HFS 3745 (N-4-99) IL478-2471 - Illinois.gov · 8 SNF 26,310 12,638 6,013 44,961 8 9 SNF/PED 9 Medicare Intermediary WPS 10 ICF 10 11 ICF/DD 11 IV. ACCOUNTING BASIS 12 SC 12 MODIFIED

FOR BHF USE IMPORTANT NOTICELL1 THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION

THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY2010 PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE

STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDEDEPARTMENT OF HEALTHCARE AND FAMILY SERVICES ANY INFORMATION ON OR BEFORE THE DUE DATE WILLFINANCIAL AND STATISTICAL REPORT (COST REPORT) RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM

FOR LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.(FISCAL YEAR 2010)

I. IDPH License ID Number: 0048066 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

Facility Name: Heritage Manor-Streator I have examined the contents of the accompanying report to the

Address: 1525 East Main Street Streator 61364 State of Illinois, for the period from 1-01-10 to 12-31-10Number City Zip Code and certify to the best of my knowledge and belief that the said contents

are true, accurate and complete statements in accordance withCounty: LaSalle applicable instructions. Declaration of preparer (other than provider)

is based on all information of which preparer has any knowledge.Telephone Number: ( 815 ) 672-4516 Fax # ( )

Intentional misrepresentation or falsification of any informationHFS ID Number: in this cost report may be punishable by fine and/or imprisonment.

Date of Initial License for Current Owners: 07/2006 (Signed)Officer or (Date)

Type of Ownership: Administrator (Type or Print Name) Craig L. Aterof Provider

VOLUNTARY,NON-PROFIT xx PROPRIETARY GOVERNMENTAL (Title) Exec V.P. & CFOCharitable Corp. Individual StateTrust Partnership County (Signed)

IRS Exemption Code Corporation Other (Date)"Sub-S" Corp. Paid (Print Name

xx Limited Liability Co. Preparer and Title)TrustOther (Firm Name

& Address)

(Telephone) ( ) Fax # ( ) MAIL TO: BUREAU OF HEALTH FINANCE

In the event there are further questions about this report, please contact: ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICESName:Craig Ater Telephone Number: ( 309 )823-7135 201 S. Grand Avenue East

Email Address: Springfield, IL 62763-0001 Phone # (217) 782-1630

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 2Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10

III. STATISTICAL DATA D. How many bed-hold days during this year were paid by the Department?A. Licensure/certification level(s) of care; enter number of beds/bed days, 0 (Do not include bed-hold days in Section B.) (must agree with license). Date of change in licensed beds

E. List all services provided by your facility for non-patients. 1 2 3 4 (E.g., day care, "meals on wheels", outpatient therapy)

none Beds at Licensed Beginning of Licensure Beds at End of Bed Days During F. Does the facility maintain a daily midnight census? yes Report Period Level of Care Report Period Report Period

G. Do pages 3 & 4 include expenses for services or1 130 Skilled (SNF) 130 47,450 1 investments not directly related to patient care?2 Skilled Pediatric (SNF/PED) 2 YES NO x3 Intermediate (ICF) 34 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?5 Sheltered Care (SC) 5 YES NO x6 ICF/DD 16 or Less 6

I. On what date did you start providing long term care at this location?7 130 TOTALS 130 47,450 7 Date started 07/2006

J. Was the facility purchased or leased after January 1, 1978?B. Census-For the entire report period. YES Date NO x

1 2 3 4 5 Level of Care Patient Days by Level of Care and Primary Source of Payment K. Was the facility certified for Medicare during the reporting year?

Medicaid YES x NO If YES, enter numberRecipient Private Pay Other Total of beds certified and days of care provided 6,013

8 SNF 26,310 12,638 6,013 44,961 8 9 SNF/PED 9 Medicare Intermediary WPS10 ICF 1011 ICF/DD 11 IV. ACCOUNTING BASIS12 SC 12 MODIFIED13 DD 16 OR LESS 13 ACCRUAL xx CASH* CASH*

14 TOTALS 26,310 12,638 6,013 44,961 14 Is your fiscal year identical to your tax year? YES x NO

C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: Fiscal Year: bed days on line 7, column 4.) 94.75% * All facilities other than governmental must report on the accrual basis.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 3Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)

Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Operating Expenses Salary/Wage Supplies Other Total ification Total ments TotalA. General Services 1 2 3 4 5 6 7 8 9 10

1 Dietary 191,355 22,185 213,540 213,540 5,181 218,721 12 Food Purchase 322,304 322,304 322,304 (1,224) 321,080 23 Housekeeping 144,295 22,519 166,814 166,814 166,814 34 Laundry 71,739 20,028 91,767 91,767 91,767 45 Heat and Other Utilities 167,450 167,450 167,450 2,239 169,689 56 Maintenance 94,522 96,248 47,794 238,564 238,564 15,426 253,990 67 Other (specify):* 7

8 TOTAL General Services 501,911 483,284 215,244 1,200,439 1,200,439 21,622 1,222,061 8B. Health Care and Programs

9 Medical Director 2,400 2,400 2,400 3,806 6,206 910 Nursing and Medical Records 2,546,945 220,747 17,727 2,785,419 2,785,419 2,785,419 10

10a Therapy 403,138 606,442 1,009,580 (438,227) 571,353 148,687 720,040 10a11 Activities 90,715 3,026 93,741 93,741 5 93,746 1112 Social Services 31,769 193 3,199 35,161 35,161 35,161 1213 CNA Training 9,227 1,051 10,278 10,278 1,718 11,996 1314 Program Transportation 1415 Other (specify):* 15

16 TOTAL Health Care and Programs 2,678,656 628,155 629,768 3,936,579 (438,227) 3,498,352 154,216 3,652,568 16C. General Administration

17 Administrative 101,999 101,999 101,999 110,052 212,051 1718 Directors Fees 1819 Professional Services 355,825 355,825 355,825 (333,355) 22,470 1920 Dues, Fees, Subscriptions & Promotions 110,235 110,235 (71,175) 39,060 (7,155) 31,905 2021 Clerical & General Office Expenses 175,167 25,427 5,436 206,030 206,030 225,276 431,306 2122 Employee Benefits & Payroll Taxes 647,922 647,922 647,922 41,336 689,258 2223 Inservice Training & Education 4,656 4,656 4,656 (2,657) 1,999 2324 Travel and Seminar 2,091 2,091 2,091 (92) 1,999 2425 Other Admin. Staff Transportation 2526 Insurance-Prop.Liab.Malpractice 60,442 60,442 60,442 14,787 75,229 2627 Other (specify):* 4,475 4,475 4,475 (3,000) 1,475 27

28 TOTAL General Administration 277,166 25,427 1,191,082 1,493,675 (71,175) 1,422,500 45,192 1,467,692 28TOTAL Operating Expense

29 (sum of lines 8, 16 & 28) 3,457,733 1,136,866 2,036,094 6,630,693 (509,402) 6,121,291 221,030 6,342,321 29*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.NOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 4Facility Name & ID Number Heritage Manor-Streator #0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10

