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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:0010637II.CERTIFICATION BY AUTHORIZED FACILITY OFFICERLasalle County Nursing HomeAddress:1380 North 27th RdNumberCounty:LasalleTelephone Number:(815) 433-0476OttawaCity61350Zip CodeDate of Initial License for Current Owners:Intentional misrepresentation or falsification of any informationin this cost report may be punishable by fine and/or imprisonment.1945Type of Ownership:VOLUNTARY,NON-PROFITCharitable Corp.TrustIRS Exemption CodeI have examined the contents of the accompanying report to the12/01/15to11/30/16State 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 # (815) 433-7141HFS ID n"Sub-S" Corp.Limited Liability Co.TrustOtherIn the event there are further questions about this report, please contact:Name: Steven N. LavendaTelephone 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.GOVERNMENTALStateX(847) 282-6300(Signed)Officer orAdministrator (Type or Print Name)of Provider(Title)CountyOther(Signed)** Subject to the attached Accountants Consulting ReportPaidPreparer(Date)(Date)(Print Nameand Title)(Firm Name& Address)Marcum, LLP111 Pfingsten Road, Suite 300 Deerfield, IL 60015(847) 282-6300Fax #(847) 282-6301(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 NumberLasalle County Nursing HomeIII.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 Period1234569178910111213LicensureLevel of Care91N/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 LessTOTALS919133,30633,306B. Census-For the entire report period.12345Level of CarePatient Days by Level of Care and Primary Source of PaymentMedicaidRecipientPrivate F/DDSCDD 16 OR LESS14 TOTALS13,4047,768C. Percent Occupancy. (Column 5, line 14 divided by total licensedbed days on line 7, column 4.)69.15%HFS 3745 (N-4-99)1,859Page 2#0010637Report Period Beginning:12/01/15Ending:11/30/16D. How many bed-hold days during this year were paid by the Department?None(Do not include bed-hold days in Section B.)23,031F. Does the facility maintain a daily midnight census?1234567YesG. Do pages 3 & 4 include expenses for services orinvestments not directly related to patient care?YESNOXH. 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 started11/01/1965J. Was the facility purchased or leased after January 1, 1978?YESDateNOXK. Was the facility certified for Medicare during the reporting year?YESXNOIf YES, enter numberof beds certified91and days of care provided891011121314Medicare Intermediary1,784National Government ServicesIV. ACCOUNTING BASISACCRUALXMODIFIEDCASH*Is your fiscal year identical to your tax year?CASH*YESXNOTax Year:11/30/16Fiscal Year:11/30/16* All facilities other than governmental must report on the accrual basis.IL478-2471
STATE OF ILLINOISFacility Name & ID NumberLasalle County Nursing Home#0010637Report Period Beginning:V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)Costs Per General LedgerReclassReclassifiedAdjustOperating lmentsA. General Services1234567DietaryFood 340182,340Heat and Other 557,720679,560679,560(393,743)Other (specify):*1234567891010a1112131415TOTAL General ServicesB. Health Care and ProgramsMedical DirectorNursing and Medical RecordsTherapyActivitiesSocial ServicesCNA TrainingProgram TransportationOther (specify):*16 TOTAL Health Care and Programs1718192021222324252627C. General AdministrationAdministrativeDirectors FeesProfessional ServicesDues, Fees, Subscriptions & PromotionsClerical & General Office ExpensesEmployee Benefits & Payroll TaxesInservice Training & EducationTravel and SeminarOther Admin. Staff TransportationInsurance-Prop.Liab.MalpracticeOther (specify):*28 TOTAL General AdministrationTOTAL Operating 147,650237,65022,90122,901HFS 3745 (N-4-99)AdjustedTotal8FOR BHF USE 34,140205,693*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.29 (sum of lines 8, 16 & 28)Ending:1,467,03590,000(77,189)Page 83329IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS#0010637#Lasalle County Nursing HomeReport Period g:Page 411/30/16V. COST CENTER EXPENSES (continued)30313233343536Capital ExpenseD. OwnershipDepreciationAmortization