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FOR BHF USELL12015STATE OF ILLINOISDEPARTMENT OF HEALTHCARE AND FAMILY SERVICESFINANCIAL AND STATISTICAL REPORT (COST REPORT)FOR LONG-TERM CARE FACILITIES(FISCAL YEAR 2015)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 the01/01/2015to12/31/2015State 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 LessTOTALS302110,23000302110,230B. Census-For the entire report period.12345Level of CarePatient Days by Level of Care and Primary Source of PaymentMedicaidRecipientPrivate 081,24368551,436ICF/DDSCDD 16 OR LESS14 TOTALS82,5142,072C. Percent Occupancy. (Column 5, line 14 divided by total licensedbed days on line 7, column 4.)83.22%HFS 3745 (N-4-99)7,152Page 2#0035014Report Period Beginning:01/01/2015Ending: 12/31/2015D. How many bed-hold days during this year were paid by the Department?0(Do not include bed-hold days in Section B.)91,738F. 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?03/01/89Date startedJ. 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 Intermediary4,761Wisconsin Physicians Service Insurance CorporationIV. ACCOUNTING BASISACCRUALXMODIFIEDCASH*Is your fiscal year identical to your tax year?CASH*YESXNOTax Year:12/31/15Fiscal Year:12/31/15* 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 8,097Food 6,33210,212143,566143,566Heat and Other 77169,864166,058351,693351,6938,802Other (specify):* Allocated Employee Benefits5871234567891010a1112131415TOTAL General Services1,040,702B. Health Care and ProgramsMedical DirectorNursing and Medical ial Services231,723CNA TrainingProgram TransportationOther (specify):* Allocated Employee Benefits16 TOTAL Health Care and Programs17181920212223242526275,893,898C. General AdministrationAdministrative148,370Directors FeesProfessional ServicesDues, Fees, Subscriptions & PromotionsClerical & General Office Expenses460,225Employee Benefits & Payroll TaxesInservice Training & EducationTravel and SeminarOther Admin. Staff TransportationInsurance-Prop.Liab.MalpracticeOther (specify):* Allocated Employee Benefits28 TOTAL General ,268360,495587Page 312/31/2015FOR BHF USE OTAL Operating Expense29 (sum of lines 8, 16 & ,698,875(1,421,672)14,277,203*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#0035014#Glen Bridge N & Rehab CentreReport Period Beginning:01/01/2015Ending:Page 412/31/2015V. COST CENTER EXPENSES (continued)30313233343536Capital ExpenseSalary/WageD. Ownership1DepreciationAmortization of Pre-Op. & Org.InterestReal Estate TaxesRent-Facility & GroundsRent-Equipment & VehiclesOther (specify):* Mortgage InsuranceCost Per General 7,704FOR BHF USE ,171,397)17,407,09645388,57444 TOTAL Special Cost 47,40722037 TOTAL OwnershipAncillary ExpenseE. Special Cost CentersMedically Necessary TransportationAncillary Service CentersBarber and Beauty ShopsCoffee and Gift ShopsProvider Participation FeeOther (specify):* RAND TOTAL COST45 (sum of lines 29, 37 & 44)7,543,195*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 Bridge N & Rehab Centre# 0035014Report Period Beginning:01/01/2015Ending:12/31/2015VI. 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(14,138) 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)(1,123,816)9 Non-Straightline Depreciation4,03930935 Other- Attach Schedule10 Interest and Other Investment Income1036 SUBTOTAL (B): (sum of lines 31-35) (1,123,816)11 Discounts, Allowances, Rebates & Refunds11(sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary1237 TOTAL ADJUSTMENTS (A) and (B) ) (2,171,397)13 Sales Tax(1,051) 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(500) 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(276,180) 43243925 Fund Raising, Advertising and Promotional(16,605) 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:(743,146)2945 Other-Attach ScheduleX30 SUBTOTAL (A): (Sum of lines 1-29) (1,047,581) 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:01/01/2015Ending:12/31/2015Page 5ANON-ALLOWABLE EXPENSES123456789Adjust Mgt Co. med supplies - med "A" to costAdjust 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 expenseAdjust pharmacy expense to cost101112131415161718Non-allowable patient clothingNon-allowable insurance reimbursementNon-allowable marketing salariesNon-allowable marketing employee benefitsAmount Sch. V 262728293031313232HFS 3745 (N-4-99)IL478-2471
44454647474849 Total4849HFS 3745 (N-4-99)(743,146)IL478-2471
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 6IReport Period Beginning:01/01/2015Ending:PAGE6HPAGE6ISummary 00000000000000000000000000000000SUMMARYTOTALS(to Sch V, col.7)0 1(151,035) 20 30 45,725 58,802 6587 7(135,921) 0(145,748)000000(412,621) 00000000000000000000000000000028 TOTAL General 73,130) 28TOTAL Operating Expense29 (sum of lines 8,16 & 28)(736,736)0(607,362)220(77,794)000000(1,421,672) 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 & 7IL478-2471
