SNFData - 495363 - 12/2016 - Worksheet S-3 Part V

FAIRMONT CROSSING
AMHERST, VA 24521

Medicare Provider Number: 495363

Cost report status: Settled Without Audit

[Record Code 1215921 - 2010]

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SNF REPORTING OF DIRECT CARE EXPENDITURES				Provider CCN: 495363	PERIOD: FROM 01/01/2016 TO 12/31/2016	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