#V. COST CENTER EXPENSES (continued)

Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments TotalD. Ownership 1 2 3 4 5 6 7 8 9 10

30 Depreciation 243,243 243,243 3031 Amortization of Pre-Op. & Org. 3132 Interest 9,473 9,473 9,473 217,548 227,021 3233 Real Estate Taxes 60,061 60,061 3334 Rent-Facility & Grounds 569,400 569,400 569,400 (560,789) 8,611 3435 Rent-Equipment & Vehicles 7,636 7,636 7,636 1,579 9,215 3536 Other (specify):* 36

37 TOTAL Ownership 586,509 586,509 586,509 (38,358) 548,151 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3839 Ancillary Service Centers 438,227 438,227 438,227 3940 Barber and Beauty Shops 1,135 20,851 21,986 21,986 21,986 4041 Coffee and Gift Shops 4142 Provider Participation Fee 71,175 71,175 71,175 4243 Other (specify):* 43

44 TOTAL Special Cost Centers 1,135 20,851 21,986 509,402 531,388 531,388 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 3,457,733 1,138,001 2,643,454 7,239,188 7,239,188 182,672 7,421,860 45

*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7.

In column 2 below, reference the line on which the particular cost was included. (See instructions.) 1 2 3

Refer- BHF USE B. If there are expenses experienced by the facility which do not appear in the NON-ALLOWABLE EXPENSES Amount ence ONLY general ledger, they should be entered below.(See instructions.)

1 Day Care $ $ 1 1 22 Other Care for Outpatients 2 Amount Reference3 Governmental Sponsored Special Programs 3 31 Non-Paid Workers-Attach Schedule* $ 314 Non-Patient Meals 4 32 Donated Goods-Attach Schedule* 325 Telephone, TV & Radio in Resident Rooms 35 5 Amortization of Organization &6 Rented Facility Space 34 6 33 Pre-Operating Expense 337 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization8 Laundry for Non-Patients 8 34 Costs (Schedule VII) 221,826 349 Non-Straightline Depreciation 30 9 35 Other- Attach Schedule 35

10 Interest and Other Investment Income (1,024) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ 221,826 3611 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ 182,672 3713 Sales Tax 2 1314 Non-Care Related Interest 32 14 *These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions 33 15 licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation) (3,140) 23 16 on these lines.17 Non-Care Related Fees (1,023) 20 1718 Fines and Penalties 18 C. Are the following expenses included in Sections A to D of pages 319 Entertainment (10,475) 24 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions 27 20 reference the line on which they appear before reclassification.21 Owner or Key-Man Insurance 21 (See instructions.) 1 2 3 422 Special Legal Fees & Legal Retainers (1,035) 19 22 Yes No Amount Reference23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. $ 3824 Bad Debt (3,000) 27 24 39 3925 Fund Raising, Advertising and Promotional (19,457) 20 25 40 Gift and Coffee Shops 40

Income Taxes and Illinois Personal 41 Barber and Beauty Shops 4126 Property Replacement Tax 26 42 Laboratory and Radiology 4227 CNA Training for Non-Employees 27 43 Prescription Drugs 4328 Yellow Page Advertising 28 44 4429 Other-Attach Schedule 29 45 Other-Attach Schedule 4530 SUBTOTAL (A): (Sum of lines 1-29) $ (39,154) $ 30 46 Other-Attach Schedule 46

47 TOTAL (C): (sum of lines 38-46) $ 47BHF USE ONLY

48 49 50 51 52

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5AHeritage Manor-Streator

ID# 0048066Report Period Beginning: 1-01-10

Ending: 12-31-10Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference1 $ 12 23 34 45 0 35 56 0 34 67 78 89 0 30 910 32 1011 1112 1213 0 2 1314 32 1415 0 33 1516 24 1617 (1,023) 20 1718 1819 24 1920 0 27 2021 2122 (1,035) 19 2223 2324 (3,000) 27 2425 (19,457) 20 2526 2627 2728 2829 0 33 2930 3031 3132 3233 3334 3435 3536 3637 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 Total (24,515) 49

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary AFacility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Operating Expenses PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSA. General Services 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

1 Dietary 0 0 5,181 0 0 0 0 0 0 0 0 5,181 12 Food Purchase 0 0 (1,224) 0 0 0 0 0 0 0 0 (1,224) 23 Housekeeping 0 0 0 0 0 0 0 0 0 0 0 0 34 Laundry 0 0 0 0 0 0 0 0 0 0 0 0 45 Heat and Other Utilities 0 0 2,239 0 0 0 0 0 0 0 0 2,239 56 Maintenance 0 0 15,426 0 0 0 0 0 0 0 0 15,426 67 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 78 TOTAL General Services 0 0 21,622 0 0 0 0 0 0 0 0 21,622 8

B. Health Care and Programs9 Medical Director 0 0 3,806 0 0 0 0 0 0 0 0 3,806 9

10 Nursing and Medical Records 0 0 0 0 0 0 0 0 0 0 0 0 10 10a Therapy 0 148,687 0 0 0 0 0 0 0 0 0 148,687 10a11 Activities 0 0 5 0 0 0 0 0 0 0 0 5 1112 Social Services 0 0 0 0 0 0 0 0 0 0 0 0 1213 CNA Training 0 0 1,718 0 0 0 0 0 0 0 0 1,718 1314 Program Transportation 0 0 0 0 0 0 0 0 0 0 0 0 1415 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 15

16 TOTAL Health Care and Programs 0 148,687 5,529 0 0 0 0 0 0 0 0 154,216 16C. General Administration

17 Administrative 0 0 110,052 0 0 0 0 0 0 0 0 110,052 1718 Directors Fees 0 0 0 0 0 0 0 0 0 0 0 0 1819 Professional Services (1,035) (354,790) 22,470 0 0 0 0 0 0 0 0 (333,355) 1920 Fees, Subscriptions & Promotions (20,480) 0 13,325 0 0 0 0 0 0 0 0 (7,155) 2021 Clerical & General Office Expenses 0 0 225,276 0 0 0 0 0 0 0 0 225,276 2122 Employee Benefits & Payroll Taxes 0 0 41,336 0 0 0 0 0 0 0 0 41,336 2223 Inservice Training & Education (3,140) 0 483 0 0 0 0 0 0 0 0 (2,657) 2324 Travel and Seminar (10,475) 0 10,383 0 0 0 0 0 0 0 0 (92) 2425 Other Admin. Staff Transportation 0 0 0 0 0 0 0 0 0 0 0 0 2526 Insurance-Prop.Liab.Malpractice 0 0 14,787 0 0 0 0 0 0 0 0 14,787 2627 Other (specify):* (3,000) 0 0 0 0 0 0 0 0 0 0 (3,000) 27

