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FOR BHF USELL12014STATE OF ILLINOISDEPARTMENT OF HEALTHCARE AND FAMILY SERVICESFINANCIAL AND STATISTICAL REPORT (COST REPORT)FOR LONG-TERM CARE FACILITIES(FISCAL YEAR 2014)I.IDPH License ID Number:Facility Name:0022111II.CERTIFICATION BY AUTHORIZED FACILITY OFFICERGlen Oaks Nrsg & Rehab CtrAddress:270 Skokie HighwayNumberCounty:CookTelephone Number:(847) 498-9320NorthbrookCity60062Zip CodeIntentional misrepresentation or falsification of any informationin this cost report may be punishable by fine and/or imprisonment.Date of Initial License for Current Owners:12/01/1975Type of Ownership:VOLUNTARY,NON-PROFITCharitable Corp.I have examined the contents of the accompanying report to the01/01/2014to12/31/2014State of Illinois, for the period fromand certify to the best of my knowledge and belief that the said contentsare true, accurate and complete statements in accordance withapplicable instructions. Declaration of preparer (other than provider)is based on all information of which preparer has any knowledge.Fax # (847) 498-2990HFS ID Number:XPROPRIETARYIndividualTrustIRS Exemption " Corp.Limited Liability Co.TrustOtherIn the event there are further questions about this report, please contact:Name:Charles J. FischerTelephone Number:Email Address:HFS 3745 (N-4-99)IMPORTANT NOTICETHIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATIONTHAT IS NECESSARY TO ACCOMPLISH THE STATUTORYPURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSUREOF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDEANY INFORMATION ON OR BEFORE THE DUE DATE WILLRESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORMHAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.(312) 634-4580(Signed)Officer orAdministrator (Type or Print Name)of Provider(Title) PresidentCountyOther(Date)Sidney Glenner(Signed)(Date)PaidPreparer(Print Nameand Title)(Firm Name& Address)McGladrey LLPOne S. Wacker Drive, Suite 800, Chicago, IL 60606-4650(312) 384-6000Fax # (312) 634-5518(Telephone)MAIL TO: BUREAU OF HEALTH FINANCEILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICES201 S. Grand Avenue EastPhone # (217) 782-1630Springfield, IL 62763-0001IL478-2471
STATE OF ILLINOISFacility Name & ID NumberGlen Oaks Nrsg & Rehab CtrIII. STATISTICAL DATAA. Licensure/certification level(s) of care; enter number of beds/bed days,(must agree with license). Date of change in licensed beds12Beds atBeginning ofReport Period12345616413478910111213LicensureLevel of Care298N/AE. List all services provided by your facility for non-patients.(E.g., day care, "meals on wheels", outpatient therapy)None34Beds at End ofReport PeriodLicensedBed Days DuringReport PeriodSkilled (SNF)Skilled Pediatric (SNF/PED)Intermediate (ICF)Intermediate/DDSheltered Care (SC)ICF/DD 16 or LessTOTALS16459,86013448,910298108,770B. Census-For the entire report period.12345Level of CarePatient Days by Level of Care and Primary Source of PaymentMedicaidRecipientPrivate 781,654069,332ICF/DDSCDD 16 OR LESS14 TOTALS90,2382,205C. Percent Occupancy. (Column 5, line 14 divided by total licensedbed days on line 7, column 4.)86.98%HFS 3745 (N-4-99)2,162Page 2#0022111Report Period Beginning:01/01/2014Ending: 12/31/2014D. How many bed-hold days during this year were paid by the Department?0(Do not include bed-hold days in Section B.)94,605F. Does the facility maintain a daily midnight census?1234567YesG. Do pages 3 & 4 include expenses for services orinvestments not directly related to patient care?YESXNOH. Does the BALANCE SHEET (page 17) reflect any non-care