Worksheet S-3, Parts II and III
- Return to Cost Report Summary
- Form S302
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3509.1, REV 16
CARE LIVING OF EL RENO
EL RENO, OK 73036
EL RENO, OK 73036
Medicare Provider Number: 375448
Cost report status: Settled Without Audit
[Record Code 350539 - 1996]
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SNF WAGE INDEX INFORMATION | PROVIDER NO: 375448 |
PERIOD: FROM 01/01/2008 TO 12/31/2008 |
WORKSHEET S-3, Part II | |||||
PART II DIRECT SALARIES | Amount Reported |
Reclass. of Salaries from Wkst. A-6 |
Adjusted Salaries (col. 1 ± col. 2) |
Paid Hours Related to Salary in col. 3 |
Average Hourly Wage (col. 3 ÷ col. 4) |
Data Source |
||
1 | 2 | 3 | 4 | 5 | 6 | |||
1 | Total salary (See Instructions) | ### | ### | ### | ### | 1 | ||
2 | Physician salaries-Part A | 2 | ||||||
3 | Physician salaries-Part B | 3 | ||||||
4 | Interns & Residents (approved) | 4 | ||||||
5 | Home office personnel | 5 | ||||||
6 | Sum of lines 2 thru 5 | 6 | ||||||
7 | Revised wages (line 1 minus line 6) | ### | ### | ### | ### | 7 | ||
8 | Other Long Term Care | 8 | ||||||
9 | Other Inpatient Routine Service | 9 | ||||||
10 | Interns & Residents (Not In Approved Program) | 10 | ||||||
11 | HHA | 11 | ||||||
12 | Outpatient Rehabilitation Providers | 12 | ||||||
13 | Hospice | 13 | ||||||
14 | Non-reimbursable | 14 | ||||||
15 | Total Excluded salary (Sum of lines 8 through 14) | 15 | ||||||
16 | Subtotal (line 7 minus line 15) | ### | ### | ### | ### | 16 | ||
17 | Contract Labor: Patient Related & Mgmt | CMS 339 | 17 | |||||
18 | Home office salaries & wage related costs | 18 | ||||||
19 | Wage related costs (core) | ### | ### | CMS 339 | 19 | |||
20 | Wage related costs (other) | CMS 339 | 20 | |||||
21 | Wage related costs (excluded units) | CMS 339 | 21 | |||||
22 | Subtotal (see instructions) | ### | ### | ### | 22 | |||
23 | Total (see instructions) | ### | ### | ### | ### | 23 | ||
24 | Contract Labor: Physician services-Part A | 24 | ||||||
PART III - OVERHEAD COST - DIRECT SALARIES | ||||||||
Amount Reported |
Reclass. of Salaries from Wkst. A-6 |
Adjusted Salaries (col. 1 ± col. 2) |
Paid Hours Related to Salary in col. 3 |
Average Hourly Wage (col. 3 ÷ col. 4) |
||||
1 | Employee Benefits | 1 | ||||||
2 | Administrative & General | ### | ### | ### | ### | 2 | ||
3 | Plant Operation, Maintenance & Repairs | ### | ### | ### | ### | 3 | ||
4 | Laundry & Linen Service | 4 | ||||||
5 | Housekeeping | ### | ### | ### | ### | 5 | ||
6 | Dietary | ### | ### | ### | ### | 6 | ||
7 | Nursing Administration | 7 | ||||||
8 | Central Services and Supply | 8 | ||||||
9 | Pharmacy | 9 | ||||||
10 | Medical Records & Library | 10 | ||||||
11 | Social Service | 11 | ||||||
12 | Interns & Residents (Apprvd Teaching Prog) | 12 | ||||||
13 | Other General Service (specify) | 13 | ||||||
14 | Total (sum lines 1 thru 13) | ### | ### | ### | ### | 14 |