28 TOTAL General Administration (38,130) (354,790) 438,112 0 0 0 0 0 0 0 0 45,192 28TOTAL Operating Expense

29 (sum of lines 8,16 & 28) (38,130) (206,103) 465,263 0 0 0 0 0 0 0 0 221,030 29

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary BFacility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10

SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSD. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

30 Depreciation 0 230,878 0 12,365 0 0 0 0 0 0 0 243,243 3031 Amortization of Pre-Op. & Org. 0 0 0 0 0 0 0 0 0 0 0 0 3132 Interest (1,024) 217,787 0 785 0 0 0 0 0 0 0 217,548 3233 Real Estate Taxes 0 59,990 0 71 0 0 0 0 0 0 0 60,061 3334 Rent-Facility & Grounds 0 (569,400) 0 8,611 0 0 0 0 0 0 0 (560,789) 3435 Rent-Equipment & Vehicles 0 0 0 1,579 0 0 0 0 0 0 0 1,579 3536 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 36

37 TOTAL Ownership (1,024) (60,745) 0 23,411 0 0 0 0 0 0 0 (38,358) 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 0 0 0 0 0 0 0 0 0 0 0 0 3839 Ancillary Service Centers 0 0 0 0 0 0 0 0 0 0 0 0 3940 Barber and Beauty Shops 0 0 0 0 0 0 0 0 0 0 0 0 4041 Coffee and Gift Shops 0 0 0 0 0 0 0 0 0 0 0 0 4142 Provider Participation Fee 0 0 0 0 0 0 0 0 0 0 0 0 4243 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 43

44 TOTAL Special Cost Centers 0 0 0 0 0 0 0 0 0 0 0 0 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) (39,154) (266,848) 465,263 23,411 0 0 0 0 0 0 0 182,672 45

HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES A. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Attach an additional schedule if necessary.

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of BusinessHeritage Enterprises, Inc. 100 See Attached

B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,management fees, purchase of supplies, and so forth. x YES NO

If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance withthe instructions for determining costs as specified for this form.1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:

Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization

Ownership Organization Costs (7 minus 4)1 V $ $ $ 12 V 10a Adjustment for Related Organization GreenTree Pharmacy 0.00% 148,687 148,687 23 V 34 V 19 Adjustment for Related Organization 354,790 Heritage Operations Group, LLC 0.00% (354,790) 45 V 56 V 34 Adjustment for Related Organization 569,400 Heritage Manor Real Estate, LLC 0.00% (569,400) 67 V 33 Adjustment for Related Organization Heritage Manor Real Estate, LLC 59,990 59,990 78 V 32 Adjustment for Related Organization Heritage Manor Real Estate, LLC 206,830 206,830 89 V 30 Adjustment for Related Organization Heritage Manor Real Estate, LLC 230,878 230,878 910 V 32 Adjustment for Related Organization Heritage Manor Real Estate, LLC 10,957 10,957 1011 V 1112 V 1213 V 1314 Total $ 924,190 $ 657,342 $ * (266,848) 14

* Total must agree with the amount recorded on line 34 of Schedule VI.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6AFacility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10

VII. RELATED PARTIES (continued) B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,

management fees, purchase of supplies, and so forth. YES NO



Ownership Organization Costs (7 minus 4)15 V 1 Dietary $ Heritage Enterprises, Inc. $ $ 5,181 1516 V 2 Food Purchase (1,224) 1617 V 3 Housekeeping 0 1718 V 4 Laundry 0 1819 V 5 Heat & Other Utilities 2,239 1920 V 6 Maintenance 15,426 2021 V 7 Other 0 2122 V 9 Medical Director 3,806 2223 V 10 Nursing & Medical Records 0 2324 V 11 Activities 5 2425 V 12 Social Service 0 2526 V 13 Nurse Aide Training 1,718 2627 V 14 Program Transportation 0 2728 V 15 Other 0 2829 V 17 Administrative 110,052 2930 V 18 Directors Fees 0 3031 V 19 Professional Services 22,470 3132 V 20 Fees, Subscription, Promotions 13,325 3233 V 21 Clerical & General Office Expenses 225,276 3334 V 22 Employee Benefits & Payroll Taxes 41,336 3435 V 23 Inservice Training & Education 483 3536 V 24 Travel and Seminar 10,383 3637 V 25 Other Admin. Staff Transportation 0 3738 V 26 Insurance-Prop.Liab.Malpract 14,787 38

39 Total $ $ 0 $ * 465,263 39


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6BFacility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10

VII. RELATED PARTIES (continued) B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,

management fees, purchase of supplies, and so forth. YES NO



Ownership Organization Costs (7 minus 4)15 V 27 Other $ Heritage Enterprises, Inc. $ $ 0 1516 V 30 Depreciation 12,365 1617 V 31 Amortization of Pre-Op & Org 0 1718 V 32 Interest 785 1819 V 33 Real Estate Taxes 71 1920 V 34 Rent-Facility & Grounds 8,611 2021 V 35 Rent-Equipment & Vehicles 1,579 2122 V 36 Other 0 2223 V 38 Medically Nec Transportation 0 2324 V 39 Ancillary Service Centers 0 2425 V 40 Barber and Beauty Shops 0 2526 V 41 Coffee and Gift Shops 0 2627 V 42 Other 0 2728 V 2829 V 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 38

39 Total $ $ 0 $ * 23,411 39


HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES (continued)C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors. NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this home must be listed on this schedule.

1 2 3 4 5 6 7 8Average Hours Per Work

Compensation Week Devoted to this Compensation Included Schedule V.Received Facility and % of Total in Costs for this Line &

Ownership From Other Work Week Reporting Period** ColumnName Title Function Interest Nursing Homes* Hours Percent Description Amount Reference

1 Heritage Enterprises Inc. Member 100.00 $ 0 18/7 12 23 34 45 56 67 78 89 9

10 1011 1112 12

13 TOTAL $ 13

* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s)of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS.

** This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees).FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME,ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATION

HFS 3745 (N-4-99) IL478-2471


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization Heritage Operations Group

A. Are there any costs included in this report which were derived from allocations of central office Street Address box 3188 or parent organization costs? (See instructions.) YES X NO City / State / Zip Code Bloomington, Il 61701

Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( )

1 2 3 4 5 6 7 8 9Schedule V Unit of Allocation Number of Total Indirect Amount of Salary

Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility AllocationReference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6

1 1 Dietary Beds 2,634 25 $ 104,969 $ 104,969 130 $ 5,181 12 2 Food Purchase Beds 2,634 25 (24,794) 0 130 (1,224) 23 3 Housekeeping Beds 2,634 25 0 0 130 0 34 4 Laundry Beds 2,634 25 0 0 130 0 45 5 Heat & Other Utilities Beds 2,634 25 45,364 0 130 2,239 56 6 Maintenance Beds 2,634 25 312,555 75,007 130 15,426 67 7 Other Beds 2,634 25 0 0 130 0 78 9 Medical Director Beds 2,634 25 77,111 0 130 3,806 89 10 Nursing & Medical Records Beds 2,634 25 0 77,111 130 0 9