assets?YESNOXI. On what date did you start providing long term care at this location?12/01/75Date startedJ. Was the facility purchased or leased after January 1, 1978?YESX Date 1/15/85NOK. Was the facility certified for Medicare during the reporting year?YESXNOIf YES, enter numberof beds certified150and days of care provided891011121314Medicare Intermediary1,362Wisconsin Physicians Service Insurance CorporationIV. ACCOUNTING BASISACCRUALXMODIFIEDCASH*Is your fiscal year identical to your tax year?CASH*YESXNOTax Year:12/31/14Fiscal Year:12/31/14* All facilities other than governmental must report on the accrual basis.IL478-2471
STATE OF ILLINOISFacility Name & ID NumberGlen Oaks Nrsg & Rehab Ctr#0022111Report Period Beginning:V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)Costs Per General LedgerReclassReclassifiedAdjustOperating lmentsA. General ,044Food ,10418,468165,459165,459Heat and Other 77341,81786,735269,325269,3259,576Other (specify):* Allocated Employee Benefits6251234567891010a1112131415TOTAL General Services1,179,907B. Health Care and ProgramsMedical DirectorNursing and Medical ial Services171,847CNA TrainingProgram TransportationOther (specify):* Allocated Employee Benefits16 TOTAL Health Care and Programs17181920212223242526274,620,875C. General AdministrationAdministrative198,619Directors FeesProfessional ServicesDues, Fees, Subscriptions & PromotionsClerical & General Office Expenses390,632Employee Benefits & Payroll TaxesInservice Training & EducationTravel and SeminarOther Admin. Staff TransportationInsurance-Prop.Liab.MalpracticeOther (specify):* Allocated Employee Benefits28 TOTAL General 044558,203458,835165,459264,033278,901625Page 312/31/2014FOR BHF USE 31(33,414)3,485,717(484,165)3,001,552TOTAL Operating Expense29 (sum of lines 8, 16 & ,666,519(760,955)10,905,564*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)Ending:2829IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS#0022111#Glen Oaks Nrsg & Rehab CtrReport Period Beginning:01/01/2014Ending:Page 412/31/2014V. COST CENTER EXPENSES (continued)30313233343536Capital ExpenseSalary/WageD. Ownership1DepreciationAmortization of Pre-Op. & Org.InterestReal Estate TaxesRent-Facility & GroundsRent-Equipment & VehiclesOther (specify):* Mortgage InsuranceCost Per General 2,338FOR BHF USE 1,26315,651,263(1,745,856)13,905,40745144,37944 TOTAL Special Cost CentersReclassification534,64537 TOTAL OwnershipAncillary ExpenseE. Special Cost CentersMedically Necessary TransportationAncillary Service CentersBarber and Beauty ShopsCoffee and Gift ShopsProvider Participation FeeOther (specify):* Non-AllowableTotal4130,973729,103383940414243GRAND TOTAL COST45 (sum of lines 29, 37 & 44)6,390,033*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 ILLINOISPage 5Facility Name & ID Number Glen Oaks Nrsg & Rehab Ctr# 0022111Report Period Beginning:01/01/2014Ending:12/31/2014VI. ADJUSTMENT DETAILA. 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.)123ReferBHF USEB. If there are expenses experienced by the facility which do not appear in theNON-ALLOWABLE EXPENSESAmountenceONLYgeneral ledger, they should be entered below.