of Pre-Op. & Org.InterestReal Estate TaxesRent-Facility & GroundsRent-Equipment & VehiclesOther (specify):*Salary/Wage1Cost Per General 344768,6612,256,1246,071,8076,071,8076,334,1804537 TOTAL Ownership383940414243Ancillary ExpenseE. Special Cost CentersMedically Necessary TransportationAncillary Service CentersBarber and Beauty ShopsCoffee and Gift ShopsProvider Participation FeeOther (specify):*34,38544 TOTAL Special Cost CentersGRAND TOTAL COST45 (sum of lines 29, 37 & 44)3,047,022Reclassification5262,373FOR BHF USE ONLY9103031323334353637*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 Lasalle County Nursing Home# 0010637Report Period Beginning:12/01/15Ending:11/30/16VI. 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(8,585) 205Amortization 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)672,1259 Non-Straightline Depreciation70,82430935 Other- Attach Schedule10 Interest and Other Investment Income1036 SUBTOTAL (B): (sum of lines 31-35) 672,12511 Discounts, Allowances, Rebates & Refunds11(sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary1237 TOTAL ADJUSTMENTS (A) and (B) ) 262,37313 Sales Tax021314 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 Contributions20reference 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. 24 Bad Debt243925 Fund Raising, Advertising and Promotional2540 Gift and Coffee ShopsIncome Taxes and Illinois Personal41 Barber and Beauty Shops26 Property Replacement Tax2642 Laboratory and Radiology27 CNA Training for Non-Employees2743 Prescription Drugs28 Yellow Page Advertising284429 Other-Attach Schedule(471,991)2945 Other-Attach Schedule30 SUBTOTAL (A): (Sum of lines 1-29) (409,752) 3046 Other-Attach Schedule47 TOTAL (C): (sum of lines 38-46) BHF USE ONLY4849505152HFS 3745 71
STATE OF ILLINOISLasalle County Nursing HomeID#0010637Report Period Beginning:12/01/15Ending:11/30/16Page 5ANON-ALLOWABLE EXPENSES123456789MarketingPatient Insurance PaymentsRefundsChamber of CommerceJury Duty IncomeMiscellaneous IncomeCapitalized R&MPAC DuesAmount 06)Sch. V 36373839404142434445464041424344454647474849 TotalHFS 3745 (N-4-99)(471,991)4849IL478-2471
STATE OF ILLINOISLasalle County Nursing HomeID#0010637Report Period Beginning:12/01/15Ending:11/30/16Page 5BNON-ALLOWABLE 969798 TotalHFS 3745 (N-4-99)Amount Sch. V 49IL478-2471
STATE OF ILLINOIS# 0010637Facility Name & ID Number Lasalle County Nursing HomeSUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I1234567891010a1112131415Operating 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):*28 TOTAL General AdministrationTOTAL Operating Expense29 (sum of lines 8,16 & 28)HFS 3745 (N-4-99)PAGES5 & 5APAGE6PAGE6APAGE6BPAGE6CPAGE6DReport Period AGE6ISummary A11/30/16SUMMARYTOTALS(to Sch V, 9(300)(300) 1010a1112131415(300)(300) 1697,04597,045575,080171819(9,596) 20(62,793) 21575,080 25205,69329(9,596)(62,793)IL478-2471
STATE OF ILLINOISFacility Name & ID NumberLasalle County Nursing Home#0010637Report Period Beginning:12/01/15Ending:Summary B11/30/16SUMMARY 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 & AGE6GPAGE6HPAGE6ISUMMARYTOTALS(to Sch V, col.7)70,824 414243(14,144)(14,144) 44GRAND TOTAL COST45 (sum of lines 29, 37 & 44)HFS 3745 (N-4-99)(409,752)672,125262,37345IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 611/30/16VII. 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 BusinessSee 6-SupplementalSee 6-SupplementalSee 6-SupplementalB. 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 VLineVVVVVVVVVVVVV14 unty TreasurerCounty Board OfficeCounty AttorneyCounty AuditorCounty CourthouseAmount Name of Related OrganizationLasalle County, IllinoisLasalle County, IllinoisLaSalle County, IllinoisLaSalle County, IllinoisLaSalle County, IllinoisLaSalle County, IllinoisLasalle County, Illinois678 Difference:Operating CostAdjustments forPercentofof RelatedRelated OrganizationCosts (7 minus 4)OwnershipOrganization100.00% 344,960 ,405100.00%4,3894,389 672,125 *672,1251234567891011121314* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6A11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6B11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6C11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6D11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6E11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6F11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6G11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6H11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Ending:Page 6I11/30/16VII. 