10 11 Activities Beds 2,634 25 95 0 130 5 1011 12 Social Service Beds 2,634 25 0 0 130 0 1112 13 Nurse Aide Training Beds 2,634 25 34,804 0 130 1,718 1213 14 Program Transportation Beds 2,634 25 0 0 130 0 1314 15 Other Beds 2,634 25 0 0 130 0 1415 17 Administrative Beds 2,634 25 2,229,831 2,229,831 130 110,052 1516 18 Directors Fees Beds 2,634 25 0 0 130 0 1617 19 Professional Services Beds 2,634 25 455,276 0 130 22,470 1718 20 Fees, Subscription, Promotions Beds 2,634 25 269,994 0 130 13,325 1819 21 Clerical & General Office ExpenseBeds 2,634 25 4,564,447 4,163,572 130 225,276 1920 22 Employee Benefits & Payroll TaxeBeds 2,634 25 837,533 0 130 41,336 2021 23 Inservice Training & Education Beds 2,634 25 9,793 0 130 483 2122 24 Travel and Seminar Beds 2,634 25 210,373 0 130 10,383 2223 25 Other Admin. Staff TransportatioBeds 2,634 25 0 0 130 0 2324 26 Insurance-Prop.Liab.Malpract Beds 2,634 25 299,608 0 130 14,787 2425 TOTALS $ 9,426,959 $ 6,650,490 $ 465,263 25

HFS 3745 (N-4-99) IL478-2471


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization

A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code

Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( )

1 2 3 4 5 6 7 8 9Schedule V Unit of Allocation Number of Total Indirect Amount of Salary

Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility AllocationReference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6

1 27 Other Beds 2,634 25 $ $ 130 $ 12 30 Depreciation Beds 2,634 25 250,538 130 12,365 23 31 Amortization of Pre-Op & Org Beds 2,634 25 130 34 32 Interest Beds 2,634 25 15,900 130 785 45 33 Real Estate Taxes Beds 2,634 25 1,448 130 71 56 34 Rent-Facility & Grounds Beds 2,634 25 174,472 130 8,611 67 35 Rent-Equipment & Vehicles Beds 2,634 25 31,994 130 1,579 78 36 Other Beds 2,634 25 130 89 38 Medically Nec Transportation Beds 2,634 25 130 9

10 39 Ancillary Service Centers Beds 2,634 25 130 1011 40 Barber and Beauty Shops Beds 2,634 25 130 1112 41 Coffee and Gift Shops Beds 2,634 25 130 1213 42 Other Beds 2,634 25 130 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ 474,352 $ $ 23,411 25

HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)

1 2 3 4 5 6 7 8 9 10Reporting

Monthly Maturity Interest PeriodName of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest

YES NO Required Note Original Balance (4 Digits) ExpenseA. Directly Facility Related Long-Term

1 Bank of America xx Mortgage $ $ 3,026,294 3/2011 variable $ 206,830 12 Bank of America xx Loan Fees 10,957 23 34 45 5

Working Capital6 Bank of America xx Accounts Receivable 9,473 67 78 8

9 TOTAL Facility Related $ $ 3,026,294 $ 227,260 9B. Non-Facility Related*

10 Interest Income (1,024) 1011 Allocated Corporate 785 1112 1213 13

14 TOTAL Non-Facility Related $ $ $ (239) 14

15 TOTALS (line 9+line14) $ $ 3,026,294 $ 227,021 15

16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ Line #

* Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7.(See instructions.)

** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.(See instructions.)

HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued) B. Real Estate Taxes

Important, please see the next worksheet, "RE_Tax". The real estate tax 1. Real Estate Tax accrual used on 2009 report. statement and bill must accompany the cost report. $ 1

2. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 59,990 2

3. Under or (over) accrual (line 2 minus line 1). $ 59,990 3

4. Real Estate Tax accrual used for 2010 report. (Detail and explain your calculation of this accrual on the lines below.) $ 4

5. Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C. (Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) $ 5

6. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costs classified as a real estate tax cost plus one-half of any remaining refund. TOTAL REFUND $ For Tax Year. (Attach a copy of the real estate tax appeal board's decision.) $ 6

7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. $ 59,990 7

Real Estate Tax History:

Real Estate Tax Bill for Calendar Year: 2005 57,575 8 FOR BHF USE ONLY2006 71,142 92007 56,544 10 13 FROM R. E. TAX STATEMENT FOR 2009 $ 132008 59,268 112009 59,990 12 14 PLUS APPEAL COST FROM LINE 5 $ 14

15 LESS REFUND FROM LINE 6 $ 15

16 AMOUNT TO USE FOR RATE CALCULATION $ 16

NOTES: 1. Please indicate a negative number by use of brackets( ). Deduct any overaccrual of taxes from prior year.

2. If facility is a non-profit which pays real estate taxes, you must attach a denial of an application for real estate tax exemption unless the building is rented from a for-profit entity. This denial must be no more than four years old at the time the cost report is filed.

HFS 3745 (N-4-99) IL478-2471

2009 LONG TERM CARE REAL ESTATE TAX STATEMENTFACILITY NAME Heritage Manor-Streator COUNTY LaSalle

FACILITY IDPH LICENSE NUMBER 0048066

CONTACT PERSON REGARDING THIS REPORT

TELEPHONE ( ) FAX #: ( )

A. Summary of Real Estate Tax Cost

Enter the tax index number and real estate tax assessed for 2009 on the lines provided below. Enter only the portion of thecost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursinghome property which is vacant, rented to other organizations, or used for purposes other than long term care must not beentered in Column D. Do not include cost for any period other than calendar year 2009.

(A) (B) (C) (D)Tax

Applicable toTax Index Number Property Description Total Tax Nursing Home

1. 3431134000 nursing home $ 59,990.00 $ 59,990.00

2. $ $

3. $ $

4. $ $

5. $ $

6. $ $

7. $ $

8. $ $

9. $ $

10. $ $

TOTALS $ 59,990.00 $ 59,990.00

B. Real Estate Tax Cost Allocations

Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directlyused for nursing home services? YES NO

If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)

C. Tax Bills

Attach a copy of the original 2009 tax bills which were listed in Section A to this statement. Be sure to use the 2009tax bill which is normally paid during 2010.

PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax billdocumentation . Facilities located in Cook County are required to provide copies of their original second installment tax bill.

Page 10A

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 11Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10X. BUILDING AND GENERAL INFORMATION:

A. Square Feet: 19,262 B. General Construction Type: Exterior brick Frame wood Number of Stories 1

C. Does the Operating Entity? (a) Own the Facility x (b) Rent from a Related Organization. (c) Rent from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI. Those checking (c) may complete Schedule XI or Schedule XII-A. See instructions.)

