Mendota Lutheran Home-2001-0011593 - HFS - State of Illinois

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Mendota Lutheran Home XX General Information Question 12 2001 E. Other Revenue (specify):**** Tax Return? Yes If not, please attach a reconciliation. 27 Settlement Income (Insurance, Legal, Etc.) 27 28 Other revenue (see schedule) 46,313 28 *** See the instructions. If this total amount has not been offset 28a 28a against interest expense on Schedule V, line 32, please include a 29 SUBTOTAL Other Revenue (lines 27, 28 and 28a) $ 46,313 29 detailed explanation. 30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 5,066,282 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet. 31 of 31
Mendota Lutheran Home XX General Information Question 12 2001 STATE OF ILLINOIS Page 20 Facility Name & ID Number Mendota Lutheran Home # 0011593 Report Period Beginning: 01/01/01 Ending: 12/31/01 XVIII. A. STAFFING AND SALARY COSTS (Please report each line separately.) (This schedule must cover the entire reporting period.) B. CONSULTANT SERVICES 1 2** 3 4 1 2 3 # of Hrs. # of Hrs. Reporting Period Average Number Total Consultant Schedule V Actually Paid and Total Salaries, Hourly of Hrs. Cost for Line & Worked Accrued Wages Wage Paid & Reporting Column 1 Director of Nursing 1,920 2,080 $ 45,358 $ 21.81 1 Accrued Period Reference 2 Assistant Director of Nursing 1,920 2,080 40,260 19.36 2 35 Dietary Consultant 182 $ 7,267 line 1, col 3 35 3 Registered Nurses 18,254 19,775 351,050 17.75 3 36 Medical Director 100 9,000 line 9, col 3 36 4 Licensed Practical Nurses 17,923 20,284 313,289 15.45 4 37 Medical Records Consultant 37 5 Nurse Aides & Orderlies 106,890 117,080 1,137,715 9.72 5 38 Nurse Consultant 36 1,814 line 10, col3 38 6 Nurse Aide Trainees 1,597 1,597 10,066 6.30 6 39 Pharmacist Consultant 144 3,540 line 10,col 3 39 7 Licensed Therapist 7 40 Physical Therapy Consultant 49 2,675 line10,col 3 40 8 Rehab/Therapy Aides 3,907 4,301 60,215 14.00 8 41 Occupational Therapy Consultant 23 1,187 line10,col 3 41 9 Activity Director 1,887 2,091 19,936 9.53 9 42 Respiratory Therapy Consultant 42 10 Activity Assistants 14,305 14,742 99,880 6.78 10 43 Speech Therapy Consultant 43 11 Social Service Workers 5,250 5,915 46,666 7.89 11 44 Activity Consultant 7 344 line11,col 3 44 12 Dietician 12 45 Social Service Consultant 16 186 line12,col 3 45 13 Food Service Supervisor 2,080 2,080 27,681 13.31 13 46 Other(specify) 46 14 Head Cook 11,082 11,969 97,643 8.16 14 47 Nursing aide training 7 140 line13,col 3 47 15 Cook Helpers/Assistants 13,378 14,228 99,854 7.02 15 48 48 16 Dishwashers 7,760 8,089 53,525 6.62 16 17 Maintenance Workers 5,884 6,249 69,472 11.12 17 49 TOTAL (lines 35 - 48) 564 $ 26,153 49 18 Housekeepers 13,796 15,215 111,495 7.33 18 19 Laundry 10,291 10,858 77,133 7.10 19 20 Administrator 2,080 2,080 70,357 33.83 20 21 Assistant Administrator 21 C. CONTRACT NURSES 22 Other Administrative 2,080 2,080 34,567 16.62 22 1 2 3 23 Office Manager 23 Number Schedule V 24 Clerical 10,306 11,283 97,437 8.64 24 of Hrs. Total Line & 25 Vocational Instruction 1,953 2,151 35,632 16.57 25 Paid & Contract Column 26 Academic Instruction 26 Accrued Wages Reference 27 Medical Director 27 50 Registered Nurses 2,412 $ 107,108 50 28 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 2,183 72,713 51 29 Resident Services Coordinator 29 52 Nurse Aides 5,064 94,061 52 30 Habilitation Aides (DD Homes) 30 31 Medical Records 6,026 6,458 95,397 14.77 31 53 TOTAL (lines 50 - 52) 9,659 $ 273,882 53 32 Other Health Care(specify) 32 30 of 31
Page 1 and 2: FOR OHF USE Mendota Lutheran Home X
Page 3 and 4: Mendota Lutheran Home XX General In
Page 19 and 20: * Total must agree with the amount
Page 23 and 24: 25 TOTALS Mendota Lutheran Home XX
Page 41 and 42: your facility. Drop-out costs can o
Page 47: Mendota Lutheran Home XX General In
Page 61: Nelson, Tammie 239 $1,482.61 Dietar

Mendota Lutheran Home-2001-0011593 - HFS - State of Illinois

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