Transcription
FOR BHF USELL12016STATE OF ILLINOISDEPARTMENT OF HEALTHCARE AND FAMILY SERVICESFINANCIAL AND STATISTICAL REPORT (COST REPORT)FOR LONG-TERM CARE FACILITIES(FISCAL YEAR 2016)I.IDPH License ID Number:Facility Name:0035014II.CERTIFICATION BY AUTHORIZED FACILITY OFFICERGlen Bridge N & Rehab CentreAddress:8333 West Golf RoadNumberCounty:CookTelephone Number:(847) 966-9190NilesCity60714Zip 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:3/01/1989Type of Ownership:VOLUNTARY,NON-PROFITCharitable Corp.I have examined the contents of the accompanying report to the01/01/2016to12/31/2016State 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) 966-4455HFS 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)RSM US 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 Bridge N & Rehab CentreIII.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 Period123456302078910111213LicensureLevel of Care302302E. 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 LessTOTALS302110,53200302110,532B. Census-For the entire report period.12345Level of CarePatient Days by Level of Care and Primary Source of PaymentMedicaidRecipientPrivate ,3932,117048,509ICF/DDSCDD 16 OR LESS14 TOTALS77,3213,528C. Percent Occupancy. (Column 5, line 14 divided by total licensedbed days on line 7, column 4.)78.32%HFS 3745 (N-4-99)5,722Page 2#0035014Report Period Beginning:01/01/2016Ending: 12/31/2016D. How many bed-hold days during this year were paid by the Department?0(Do not include bed-hold days in Section B.)86,571F. 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?Date started03/01/89J. Was the facility purchased or leased after January 1, 1978?YESX Date 03/01/89NOK. Was the facility certified for Medicare during the reporting year?YESXNOIf YES, enter numberof beds certified302and days of care provided891011121314Medicare Intermediary4,357Wisconsin Physicians Service Insurance CorporationIV. ACCOUNTING BASISACCRUALXMODIFIEDCASH*Is your fiscal year identical to your tax year?CASH*YESXNOTax Year:12/31/16Fiscal Year:12/31/16* All facilities other than governmental must report on the accrual basis.IL478-2471
STATE OF ILLINOISFacility Name & ID NumberGlen Bridge N & Rehab Centre#0035014Report Period Beginning:V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)Costs Per General LedgerReclassReclassifiedAdjustOperating lmentsA. General 4,085Food ,7808,904134,754134,754Heat and Other 48846,577147,586309,651309,65112,295Other (specify):* Allocated Employee Benefits6541234567891010a1112131415TOTAL General Services1,007,742B. Health Care and ProgramsMedical DirectorNursing and Medical ial Services227,468CNA TrainingProgram TransportationOther (specify):* Allocated Employee Benefits16 TOTAL Health Care and Programs17181920212223242526276,075,312C. General AdministrationAdministrative68,246Directors FeesProfessional ServicesDues, Fees, Subscriptions & PromotionsClerical & General Office Expenses610,190Employee Benefits & Payroll TaxesInservice Training & EducationTravel and SeminarOther Admin. Staff TransportationInsurance-Prop.Liab.MalpracticeOther (specify):* Allocated Employee 8,549326,726134,754285,413321,946654Ending:Page 312/31/2016FOR BHF USE )15,959,936(1,137,344)14,822,592*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.2928 TOTAL General (5,009)2,120(2,120)31,17326,164TOTAL Operating Expense29 (sum of lines 8, 16 & 28)HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS#0035014#Glen Bridge N & Rehab CentreReport Period Beginning:01/01/2016Ending:Page 412/31/2016V. COST CENTER EXPENSES (continued)30313233343536Capital ExpenseSalary/WageD. Ownership1DepreciationAmortization of Pre-Op. & Org.InterestReal Estate TaxesRent-Facility & GroundsRent-Equipment & VehiclesOther (specify):* Mortgage InsuranceCost Per General 5325,009383940414243GRAND TOTAL COST45 (sum of lines 29, 37 & 59FOR BHF USE 822,189,998(4,149,265)18,040,73345404,61944 TOTAL Special Cost CentersReclassifiedTotal6274,6222,054,35667,76337 TOTAL OwnershipAncillary ExpenseE. Special Cost CentersMedically Necessary TransportationAncillary Service CentersBarber and Beauty ShopsCoffee and Gift ShopsProvider Participation FeeOther ch 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 Bridge N & Rehab Centre# 0035014Report Period Beginning:01/01/2016Ending:12/31/2016VI. 