D. Does the Operating Entity? (a) Own the Equipment x (b) Rent equipment from a Related Organization. (c) Rent equipment from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI-C. Those checking (c) may complete Schedule XI-C or Schedule XII-B. See instructions.)

E. List all other business entities owned by this operating entity or related to the operating entity that are located on or adjacent to this nursing home's grounds(such as, but not limited to, apartments, assisted living facilities, day training facilities, day care, independent living facilities, CNA training facilities, etc.)List entity name, type of business, square footage, and number of beds/units available (where applicable).NONE

F. Does this cost report reflect any organization or pre-operating costs which are being amortized? YES X NOIf so, please complete the following:

1. Total Amount Incurred: 2. Number of Years Over Which it is Being Amortized:

3. Current Period Amortization: 4. Dates Incurred:

Nature of Costs:(Attach a complete schedule detailing the total amount of organization and pre-operating costs.)

XI. OWNERSHIP COSTS: 1 2 3 4

A. Land. Use Square Feet Year Acquired Cost1 $ 17,000 12 23 TOTALS $ 17,000 3

HFS 3745 (N-4-99) IL478-2471


XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar.

1 2 3 4 5 6 7 8 9 FOR BHF USE ONLY Year Year Current Book Life Straight Line Accumulated

Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation4 130 $ 348,848 $ $ $ $ 45 440,122 56 2,594,839 67 78 8

Improvement Type**9 1978 Improvements 1980 12,172 910 1979 Improvements 1981 13,748 1011 1980 Improvements 1982 18,366 1112 1981 Improvements 1983 9,250 1213 1982 Improvements 1984 1,329 1314 1983 Improvements 1985 4,100 1415 1984 Improvements 1986 57,336 1516 1985 Improvements 1987 6,225 1617 1986 Improvements 1988 48,818 1718 1988 Improvements 1989 22,687 1819 1989 Improvements 1990 31,584 1920 1990 Improvements 1991 3,560 2021 1991 Improvements 1992 19,172 2122 1992 Improvements 1993 23,135 2223 1993 Improvements 1994 22,036 2324 1994 Improvements 1995 39,228 2425 1995 Improvements 1996 3,910 2526 BOILER 2627 EXHAUST HOOD 2728 CODE ALERT 2829 PHONE SYSTEM 2930 INTERIOR REMODEL 3031 3132 3233 C/O Allocation 12,365 12,365 3334 Book Depreciation 163,341 163,341 3435 3536 36

*Total beds on this schedule must agree with page 2. See Page 12A, Line 70 for total**Improvement type must be detailed in order for the cost report to be considered complete.

HFS 3745 (N-4-99) IL478-2471



1 3 4 5 6 7 8 9Year Current Book Life Straight Line Accumulated

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation37 Interior Rehab---Facility 1997 $ 286,974 $ $ $ $ 3738 Roof 1997 5,232 3839 Sprinkler System 1997 9,530 3940 Code Alert 1997 1,879 4041 4142 Code Alert 1998 2,000 4243 Bathroom Door 1998 656 4344 Interior Rehab 1998 11,815 4445 4546 Door Alarms 1999 3,675 4647 4748 Water Heater 2000 4,114 4849 Exhaust Fans 2000 931 4950 Booster Heater -- Water Heater 2000 1,465 5051 5152 Professional Fees---Building Renovation 2001 27,964 5253 Sprinkler Replacement 2001 4,955 5354 AC Unit with Installation 2001 4,372 5455 Exterior Painting 2001 6,545 5556 Code Alert System 2001 4,592 5657 5758 Roof 2002 48,840 5859 Sewer line 2002 20,615 5960 Condensing Unit 2002 1,213 6061 6162 Exterior Door 2003 6,556 6263 Exit Lights 2003 1,013 6364 Heating Pump 2003 1,746 6465 6566 6667 6768 6869 6970 TOTAL (lines 4 thru 69) $ 4,177,147 $ 163,341 $ 175,706 $ 12,365 $ 70

**Improvement type must be detailed in order for the cost report to be considered complete.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12BFacility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12A, Carried Forward $ 4,177,147 $ 163,341 $ 175,706 $ 12,365 $ 12 Doors 2004 1,386 23 A/C 2004 5,061 34 PVC kickplate 2004 2,859 45 Disposal 2004 1,175 56 67 Roof 2005 54,596 78 A/C Condensing Unit 2005 5,800 89 Window Replacement 2005 51,893 910 Water Main 2005 1,706 1011 1112 1213 Roof 2006 19,500 1314 A/C Replacement 2006 1,974 1415 Boiler 2006 58,327 1516 Landscapping 2006 5,398 1617 1718 Nurse's station 2007 9,580 1819 Nurse call system 2007 96,193 1920 Wireless network 2007 26,272 2021 Corridor Paint and floors 2007 37,819 2122 A/C 2007 23,747 2223 Wander guard 2007 4,177 2324 Garage --Construction of new Maintenance Garage 2007 42,453 2425 Professional Fee -- remodel 2007 1,286 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 4,628,349 $ 163,341 $ 175,706 $ 12,365 $ 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12CFacility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12B, Carried Forward $ 4,628,349 $ 163,341 $ 175,706 $ 12,365 $ 12 Landscaping 2008 22,238 23 Garage --Construction of new Maintenance Garage 2008 9,644 34 South Wing Windows 2008 63,040 45 Air Handler 2008 10,301 56 Redo North Nurses Station 2008 8,101 67 78 Wireless Network 2009 4,035 89 South Dining Room Electric 2009 2,752 910 Corridor Doors 2009 22,230 1011 1112 Lennox condensor 2010 6,864 1213 Walkin Cooler 2010 4,313 1314 Nurse Call System 2010 6,594 1415 Wood Blinds 2010 2,914 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 4,791,375 $ 163,341 $ 175,706 $ 12,365 $ 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12DFacility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12C, Carried Forward $ 4,791,375 $ 163,341 $ 175,706 $ 12,365 $ 12 23 34 45 56 67 78 89 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 4,791,375 $ 163,341 $ 175,706 $ 12,365 $ 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 13Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10XI. OWNERSHIP COSTS (continued)

C. Equipment Depreciation-Excluding Transportation. (See instructions.) Category of 1 Current Book Straight Line 4 Component Accumulated Equipment Cost Depreciation 2 Depreciation 3 Adjustments Life 5 Depreciation 6

71 Purchased in Prior Years $ 1,160,979 $ 67,537 $ 67,537 $ $ 7172 Current Year Purchases 64,531 7273 Fully Depreciated Assets 7374 7475 TOTALS $ 1,225,510 $ 67,537 $ 67,537 $ $ 75

D. Vehicle Depreciation (See instructions.)*1 Model, Make Year 4 Current Book Straight Line 7 Life in Accumulated

Use and Year 2 Acquired 3 Cost Depreciation 5 Depreciation 6 Adjustments Years 8 Depreciation 976 $ $ $ $ $ 7677 7778 7879 7980 TOTALS $ $ $ $ $ 80

E. Summary of Care-Related Assets 1 2Reference Amount

81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 6,033,885 8182 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 230,878 8283 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 243,243 83 **84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ 12,365 8485 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 85

F. Depreciable Non-Care Assets Included in General Ledger. (See instructions.) G. Construction-in-Progress1 2 Current Book Accumulated

Description & Year Acquired Cost Depreciation 3 Depreciation 4 Description Cost86 $ $ $ 86 92 $ 9287 87 93 9388 88 94 9489 89 95 $ 9590 9091 TOTALS $ $ $ 91 * Vehicles used to transport residents to & from

day training must be recorded in XI-F, not XI-D.