(See instructions.)1 Day Care 1122 Other Care for Outpatients2AmountReference3 Governmental Sponsored Special Programs331 Non-Paid Workers-Attach Schedule* 4 Non-Patient Meals432 Donated Goods-Attach Schedule*5 Telephone, TV & Radio in Resident Rooms(15,714) 215Amortization of Organization &6 Rented Facility Space633 Pre-Operating Expense7 Sale of Supplies to Non-Patients7Adjustments for Related Organization8 Laundry for Non-Patients834 Costs (Schedule VII)(1,283,100)9 Non-Straightline Depreciation5,17430935 Other- Attach Schedule10 Interest and Other Investment Income(11,083) 321036 SUBTOTAL (B): (sum of lines 31-35) (1,283,100)11 Discounts, Allowances, Rebates & Refunds11(sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary1237 TOTAL ADJUSTMENTS (A) and (B) ) (1,745,856)13 Sales Tax(2,341) 431314 Non-Care Related Interest14*These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions15licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation)16on these lines.17 Non-Care Related Fees1718 Fines and Penalties18C. Are the following expenses included in Sections A to D of pages 319 Entertainment19and 4? If so, they should be reclassified into Section E. Please20 Contributions(1,649) 4320reference the line on which they appear before reclassification.21 Owner or Key-Man Insurance21(See instructions.)123422 Special Legal Fees & Legal Retainers22Yes NoAmountReference23 Malpractice Insurance for Individuals2338 Medically Necessary Transport.X 24 Bad Debt(125,537) 43243925 Fund Raising, Advertising and Promotional2540 Gift and Coffee ShopsXIncome Taxes and Illinois Personal41 Barber and Beauty ShopsX26 Property Replacement Tax2642 Laboratory and RadiologyX27 CNA Training for Non-Employees2743 Prescription DrugsX28 Yellow Page Advertising2844 Exceptional Care ProgramX29 Other-Attach Schedule See Attached Schedule F:(311,606)2945 Other-Attach ScheduleX30 SUBTOTAL (A): (Sum of lines 1-29) (462,756) 3046 Other-Attach ScheduleX47 TOTAL (C): (sum of lines 38-46) BHF USE ONLY4849505152HFS 3745 71
STATE OF ILLINOISGlen Oaks Nrsg & Rehab CtrID#0022111Report Period Beginning:01/01/2014Ending:12/31/2014NON-ALLOWABLE EXPENSES123456789Adjust Mgt Co. medical supplies"A" to cost Adjust Mgt Co. medical supplies"other" to costAdjust Mgt Co. food to costNon-allowable professional feesNon-allowable patient clothingNon-allowable Illinois Council on Long Term Care DuesNon-allowable office expenseNon-allowable auto expense - marketingNon-allowable parking tickets101112131415161718Adjust pharmacy expense to costNon-allowable miscellaneous expenseNon-allowable insurance reimbursementNon-allowable marketing salariesNon-allowable marketing employee benefitsNon-allowable annual credit card feesPage 5AAmountSch. V 425262728293031313232HFS 3745 (N-4-99)IL478-2471
44454647474849 Total4849HFS 3745 (N-4-99)(311,606)IL478-2471
STATE OF ILLINOIS# 0022111Facility Name & ID Number Glen Oaks Nrsg & Rehab CtrSUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6IReport Period Beginning:01/01/2014Ending:PAGE6HPAGE6ISummary 0000000000000000000000000000SUMMARYTOTALS(to Sch V, col.7)0 1(66,329) 20 30 46,623 59,576 6625 7(49,505) 0(106,276)000000(227,285) 00000000000000000000028 TOTAL General 0(484,165) 28TOTAL Operating Expense29 (sum of lines 8,16 & ) 291234567891010a1112131415Operating ExpensesA. General ServicesDietaryFood PurchaseHousekeepingLaundryHeat and Other UtilitiesMaintenanceOther (specify):*TOTAL General ServicesB. Health Care and ProgramsMedical DirectorNursing and Medical RecordsTherapyActivitiesSocial ServicesCNA TrainingProgram TransportationOther (specify):*16 TOTAL Health Care and Programs1718192021222324252627C. General AdministrationAdministrativeDirectors FeesProfessional ServicesFees, Subscriptions & PromotionsClerical & General Office ExpensesEmployee Benefits & Payroll TaxesInservice Training & EducationTravel and SeminarOther Admin. Staff TransportationInsurance-Prop.Liab.MalpracticeOther (specify):*HFS 3745 (N-4-99)PAGES5 & IL478-2471
