SNFData - 365324 - 05/2017 - Worksheet S-3 Part V

MC-BELDEN VILLAGE OF CANTON OH LLC
CANTON, OH 44718

Medicare Provider Number: 365324

Cost report status: Settled Without Audit

[Record Code 1193967 - 2010]

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SNF REPORTING OF DIRECT CARE EXPENDITURES				Provider CCN: 365324	PERIOD: FROM 06/01/2016 TO 05/31/2017	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)
OCCUPATIONAL CATEGORY		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