** This must agree with Schedule V line 30, column 8.

HFS 3745 (N-4-99) IL478-2471


XII. RENTAL COSTSA. Building and Fixed Equipment (See instructions.) 1. Name of Party Holding Lease: 2. Does the facility also pay real estate taxes in addition to rental amount shown below on line 7, column 4? If NO, see instructions. YES NO 00

001 2 3 4 5 6

Year Number Original Rental Total Years Total YearsConstructed of Beds Lease Date Amount of Lease Renewal Option*

Original 10. Effective dates of current rental agreement:3 Building: $ 3 Beginning4 Additions 4 Ending5 56 6 11. Rent to be paid in future years under the current7 TOTAL $ 7 rental agreement:

** 8. List separately any amortization of lease expense included on page 4, line 34. Fiscal Year Ending Annual Rent This amount was calculated by dividing the total amount to be amortized by the length of the lease . 12. /2011 $

13. /2012 $ 9. Option to Buy: YES NO Terms: * 14. /2013 $

B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.) 15. Is Movable equipment rental included in building rental? YES X NO 16. Rental Amount for movable equipment: $ 7,636 Description:

(Attach a schedule detailing the breakdown of movable equipment)C. Vehicle Rental (See instructions.)

1 2 3 4Model Year Monthly Lease Rental Expense

Use and Make Payment for this Period * If there is an option to buy the building,17 $ $ 17 please provide complete details on attached18 18 schedule.19 1920 20 ** This amount plus any amortization of lease21 TOTAL $ $ 21 expense must agree with page 4, line 34.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 15Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.)

A. TYPE OF TRAINING PROGRAM (If CNAs are trained in another facility program, attach a schedule listing the facility name, address and cost per CNA trained in that facility.)

1. HAVE YOU TRAINED CNAs YES 2. CLASSROOM PORTION: 3. CLINICAL PORTION: DURING THIS REPORT PERIOD? NO IN-HOUSE PROGRAM IN-HOUSE PROGRAM

IN OTHER FACILITY IN OTHER FACILITY If "yes", please complete the remainder of this schedule. If "no", provide an COMMUNITY COLLEGE HOURS PER CNA explanation as to why this training was not necessary. HOURS PER CNA

B. EXPENSES C. CONTRACTUAL INCOMEALLOCATION OF COSTS (d)

In the box below record the amount of income your1 2 3 4 facility received training CNAs from other facilities.

FacilityDrop-outs Completed Contract Total $

1 Community College Tuition $ $ $ $2 Books and Supplies 1,051 1,051 D. NUMBER OF CNAs TRAINED3 Classroom Wages (a)4 Clinical Wages (b) 9,227 9,227 COMPLETED5 In-House Trainer Wages (c) 1. From this facility6 Transportation 2. From other facilities (f)7 Contractual Payments DROP-OUTS8 CNA Competency Tests 1. From this facility9 TOTALS $ $ 10,278 $ $ 10,278 2. From other facilities (f)10 SUM OF line 9, col. 1 and 2 (e) $ 10,278 TOTAL TRAINED

(a) Include wages paid during the classroom portion of training. Do not include fringe benefits. (e) The total amount of Drop-out and Completed Costs for(b) Include wages paid during the clinical portion of training. Do not include fringe benefits. your own CNAs must agree with Sch. V, line 13, col. 8.(c) For in-house training programs only. Do not include fringe benefits. (f) Attach a schedule of the facility names and addresses(d) Allocate based on if the CNA is from your facility or is being contracted to be trained in of those facilities for which you trained CNAs. your facility. Drop-out costs can only be for costs incurred by your own CNAs.

HFS 3745 (N-4-99) IL478-2471


XIV. SPECIAL SERVICES (Direct Cost) (See instructions.)1 2 3 4 5 6 7 8

Schedule V Staff Outside Practitioner SuppliesService Line & Column Units of Cost (other than consultant) (Actual or) Total Units Total Cost

Reference Service Units Cost Allocated) (Column 2 + 4) (Col. 3 + 5 + 6)1 Licensed Occupational Therapist hrs $ $ 270,919 $ $ 270,919 1

Licensed Speech and Language2 Development Therapist hrs 48,918 48,918 23 Licensed Recreational Therapist hrs 34 Licensed Physical Therapist hrs 248,019 3,497 251,516 45 Physician Care visits 56 Dental Care visits 67 Work Related Program hrs 78 Habilitation hrs 8

# of9 Pharmacy prescrpts 399,641 399,641 9

Psychological Services (Evaluation and Diagnosis/

10 Behavior Modification) hrs 1011 Academic Education hrs 1112 Other (specify): 12

13 Other (specify): 38,586 38,586 13

14 TOTAL $ $ 606,442 $ 403,138 $ 1,009,580 14

NOTE: This schedule should include fees (other than consultant fees) paid to licensed practitioners. Consultant fees should be detailed on Schedule XVIII-B. Salaries of unlicensed practitioners, such as CNAs, who help with the above activities should not be listed on this schedule.

HFS 3745 (N-4-99) IL478-2471


XV. BALANCE SHEET - Unrestricted Operating Fund. As of 12-31-10 (last day of reporting year) This report must be completed even if financial statements are attached.

1 2 After 1 2 After Operating Consolidation* Operating Consolidation*

A. Current Assets C. Current Liabilities1 Cash on Hand and in Banks $ 57,329 $ 1 26 Accounts Payable $ 236,575 $ 262 Cash-Patient Deposits 10,877 2 27 Officer's Accounts Payable 27

Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits 10,877 283 Patients (less allowance ) 363,814 3 29 Short-Term Notes Payable 294 Supply Inventory (priced at ) 4 30 Accrued Salaries Payable 393,215 305 Short-Term Investments 5 Accrued Taxes Payable6 Prepaid Insurance 29,998 6 31 (excluding real estate taxes) 3,788 317 Other Prepaid Expenses 7 32 Accrued Real Estate Taxes(Sch.IX-B) 328 Accounts Receivable (owners or related parties) 312,820 8 33 Accrued Interest Payable 339 Other(specify): 9 34 Deferred Compensation 34

TOTAL Current Assets 35 Federal and State Income Taxes 3510 (sum of lines 1 thru 9) $ 774,838 $ 10 Other Current Liabilities(specify):

