Worksheet S-3 Part V
- Return to Cost Report Summary
- Form S305
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
HEARTLAND OF WATERVILLE OH LLC
WATERVILLE, OH 43566
WATERVILLE, OH 43566
Medicare Provider Number: 365617
Cost report status: Settled Without Audit
[Record Code 1145255 - 2010]
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| SNF REPORTING OF DIRECT CARE EXPENDITURES | Provider CCN: 365617 | PERIOD: FROM 01/01/2015 TO 12/31/2015 |
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 | ||||||