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.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 738ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 151617181920212223242526272829303132333435363738 *39* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Page 6-SupplementalEnding:11/30/16VII. 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 627282930LASALLE COUNTY, ILLINOISHFS 3745 2324252627282930IL478-2471
Facility Name & ID NumberLasalle County Nursing HomeSTATE OF ILLINOIS#0010637Report Period Beginning:12/01/15Page 6-Supplemental (2)Ending:11/30/16VII. 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 627282930HFS 3745 627282930IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS#0010637Lasalle County Nursing HomeReport Period Beginning:12/01/15Ending:Page 711/30/16VII. 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.1Name1 estCompensationReceivedFrom OtherNursing Homes*6Average Hours Per WorkWeek Devoted to thisFacility and % of TotalWork WeekHoursPercent78Compensation Includedin Costs for thisReporting Period**DescriptionAmount TOTALSchedule V.Line &ColumnReference123456789101112 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 COMPENSATIONHFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS# 0010637 Report Period Beginning:Lasalle County Nursing HomePage 812/01/15Ending:11/30/16VIII. 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 6171819202122232425 TOTALS2ItemIMRFFICACounty TreasurerCounty Board OfficeCounty AttorneyCounty AuditorCounty CourthouseHFS 3745 (N-4-99)3Unit of Allocation(i.e.,Days, Direct Cost,Square Feet)Direct CostDirect CostTime SpentTime SpentTime SpentTime SpentSquare Feet4Total Units5Number ofSubunits BeingAllocated Among6Total IndirectCost BeingAllocated 7Amount of SalaryCost Containedin Column 6 285,052330,833209,127204,4971,958,683127,108 2,988,192County of LaSalle707 Etna RoadOttawa, Illinois 61350( 815) 433-0476()220,971256,460162,114158,525 798,07089FacilityUnitsAllocation(col.8/col.4)x col.6 344,960230,12025,65529,77518,82118,4052854,389 22232425
Facility Name & ID NumberSTATE OF ILLINOIS# 0010637 Report Period Beginning:Lasalle County Nursing HomePage 8A12/01/15Ending:11/30/16VIII. 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.)YESNOB. Show the allocation of costs below. If necessary, please attach worksheets.1Schedule 32425 TOTALSHFS 3745 (N-4-99)2Item3Unit of Allocation(i.e.,Days, Direct Cost,Square Feet)4Total Units5Number ofSubunits BeingAllocated Among6Total IndirectCost BeingAllocated((7Amount of SalaryCost Containedin Column 6))89FacilityUnitsAllocation(col.8/col.4)x col.6 1
Facility Name & ID NumberSTATE OF ILLINOIS# 0010637 Report Period Beginning:Lasalle County Nursing HomePage 8B12/01/15Ending:11/30/16VIII. 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.)YESNOB. Show the allocation of costs below. If necessary, please attach worksheets.1Schedule 32425 TOTALSHFS 3745 (N-4-99)2Item3Unit of Allocation(i.e.,Days, Direct Cost,Square Feet)4Total Units5Number ofSubunits BeingAllocated Among6Total IndirectCost BeingAllocated((7Amount of SalaryCost Containedin Column 6))89FacilityUnitsAllocation(col.8/col.4)x col.6 1
Facility Name & ID NumberSTATE OF ILLINOIS# 0010637 Report Period Beginning:Lasalle County Nursing HomePage 8C12/01/15Ending:11/30/16VIII. 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.)YESNOB. Show the allocation of costs below
Facility Name: Lasalle County Nursing Home I have examined the contents of the accompanying report to the Address: 1380 North 27th Rd Ottawa 61350 State of Illinois, for the period from 12/01/15 to 11/30/16 Number City Zip Code and certif y to the best of m knowledge and belief that the said contents