B. Long-Term Assets 36 3611 Long-Term Notes Receivable 11 37 3712 Long-Term Investments 12 TOTAL Current Liabilities13 Land 13 38 (sum of lines 26 thru 37) $ 644,455 $ 3814 Buildings, at Historical Cost 14 D. Long-Term Liabilities15 Leasehold Improvements, at Historical Cost 15 39 Long-Term Notes Payable 3916 Equipment, at Historical Cost 16 40 Mortgage Payable 4017 Accumulated Depreciation (book methods) 17 41 Bonds Payable 4118 Deferred Charges 18 42 Deferred Compensation 4219 Organization & Pre-Operating Costs 19 Other Long-Term Liabilities(specify):

Accumulated Amortization - 43 4320 Organization & Pre-Operating Costs 20 44 4421 Restricted Funds 21 TOTAL Long-Term Liabilities22 Other Long-Term Assets (specify): 22 45 (sum of lines 39 thru 44) $ $ 4523 Other(specify): 23 TOTAL LIABILITIES

TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 644,455 $ 4624 (sum of lines 11 thru 23) $ $ 24

47 TOTAL EQUITY(page 18, line 24) $ 130,383 $ 47TOTAL ASSETS TOTAL LIABILITIES AND EQUITY

25 (sum of lines 10 and 24) $ 774,838 $ 25 48 (sum of lines 46 and 47) $ 774,838 $ 48

*(See instructions.)

HFS 3745 (N-4-99) IL478-2471


XVI. STATEMENT OF CHANGES IN EQUITY1

Total1 Balance at Beginning of Year, as Previously Reported $ (697,833) 12 Restatements (describe): 23 34 45 56 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ (697,833) 6

A. Additions (deductions):7 NET Income (Loss) (from page 19, line 43) 828,216 78 Aquisitions of Pooled Companies 89 Proceeds from Sale of Stock 9

10 Stock Options Exercised 1011 Contributions and Grants 1112 Expenditures for Specific Purposes 1213 Dividends Paid or Other Distributions to Owners ( ) 1314 Donated Property, Plant, and Equipment 1415 Other (describe) 1516 Other (describe) 1617 TOTAL Additions (deductions) (sum of lines 7-16) $ 828,216 17

B. Transfers (Itemize):18 1819 1920 2021 2122 2223 TOTAL Transfers (sum of lines 18-22) $ 2324 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ 130,383 24 *

* This must agree with page 17, line 47.

HFS 3745 (N-4-99) IL478-2471


XVII. INCOME STATEMENT (attach any explanatory footnotes necessary to reconcile this schedule to Schedules V and VI.) All required classifications of revenue and expense must be provided on this form, even if financial statements are attached. Note: This schedule should show gross revenue and expenses. Do not net revenue against expense.

1 2Revenue Amount Expenses Amount

A. Inpatient Care A. Operating Expenses1 Gross Revenue -- All Levels of Care $ 7,854,241 1 31 General Services 1,200,439 312 Discounts and Allowances for all Levels (2,377,400) 2 32 Health Care 3,936,579 323 SUBTOTAL Inpatient Care (line 1 minus line 2) $ 5,476,841 3 33 General Administration 1,493,675 33

B. Ancillary Revenue B. Capital Expense4 Day Care 4 34 Ownership 586,509 345 Other Care for Outpatients 5 C. Ancillary Expense6 Therapy 1,829,428 6 35 Special Cost Centers 21,986 357 Oxygen 7 36 Provider Participation Fee 368 SUBTOTAL Ancillary Revenue (lines 4 thru 7) $ 1,829,428 8 D. Other Expenses (specify):

C. Other Operating Revenue 37 379 Payments for Education 9 38 38

10 Other Government Grants 10 39 3911 CNA Training Reimbursements 1112 Gift and Coffee Shop 1,350 12 40 TOTAL EXPENSES (sum of lines 31 thru 39)* $ 7,239,188 4013 Barber and Beauty Care 27,776 1314 Non-Patient Meals 14 41 Income before Income Taxes (line 30 minus line 40)** 828,216 4115 Telephone, Television and Radio 1516 Rental of Facility Space 16 42 Income Taxes 4217 Sale of Drugs 708,362 1718 Sale of Supplies to Non-Patients 18 43 NET INCOME OR LOSS FOR THE YEAR (line 41 minus line 42) $ 828,216 4319 Laboratory 1920 Radiology and X-Ray 2021 Other Medical Services 15,414 2122 Laundry 2223 SUBTOTAL Other Operating Revenue (lines 9 thru 22) $ 752,902 23

D. Non-Operating Revenue24 Contributions 24 * This must agree with page 4, line 45, column 4.25 Interest and Other Investment Income*** 1,024 2526 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 1,024 26 ** Does this agree with taxable income (loss) per Federal Income

E. Other Revenue (specify):**** Tax Return? If not, please attach a reconciliation.27 Settlement Income (Insurance, Legal, Etc.) 2728 Other 7,209 28 *** See the instructions. If this total amount has not been offset

28a 28a against interest expense on Schedule V, line 32, please include a29 SUBTOTAL Other Revenue (lines 27, 28 and 28a) $ 7,209 29 detailed explanation.

30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 8,067,404 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 20Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10XVIII. 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 VActually Paid and Total Salaries, Hourly of Hrs. Cost for Line &Worked Accrued Wages Wage Paid & Reporting Column

1 Director of Nursing 1,871 2,085 $ 66,329 $ 31.81 1 Accrued Period Reference2 Assistant Director of Nursing 1,748 2,080 55,011 26.45 2 35 Dietary Consultant $ 0 353 Registered Nurses 13,218 13,872 382,827 27.60 3 36 Medical Director 2,400 364 Licensed Practical Nurses 22,819 24,753 562,086 22.71 4 37 Medical Records Consultant 7,800 375 CNAs & Orderlies 107,629 115,773 1,406,016 12.14 5 38 Nurse Consultant 386 CNA Trainees 1,600 1,600 9,227 5.77 6 39 Pharmacist Consultant 0 397 Licensed Therapist 7 40 Physical Therapy Consultant 408 Rehab/Therapy Aides 2,218 2,376 74,676 31.43 8 41 Occupational Therapy Consultant 419 Activity Director 9 42 Respiratory Therapy Consultant 4210 Activity Assistants 6,508 7,288 90,715 12.45 10 43 Speech Therapy Consultant 4311 Social Service Workers 1,932 2,076 31,769 15.30 11 44 Activity Consultant 4412 Dietician 12 45 Social Service Consultant 3,199 4513 Food Service Supervisor 13 46 Other(specify) 4614 Head Cook 14 47 4715 Cook Helpers/Assistants 34,839 36,680 191,355 5.22 15 48 4816 Dishwashers 1617 Maintenance Workers 6,575 7,085 94,522 13.34 17 49 TOTAL (lines 35 - 48) $ 13,399 4918 Housekeepers 14,784 15,561 144,295 9.27 1819 Laundry 5,318 5,807 71,739 12.35 1920 Administrator 1,900 2,080 101,999 49.04 2021 Assistant Administrator 21 C. CONTRACT NURSES22 Other Administrative 22 1 2 323 Office Manager 23 Number Schedule V24 Clerical 9,703 10,791 175,167 16.23 24 of Hrs. Total Line &25 Vocational Instruction 25 Paid & Contract Column26 Academic Instruction 26 Accrued Wages Reference27 Medical Director 27 50 Registered Nurses 0 $ 0 5028 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 0 0 5129 Resident Services Coordinator 29 52 Certified Nurse Assistants/Aides 0 0 5230 Habilitation Aides (DD Homes) 3031 Medical Records 31 53 TOTAL (lines 50 - 52) $ 5332 Other Health Care(specify) 3233 Other(specify) 3334 TOTAL (lines 1 - 33) 232,662 249,907 $ 3,457,733 * $ 13.84 34