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(16,424) 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)(905,960)9 Non-Straightline Depreciation(4,040) 30935 Other- Attach Schedule10 Interest and Other Investment Income1036 SUBTOTAL (B): (sum of lines 31-35) (905,960)11 Discounts, Allowances, Rebates & Refunds11(sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary1237 TOTAL ADJUSTMENTS (A) and (B) ) (4,149,265)13 Sales Tax(910) 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 Entertainment(500) 4319and 4? If so, they should be reclassified into Section E. Please20 Contributions(5,000) 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(2,510,588) 43243925 Fund Raising, Advertising and Promotional(21,520) 432540 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 Advertising2844X29 Other-Attach Schedule See Attached Schedule F:(684,323)2945 Other-Attach ScheduleX30 SUBTOTAL (A): (Sum of lines 1-29) (3,243,305) 3046 Other-Attach ScheduleX47 TOTAL (C): (sum of lines 38-46) BHF USE ONLY4849505152HFS 3745 71
STATE OF ILLINOISGlen Bridge N & Rehab CentreID#0035014Report Period Beginning:01/01/2016Ending:12/31/2016NON-ALLOWABLE EXPENSES123456789Adjust Mgt Co. med supplies - med "A" to cost Adjust Mgt Co. med supplies - "other" to costAdjust Mgt Co. food to costNon-allowable professional feesNon-allowable auto expense - marketingNon-allowable clerical expenseNon-allowable IL Council on Long Term Care FeeNon-allowable related party interest expenseNon-allowable patient clothing10 Non-allowable marketing salaries11 Non-allowable marketing employee benefits12 Non-allowable patient storage131415161718Page 5AAmountSch. V 41424344454647474849 TotalHFS 3745 (N-4-99)(684,323)4849IL478-2471
STATE OF ILLINOIS# 0035014Facility Name & ID Number Glen Bridge N & Rehab CentreSUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6IOperating ExpensesA. General ServicesDietaryFood PurchaseHousekeepingLaundryHeat and Other UtilitiesMaintenanceOther (specify):*TOTAL General ServicesB. Health Care and ProgramsMedical DirectorNursing and Medical RecordsTherapyActivitiesSocial ServicesCNA TrainingProgram TransportationOther (specify):*PAGES5 & ,852)000000(180,652) 927,133) 28(462,515)10,009(20,782)000000(1,137,344) 335141,43928 TOTAL General Administration(514,962)0TOTAL Operating Expense29 (sum of lines 8,16 & 28)(664,056)016 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 41501/01/2016SUMMARYTOTALS(to Sch V, col.7)0 1(48,294) 20 30 45,786 512,295 6654 7(29,559) 80(48,294)00000(48,294)12345678Report Period Beginning:Summary 324252627IL478-2471
STATE OF ILLINOISFacility Name & ID NumberGlen Bridge N & Rehab Centre#0035014Report Period Beginning:Summary B12/31/201601/01/2016 Ending:SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I30313233343536Capital ExpenseD. OwnershipDepreciationAmortization of Pre-Op. & Org.InterestReal Estate TaxesRent-Facility & GroundsRent-Equipment & VehiclesOther (specify):*37 TOTAL Ownership383940414243Ancillary ExpenseE. Special Cost CentersMedically Necessary TransportationAncillary Service CentersBarber and Beauty ShopsCoffee and Gift ShopsProvider Participation FeeOther (specify):*44 TOTAL Special Cost CentersPAGES5 & 000000000000000000000SUMMARYTOTALS(to Sch V, col.7)283,637 300 31444,629 32744,582 33(2,054,356) 3417,099 3592,209 36(474,954)0000000(472,200) 0000000000000(2,539,721)009560000000(2,539,721) 440(421,189)000000(4,149,265) 3GRAND TOTAL COST45 (sum of lines 29, 37 & 44)HFS 3745 (N-4-99)(463,989)(20,782)IL478-2471