STATE OF ILLINOISFacility Name & ID NumberGlen Oaks Nrsg & Rehab Ctr#0022111Report Period Beginning:Summary B12/31/201401/01/2014 Ending:SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 632) 000(142)000(130,127)6880000000(130,269) 44000000(1,745,856) 30,815)00000000000044 TOTAL Special Cost Centers(130,957)00GRAND TOTAL COST45 (sum of lines 29, 37 & 44)(462,756)0(352,052)383940414243Ancillary ExpenseE. Special Cost CentersMedically Necessary TransportationAncillary Service CentersBarber and Beauty ShopsCoffee and Gift ShopsProvider Participation FeeOther (specify):*HFS 3745 5,173(2,770,573)0185,90037 TOTAL OwnershipPAGES5 & 5A5,1740(11,083)0000SUMMARYTOTALS(to Sch V, col.7)161,365 300 31951,094 32608,035 33(2,770,573) 349,547 35185,900 36PAGE6A14,8790012,86209,547030313233343536Capital ExpenseD. OwnershipDepreciationAmortization of Pre-Op. & Org.InterestReal Estate TaxesRent-Facility & GroundsRent-Equipment & VehiclesOther 6GPAGE6HPAGE6I383940414243IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS#0022111Glen Oaks Nrsg & Rehab CtrReport Period Beginning:01/01/2014Ending:Page 612/31/2014VII. RELATED PARTIESA. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.123OWNERSRELATED NURSING HOMESOTHER RELATED BUSINESS ENTITIESNameOwnership %NameCityNameCityType of BusinessSidney Glenner100.00%See Page 6-SupplementalSee Attached Schedule AB. 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 YESNOIf 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.123 Cost Per General Ledger45 Cost to Related OrganizationSchedule VVVVVVVVVVVVVV14 Total12345678910111213LineItemAmountName of Related Organization6PercentofOwnership 7Operating Costof RelatedOrganization 8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) From Page 6A1,313,240Glen Health and Home Management, Inc.A961,188(352,052)From Page 6B2,770,573Glen Oaks Real Estate and Development, L.L.C.B1,919,995(850,578)From Page 6C577,846Therapy Masters, Inc.C497,376(80,470)OWNERSHIP REFERENCE:A - Sidney Glenner - 100.00 % through attributionB - Sidney Glenner - 100.00 %C - Sidney Glenner - 100.00 % 4,661,659 3,378,559 *12345678910111213(1,283,100) 14* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberGlen Oaks Nrsg & Rehab CtrSTATE OF ILLINOIS#0022111Report Period Beginning:Page 6-Supplemental01/01/2014 Ending:12/31/2014VII. RELATED PARTIESA. (Continued)Enter below the names of ALL owners and related organizations (parties) as defined in the instructions.123OWNERSRELATED NURSING HOMESOTHER RELATED BUSINESS ENTITIESNameOwnership %NameCityNameCityType of 627282930Sidney Glenner100.00 %GlenBridge Nursing & RehabilitationCentre, Ltd.NilesSidney Glenner100.00 %GlenCrest Nursing & RehabilitationCentre, Ltd.ChicagoSidney Glenner100.00 %Glen Elston Nursing & RehabilitationCentre, Ltd.ChicagoSidney Glenner100.00 %GlenShire Nursing & RehabilitationCentre, Ltd.Richton ParkSidney GlennerJoshua Ray80.00 %20.00 %GlenLake Terrace Nursing & RehabilitationCentre, Ltd.WaukeganSidney GlennerJoshua Ray99.00 %1.00 %Brentwood North Healthcare & Rehabilitation RiverwoodsCentre, Inc.HFS 3745 (N-4-99)See Attached Schedule 30IL478-2471