STATE OF ILLINOISFacility Name & ID NumberGlen Bridge N & Rehab Centre#0035014Report Period Beginning:Summary B12/31/201501/01/2015 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 CentersGRAND TOTAL COST45 (sum of lines 29, 37 & 44)HFS 3745 (N-4-99)PAGES5 & 0000000000000000000SUMMARYTOTALS(to Sch V, col.7)290,387 300 31472,278 32698,510 33(2,017,707) 347,537 3594,541 36(469,788)0000000(454,454) 000000000(158)000(295,113)008310000000(295,271) 440(577,285)000000(2,171,397) AGE6I383940414243IL478-2471
Facility Name & ID NumberGlen Bridge N & Rehab CentreSTATE OF ILLINOIS#0035014Report Period Beginning:01/01/2015Ending:Page 612/31/2015VII. 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.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) Total from Page 6A1,506,070Glen Health and Home Management, Inc.A928,785(577,285)Total from Page 6B2,017,707GlenBridge Real Estate and Development, L.L.C.B1,548,970(468,737)Total from Page 6C1,284,294Therapy Masters, Inc.C1,206,500(77,794)A: Sidney Glenner - 100.00% through attributionB: Sidney Glenner - 100.00% (constructively)A: Sidney Glenner - 100.00% 4,808,071 3,684,255 *12345678910111213(1,123,816) 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-Supplemental01/01/2015 Ending:12/31/2015VII. 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%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:01/01/2015Ending:Page 6A12/31/2015VII. 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 1,506,070Name 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 2)(112,792)A587587A11,43711,437A100,768100,768A - OWNERSHIP: Sidney Glenner - 100% through attribution 1,506,070 928,785 577,285) 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:01/01/2015Ending:Page 6B12/31/2015VII. 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 2,017,707Name 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 831 2,017,707)B220220B(581)(581)B94,54194,541B - OWNERSHIP:Sidney Glenner - 100.00% (constructively) 2,017,707 1,548,970 468,737) 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:01/01/2015Ending:Page 6C12/31/2015VII. 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 onal FeesLicenses, Permits, and InspectionRepairs and MaintenanceClericalEmployee Benefits and PayrollTraining and EducationAuto ExpensesEmployment FeesClerical SalariesEmployee BenefitsEmployee Benefits - TherapyEmployee Benefits - ClericalInsurance - LiabilityAmount 1,284,294Name 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.678 Difference:PercentOperating CostAdjustments forofof RelatedRelated OrganizationOwnershipOrganizationCosts (7 minus 4)C 1,039,843 25C - OWNERSHIP: 100.00% Sidney Glenner 1,284,294 1,206,500 77,794) 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:01/01/2015Ending:Page 712/31/2015VII. 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*192,24645,41356,59825,459192,2466Average Hours Per WorkWeek Devoted to thisFacility and % of TotalWork WeekHoursPercent10 16.62 %7 16.62 %45 90.00 %7 16.62 %10 16.62 %78Compensation Includedin Costs for thisReporting Period**DescriptionAmountSalary 54Schedule V.Line &ColumnReferenceLn 17, Co 7Ln 21, Co 7Ln21,Co1&7Ln 21, Co 7Ln 17, Co 7See Schedule B13TOTAL 158,37412345678910111213* 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# 0035014 Report Period Beginning:Glen Bridge N & Rehab CentrePage 801/01/2015Ending:2/31/2015VIII. 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 160611,1605Number ofSubunits BeingAllocated Among999999999999999 6Total IndirectCost 03,984,5606,187,5877Amount of SalaryCost Containedin Column 6 23,245452,4003,984,560 4,460,20589FacilityAllocationUnits(col.8/col.4)x col.691,738 ,90791,738598,101(112,792)58711,437100,768 478-2471
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-TermOppenheimer MHHF, Inc.Working CapitalSidney GlennerAMJED GST TrustTOTAL Facility RelatedB. Non-Facility Related*XXXPurpose of LoanMortgageMonthlyPaymentRequiredDate ofNote 79,367.32 5/1/2013Working CapitalWorking Capital7Amount of NoteOriginalBalance VariousVarious 79,367.326 01/01/2015Ending:89MaturityDateInterestRate(4 Digits)Page 993 18,697,575 6/01/20430.0260 657,75411,907,271657,75411,907,2710.052532,390,018 31,262,60010111213 Interest Income Offset:Non-allowable related party interest: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. 94,54131,262,600Line #491,6411234518,782678510,4239(581) 10(18,782) 111213 (19,363) 14 491,0601536* 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 1012/31/2015STATE 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:01/01/2015 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 2014 report. 685,00012. 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.
Facility Name & ID Number Glen Bridge N & Rehab Centre # 0035014 Report Period Beginning: 01/01/2015 Ending: 12/31/2015 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.)