Facility Name & ID NumberGlen Bridge N & Rehab CentreSTATE OF ILLINOIS#0035014Report Period Beginning:01/01/2016Ending:Page 612/31/2016VII. 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 Glenner100.00See 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.45 Cost to Related Organization123 Cost Per General LedgerSchedule VVVVVVVVVVVVVV14 Total12345678910111213LineItemAmountName of Related Organization6PercentofOwnership 7Operating Costof RelatedOrganization 8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) Total from Page 6A1,506,072Glen Health and Home Management, Inc.A1,084,883Total from Page 6B2,054,356GlenBridge Real Estate and Development, L.L.C.B1,590,367Total from Page 6C1,223,624Therapy Masters, Inc.C1,202,842A: Sidney Glenner - 100.00% through attributionB: Sidney Glenner - 100.00% (constructively)A: Sidney Glenner - 100.00% 4,784,052 3,878,092 *123(463,989) 45(20,782) 678910111213(421,189)(905,960) 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 Bridge N & Rehab CentreSTATE OF ILLINOIS#0035014Report Period Beginning:Page 6-Supplemental01/01/2016 Ending:12/31/2016VII. RELATED PARTIESA. (Continued)Enter below the names of ALL owners and related organizations (parties) as defined in the instructions123OWNERSRELATED NURSING HOMESOTHER RELATED BUSINESS ENTITIESNameOwnership %NameCityNameCityType of 627282930Sidney Glenner100.00%GlenCrest Nursing & RehabilitationCentre, Ltd.ChicagoSidney Glenner100.00%Glen Elston Nursing & RehabilitationCentre, Ltd.ChicagoSidney Glenner100.00%Glen Oaks Nursing & RehabilitationCentre, Ltd.NorthbrookSidney 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, Ltd.Sidney GlennerJoshua Ray50.00 %50.00 %Ballard Respiratory & RehabilitationCenter, LLC.Des PlainesSidney GlennerJoshua Ray50.00 %50.00 %Glen Saint Andrew Living Community, LLC.NilesHFS 3745 (N-4-99)See Attached Schedule 30IL478-2471
Facility Name & ID NumberGlen Bridge N & Rehab CentreSTATE OF ILLINOIS#0035014Report Period Beginning:01/01/2016Ending:Page 6A12/31/2016VII. 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 ExpenseInsuranceDepreciationReal Estate TaxesEquipment and Vehicle RentalJanitorial SalariesOfficer's SalariesAdministrative SalariesEmployee BenefitsEmployee Benefits - JanitorialEmployee Benefits - Officer'sEmployee Benefits - AdminAmount 1,506,072Name 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 A - OWNERSHIP: Sidney Glenner - 100% through attribution 1,506,072 1,084,883 421,189) 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 Bridge N & Rehab CentreSTATE OF ILLINOIS#0035014Report Period Beginning:01/01/2016Ending:Page 6B12/31/2016VII. 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 t ExpenseReal Estate TaxesRentalProfessional FeesInterest IncomeMortgage Insurance PremiumAmount 2,054,356Name of Related OrganizationGlenBridge Real Estate & Development, L.L.C.GlenBridge Real Estate & Development, L.L.C.GlenBridge Real Estate & Development, L.L.C.GlenBridge Real Estate & Development, L.L.C.GlenBridge Real Estate & Development, L.L.C.GlenBridge Real Estate & Development, L.L.C.GlenBridge Real Estate & Development, L.L.C.GlenBridge Real Estate & Development, L.L.C.678 Difference:PercentOperating CostAdjustments forofof RelatedRelated OrganizationOwnershipOrganizationCosts (7 minus 4)B 956 2,054,356)B10,00910,009B(357)(357)B92,20992,209B - OWNERSHIP:Sidney Glenner - 100.00% (constructively) 2,054,356 1,590,367 463,989) 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 Bridge N & Rehab CentreSTATE OF ILLINOIS#0035014Report Period Beginning:01/01/2016Ending:Page 6C12/31/2016VII. 