | ||||||
| 5 | 401K/TSA Plan Administration fees | 5 | ||||
| 6 | Legal/Accounting/Management Fees-Pension Plan | 6 | ||||
| 7 | Employee Managed Care Program Administration Fees | 7 | ||||
| HEALTH AND INSURANCE COST | ||||||
| 8 | Health Insurance (Purchased or Self Funded) | ### | 8 | |||
| 9 | Prescription Drug Plan | 9 | ||||
| 10 | Dental, Hearing and Vision Plan | ### | 10 | |||
| 11 | Life Insurance (If employee is owner or beneficiary) | ### | 11 | |||
| 12 | Accidental Insurance (If employee is owner or beneficiary) | 12 | ||||
| 13 | Disability Insurance (If employee is owner or beneficiary) | 13 | ||||
| 14 | Long-Term Care Insurance (If employee is owner or beneficiary) | 14 | ||||
| 15 | Workers' Compensation Insurance | ### | 15 | |||
| 16 | Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106 Non cumulative portion) | 16 | ||||
| TAXES | ||||||
| 17 | FICA - Employers Portion Only | ### | 17 | |||
| 18 | Medicare Taxes - Employers Portion Only | ### | 18 | |||
| 19 | Unemployment Insurance | 19 | ||||
| 20 | State or Federal Unemployment Taxes | ### | 20 | |||
| OTHER | ||||||
| 21 | Executive Deferred Compensation | 21 | ||||
| 22 | Day Care Cost and Allowances | 22 | ||||
| 23 | Tuition Reimbursement | 23 | ||||
| 24 | Total Wage Related cost (sum of lines 1 -23) | ### | 24 | |||
| Part B Other than Core Related Cost | Amount Reported | |||||
| 25 | Other Wage Related Costs (specify) | 25 | ||||
| FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.3) | ||||||
| Rev. 7 | 08-16 | |||||