Facility Name & ID NumberGlen Oaks Nrsg & Rehab CtrSTATE OF ILLINOIS#0022111Report Period Beginning:01/01/2014Ending:Page 6A12/31/2014VII. 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.X YESNOIf 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.123 Cost Per General Ledger45 Cost to Related OrganizationSchedule VLineVVVVVVVVVVVVVVVVVVVVVVVV39 ent FeesUtilitiesRepairs and MaintenanceProfessional FeesLicenses, Permits and InspectionClericalEmployee Benefits and PayrollTraining and EducationAuto ExpensesInsuranceDepreciationReal Estate TaxesEquipment and Vehicle RentalJanitorial SalariesOfficer's SalariesAdministrative SalariesEmployee BenefitsEmployee Benefits - JanitorialEmployee Benefits - Officer'sEmployee Benefits - AdminAmount 1,313,240 1,313,240Name of Related OrganizationGlen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.Glen Health and Home Management, Inc.678 Difference:PercentOperating CostAdjustments forofof RelatedRelated OrganizationOwnershipOrganizationCosts (7 minus 4)A ,211)A625625A5,9195,919A97,66797,667 961,188 352,052) 39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberGlen Oaks Nrsg & Rehab CtrSTATE OF ILLINOIS#0022111Report Period Beginning:01/01/2014Ending:Page 6B12/31/2014VII. 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.X YESNOIf 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.123 Cost Per General Ledger45 Cost to Related OrganizationSchedule VLineVVVVVVVVVVVVVVVVVVVVVVVV39 9303132333435363738ItemProfessional FeesOffice ExpenseDepreciationInterest ExpenseInterest IncomeMortgage Insurance PremiumReal Estate TaxesRental IncomeAmount 2,770,573 2,770,573Name of Related OrganizationGlen Oaks Real Estate and Development, L.L.C.Glen Oaks Real Estate and Development, L.L.C.Glen Oaks Real Estate and Development, L.L.C.Glen Oaks Real Estate and Development, L.L.C.Glen Oaks Real Estate and Development, L.L.C.Glen Oaks Real Estate and Development, L.L.C.Glen Oaks Real Estate and Development, L.L.C.Glen Oaks Real Estate and Development, L.L.C.678 Difference:PercentOperating CostAdjustments forofof RelatedRelated OrganizationOwnershipOrganizationCosts (7 minus 4)B 34,807 )(4,016)B185,900185,900B595,173595,173B(2,770,573) 1,919,995 850,578) 39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS#0022111Glen Oaks Nrsg & Rehab CtrReport Period Beginning:01/01/2014Ending:Page 6C12/31/2014VII. 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.X YESNOIf 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.123 Cost Per General Ledger45 Cost to Related OrganizationSchedule VLineVVVVVVVVVVVVVVVVVVVVVVVV39 sional FeesLicenses, Permits and InspectionRepairs and MaintenanceClerical SalariesClericalEmployee Benefits and PayrollTraining and EducationAuto ExpensesEmployment FeesEmployee BenefitsEmployee Benefits - TherapyEmployee Benefits - ClericalDepreciationInsurance - LiabilityAmount 577,846 577,846Name of Related OrganizationTherapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.Therapy Masters, Inc.678 Difference:PercentOperating CostAdjustments forofof RelatedRelated OrganizationOwnershipOrganizationCosts (7 minus 4)C 434,137 32)C37,43337,433C199199C6262C486486 497,376 80,470) 39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS#0022111Glen Oaks Nrsg & Rehab CtrReport Period Beginning:01/01/2014Ending:Page 712/31/2014VII. 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 homemust be listed on this schedule.1Name123456789101112Sidney GlennerJonathan GlennerDaniel GlennerElliot GlennerJoshua tiveV.P. of st100.00 %0.00 %0.00 %0.00 %0.00 %CompensationReceivedFrom OtherNursing Homes*181,38044,18024,73657,117181,3806Average Hours Per WorkWeek Devoted to thisFacility and % of TotalWork WeekHoursPercent12 19.36 %8 19.36 %12.00 %8 19.36 %12 19.36 %78Compensation Includedin Costs for thisReporting Period**DescriptionAmountSalary 00Schedule V.Line &ColumnReferenceLn 17, Col 7Ln 21, Col 7Ln 21, Col 7Ln 21, Col 7Ln 21, Col 7See Attached Schedule B13TOTAL 106,71512345678910111213* 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 COMPENSATIONHFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS# 0022111 Report Period Beginning:Glen Oaks Nrsg & Rehab CtrPage 801/01/2014Ending:2/31/2014VIII. ALLOCATION OF INDIRECT COSTSName of Related OrganizationGlen Health and Home Management, Inc.Street Address5454 West Fargo AvenueCity / State / Zip CodeSkokie, IL 60077Phone Number( 847) 674-5454Fax Number( 847) 674-8311A. Are there any costs included in this report which were derived from allocations of central officeor parent organization costs? (See instructions.)YES XNOB. Show the allocation of costs below. If necessary, please attach worksheets.1Schedule 345678910111213141516171819202122232425 TOTALS3Unit of Allocation(i.e.,Days, Direct Cost,ItemSquare Feet)UtilitiesResident DaysRepairs and MaintenanceResident DaysProfessional FeesResident DaysLicenses, Permits and Inspection Resident DaysClericalResident DaysEmployee Benefits and PayrollResident DaysTraining and EducationResident DaysAuto ExpensesResident DaysInsuranceResident DaysDepreciationResident DaysReal Estate TaxesResident DaysEquipment and Vehicle RentalResident DaysJanitorial SalariesResident DaysOfficer's SalariesResident DaysAdministrative SalariesResident DaysEmployee BenefitsPayrollEmployee Benefits - JanitorialPayrollEmployee Benefits - Officer'sPayrollEmployee Benefits - AdminPayrollHFS 3745 (N-4-99)24Total 928527,9285Number ofSubunits BeingAllocated Among777777777777777 6Total IndirectCost 643,3585,363,7497Amount of SalaryCost Containedin Column 6 22,970220,9803,643,358 3,887,30889FacilityAllocationUnits(col.8/col.4)x col.694,605 094,605652,892(104,211)6255,91997,667 478-2471
Facility Name & ID NumberSTATE OF ILLINOIS# 0022111Report Period Beginning:Glen Oaks Nrsg & Rehab CtrIX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSEA. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)12345Name of Lender12345A. Directly Facility RelatedLong-TermOppenheimer MHHF, Inc.Related**YES NOXPurpose of LoanMortgageMonthlyPaymentRequiredDate ofNote 150,300.68 5/1/201367Amount of NoteOriginalBalance 38,021,826 01/01/2014Ending:89MaturityDateInterestRate(4 Digits)36,776,488 1/01/2044Page 912/31/201410ReportingPeriodInterestExpense0.0260 966,19312345Working Capital6789678TOTAL Facility RelatedB. Non-Facility Related* 150,300.68 38,021,826 36,776,48810111213 Interest Income Offset:14 TOTAL Non-Facility Related 15 38,021,826 TOTALS (line 9 line14)16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. 185,90036,776,488Line #966,1939(15,099) 10111213 (15,099) 14 951,0941536* 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
Page 1012/31/2014STATE OF ILLINOISFacility Name & ID Number Glen Oaks Nrsg & Rehab CtrIX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued)B. Real Estate Taxes#0022111Report Period Beginning:01/01/2014 Ending:Important, please see the next worksheet, "RE Tax". The real estate taxstatement and bill must accompany the cost report.1. Real Estate Tax accrual used on 2013 report. 585,00012. 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.) 578,17323. Under or (over) accrual (line 2 minus line 1). 4. Real Estate Tax accrual used for 2014 report. (Detail and explain your calculation of this accrual on the lines below.) 602,0004(Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) 34,64556. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costsclassified as a real estate tax cost
Facility Name & ID Number Glen Oaks Nrsg & Rehab Ctr # 0022111 Report Period Beginning: 01/01/2014 Ending: 12/31/2014 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.)
