SNFData - 255207 - 08/2015 - Worksheet S-3 Part V

PLAZA COMMUNITY LIVING CENTER
PASCAGOULA, MS 39567

Medicare Provider Number: 255207

Cost report status: Settled Without Audit

[Record Code 1146033 - 2010]

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SNF REPORTING OF DIRECT CARE EXPENDITURES				Provider CCN: 255207	PERIOD: FROM 09/01/2014 TO 08/31/2015	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