* This total must agree with page 4, column 1, line 45. ** See instructions.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 21Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10XIX. SUPPORT SCHEDULES A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions

Name Function % Amount Description Amount Description AmountJanette Strabala $ 101,999 Workers' Compensation Insurance $ 25,367 IDPH License Fee $ 0

Unemployment Compensation Insurance 50,959 Advertising: Employee Recruitment 1,811 FICA Taxes 264,517 Health Care Worker Background CheckEmployee Health Insurance 277,803 (Indicate # of checks performed ) 3,000Employee Meals Patient Background Checks Illinois Municipal Retirement Fund (IMRF)*

0 9,884TOTAL (agree to Schedule V, line 17, col. 1) Other Benefits 29,276 Dues & Subscriptions 9,633(List each licensed administrator separately.) $ 101,999 Central Office Allocation 41,336 License & Fees 5,159B. Administrative - Other Central Office Allocation 13,325

Less: Public Relations Expense (9,884) Description Amount Non-allowable advertising (1,023)

$ Yellow page advertising ( )

TOTAL (agree to Schedule V, $ 689,258 TOTAL (agree to Sch. V, $ 31,905 line 22, col.8) line 20, col. 8)

TOTAL (agree to Schedule V, line 17, col. 3) $ E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar**(Attach a copy of any management service agreement) to Owners or EmployeesC. Professional Services Description Amount Vendor/Payee Type Amount Description Line # AmountHeritage Operations Group Mgt Fee $ 354,790 $ Out-of-State Travel $McQuellen Consulting R/E appeals 0

In-State Travel0

139

Seminar Expense 1,952

Central Office (92)Legal adj to Zero 1,035

Entertainment Expense ( )TOTAL (agree to Schedule V, line 19, column 3) TOTAL $ (agree to Sch. V,(If total legal fees exceed $5,000, attach copy of invoices.) $ 355,825 TOTAL line 24, col. 8) $ 1,999

* Attach copy of IMRF notifications **See instructions.

HFS 3745 (N-4-99) IL478-2471


XIX-H. SUPPORT SCHEDULE - DEFERRED MAINTENANCE COSTS (which have been included in Sch. V, line 6, col. 3). (See instructions.)

1 2 3 4 5 6 7 8 9 10 11 12 13Month & Year Amount of Expense Amortized Per Year

Improvement Improvement Total Cost UsefulType Was Made Life FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015

1 $ $ $ $ $ $ $ $ $ $23456789

10111213141516171819

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HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 23Facility Name & ID Number Heritage Manor-Streator # 0048066 Report Period Beginning: 1-01-10 Ending: 12-31-10XX. GENERAL INFORMATION:

(1) Are nursing employees (RN,LPN,NA) represented by a union? no (13) Have costs for all supplies and services which are of the type that can be billed tothe Department, in addition to the daily rate, been properly classified

(2) Are there any dues to nursing home associations included on the cost report? yes in the Ancillary Section of Schedule V? yesIf YES, give association name and amount. Illinois Health Care Association

(14) Is a portion of the building used for any function other than long term care services for(3) Did the nursing home make political contributions or payments to a political the patient census listed on page 2, Section B? yes For example,

action organization? yes If YES, have these costs is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attachbeen properly adjusted out of the cost report? yes a schedule which explains how all related costs were allocated to these functions.

(4) Does the bed capacity of the building differ from the number of beds licensed at the (15) Indicate the cost of employee meals that has been reclassified to employee benefitsend of the fiscal year? no If YES, what is the capacity? on Schedule V. $ 0 Has any meal income been offset against

related costs? yes Indicate the amount. $ 0(5) Have you properly capitalized all major repairs and equipment purchases? yes

What was the average life used for new equipment added during this period? 7yrs (16) Travel and Transportationa. Are there costs included for out-of-state travel? no

(6) Indicate the total amount of both disposable and non-disposable diaper expense If YES, attach a complete explanation.and the location of this expense on Sch. V. $ 5,000 Line 10 b. Do you have a separate contract with the Department to provide medical transportation for

residents? no If YES, please indicate the amount of income earned from such a(7) Have all costs reported on this form been determined using accounting procedures program during this reporting period. $

consistent with prior reports? yes If NO, attach a complete explanation. c. What percent of all travel expense relates to transportation of nurses and patients? 100%d. Have vehicle usage logs been maintained? yes

(8) Are you presently operating under a sale and leaseback arrangement? no e. Are all vehicles stored at the nursing home during the night and all otherIf YES, give effective date of lease. times when not in use? yes

f. Has the cost for commuting or other personal use of autos been adjusted(9) Are you presently operating under a sublease agreement? YES xx NO out of the cost report? yes

g. Does the facility transport residents to and from day training? no(10) Was this home previously operated by a related party (as is defined in the instructions for Indicate the amount of income earned from providing such

Schedule VII)? YES x NO If YES, please indicate name of the facility, transportation during this reporting period. $IDPH license number of this related party and the date the present owners took over.Heritage Manor Streator 38349 07/2006 (17) Has an audit been performed by an independent certified public accounting firm? yes

Firm Name: sulaski & webb(11) Indicate the amount of the Provider Participation Fees paid and accrued to the Department

during this cost report period. $ 71,175 (18) Have all costs which do not relate to the provision of long term care been adjusted outThis amount is to be recorded on line 42 of Schedule V. out of Schedule V? yes

(12) Are there any salary costs which have been allocated to more than one line on Schedule V (19) If total legal fees are in excess of $5,000, have legal invoices and a summary of servicesfor an individual employee? no If YES, attach an explanation of the allocation. performed been attached to this cost report? yes

Attach invoices and a summary of services for all architect and appraisal fees.

HFS 3745 (N-4-99) IL478-2471

Documents

HFS 3745 (N-4-99) IL478-2471 - Illinois.gov · 8 SNF 26,310 12,638 6,013 44,961 8 9 SNF/PED 9 Medicare Intermediary WPS 10 ICF 10 11 ICF/DD 11 IV. ACCOUNTING BASIS 12 SC 12 MODIFIED