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 al FeesLicenses, Permits, and InspectionRepairs and MaintenanceClericalEmployee Benefits and PayrollTraining and EducationAuto ExpensesClerical SalariesEmployee BenefitsEmployee Benefits - TherapyEmployee Benefits - ClericalInsurance - LiabilityAmount 1,223,624Name 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.678 Difference:PercentOperating CostAdjustments forofof RelatedRelated OrganizationOwnershipOrganizationCosts (7 minus 4)C 1,036,374 ,635)(107,635)C107,398107,398C237237C1,5701,570C - OWNERSHIP: 100.00% Sidney Glenner 1,223,624 1,202,842 20,782) 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#0035014Glen Bridge N & Rehab CentreReport Period Beginning:01/01/2016Ending:Page 712/31/2016VII. 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 Glenner2TitleChairman of BoardClericalPresidentDir of ativeAdministrative45OwnershipInterest100.00 %0.00 %0.00 %0.00 %CompensationReceivedFrom OtherNursing Homes*197,09445,842164,94177,8986Average Hours Per WorkWeek Devoted to thisFacility and % of TotalWork WeekHoursPercent10 16.62 %7 16.62 %7 16.62 %7 16.62 %78Compensation Includedin Costs for thisReporting Period**DescriptionAmountSalary 34,327Salary7,984Salary28,727Salary13,568Schedule V.Line &ColumnReferenceLn 17, Co 7Ln 21, Co 7Ln 21, Co 7Ln 21, Co 7See Schedule B13TOTAL 84,60613* 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)123456789101112IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS# 0035014 Report Period Beginning:Glen Bridge N & Rehab CentrePage 801/01/2016Ending:2/31/2016VIII. ALLOCATION OF INDIRECT COSTSName of Related OrganizationStreet AddressCity / State / Zip CodePhone NumberFax NumberA. 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 629583,6295Number ofSubunits BeingAllocated Among999999999999999 6Total IndirectCost 4205,055,3427,313,873Glen Health and Home Management, Inc.5454 West Fargo AvenueSkokie, IL 60077( 847) 674-5454( 847) 674-83117Amount of SalaryCost Containedin Column 6 24,431231,4205,055,342 5,311,19389FacilityAllocationUnits(col.8/col.4)x col.686,571 134,32786,571749,870(142,093)6546,195135,244 2122232425
Facility Name & ID NumberSTATE OF ILLINOIS# 0035014Report Period Beginning:Glen Bridge N & Rehab CentreIX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSEA. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)12345Name of Lender123456789Related**YES NOA. Directly Facility RelatedLong-TermWalker & Dunlop, LLCWorking CapitalSidney GlennerAMJED GST TrustTOTAL Facility RelatedB. Non-Facility Related*XXXPurpose of LoanMortgageMonthlyPaymentRequiredDate ofNote 79,367.32 5/1/2013Working CapitalWorking Capital7Amount of NoteOriginalBalance VariousVarious 79,367.32619,824,993 657,75411,907,271 01/01/2016Ending:89MaturityDateInterestRate(4 Digits)18,225,706 6/01/2043Page 912/31/201610ReportingPeriodInterestExpense0.0260 657,7540.052511,907,271Non-allowable related party interest:32,390,018 30,790,73110111213 Interest Income Offset:14 TOTAL Non-Facility Related 15 32,390,018 TOTALS (line 9 line14)16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. 92,209Line #1234534,532(34,532)678479,5189(357) 10111213 30,790,731479,518 (357) 14479,1611536* 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 1012/31/2016STATE OF ILLINOISFacility Name & ID Number Glen Bridge N & Rehab CentreIX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued)B. Real Estate Taxes#0035014Report Period Beginning:01/01/2016 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 2015 report. 697,00012. 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.) 701,14823. Under or (over) accrual (line 2 minus line 1). 4,14834. Real Estate Tax accrual used for 2016 report. (Detail and explain your calculation of this accrual on the lines be
Facility Name & ID Number Glen Bridge N & Rehab Centre # 0035014 Report Period Beginning: 01/01/2016 Ending: 12/31/2016 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.)
