FOR OHF USE LL1 THIS AGENCY IS REQUESTING … Laundry 70,817 23,646 94,463 94,463 94,463 4 5 Heat...

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

THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY2002 PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE

STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDEDEPARTMENT OF PUBLIC AID ANY INFORMATION ON OR BEFORE THE DUE DATE WILL

FINANCIAL AND STATISTICAL REPORT FOR RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.

(FISCAL YEAR 2002)

I. IDPH Facility ID Number: 0041533 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

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

Address: 1000 EAST SIXTH STREET ROAD Pana 61701 State of Illinois, for the period from 1/01/2002 to 12/31/2002Number City Zip Code and certify to the best of my knowledge and belief that the said contents

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

is based on all information of which preparer has any knowledge.Telephone Number: ( 217 ) 324-2153 Fax # ( )

Intentional misrepresentation or falsification of any informationIDPA ID Number: 370909086020 in this cost report may be punishable by fine and/or imprisonment.

Date of Initial License for Current Owners: 03/01/96 (Signed)Officer or (Date)

Type of Ownership: Administrator (Type or Print Name) CRAIG L. ATERof Provider

VOLUNTARY,NON-PROFIT xx PROPRIETARY GOVERNMENTAL (Title) Senior Vice President -- FinanceCharitable Corp. Individual StateTrust Partnership County (Signed)

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

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

& Address)

(Telephone) ( 309 )823-7135 Fax # ( )MAIL TO: OFFICE OF HEALTH FINANCE

In the event there are further questions about this report, please contact: ILLINOIS DEPARTMENT OF PUBLIC AIDName:CRAIG L. ATER Telephone Number: ( ) 201 S. Grand Avenue East

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

STATE OF ILLINOIS Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002

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

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

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

G. Do pages 3 & 4 include expenses for services or1 151 Skilled (SNF) 151 55,115 1 investments not directly related to patient care?2 Skilled Pediatric (SNF/PED) 2 YES NO XX3 0 Intermediate (ICF) 0 0 34 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?5 0 Sheltered Care (SC) 0 0 5 YES NO XX6 ICF/DD 16 or Less 6

I. On what date did you start providing long term care at this location?7 151 TOTALS 151 55,115 7 Date started 03/01/96

J. Was the facility purchased or leased after January 1, 1978?B. Census-For the entire report period. YES Date 03/01/96 NO xx

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

Public Aid YES NO xx If YES, enter numberRecipient Private Pay Other Total of beds certified and days of care provided 4,955

8 SNF 33,967 12,383 4,955 51,305 8 9 SNF/PED 0 9 Medicare Intermediary10 ICF 1011 ICF/DD 11 IV. ACCOUNTING BASIS12 SC 0 0 0 12 MODIFIED13 DD 16 OR LESS 13 ACCRUAL XX CASH* CASH*

14 TOTALS 33,967 12,383 4,955 51,305 14 Is your fiscal year identical to your tax year? YES XX NO

C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: Fiscal Year: bed days on line 7, column 4.) 93.09% * All facilities other than governmental must report on the accrual basis.

STATE OF ILLINOIS Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)

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

1 Dietary 198,428 22,212 220,640 220,640 5,174 225,814 12 Food Purchase 221,407 221,407 221,407 (857) 220,550 23 Housekeeping 81,073 17,720 98,793 98,793 98,793 34 Laundry 70,817 23,646 94,463 94,463 94,463 45 Heat and Other Utilities 87,595 87,595 87,595 1,610 89,205 56 Maintenance 74,312 41,518 20,633 136,463 136,463 13,923 150,386 67 Other (specify):* 7

8 TOTAL General Services 424,630 326,503 108,228 859,361 859,361 19,850 879,211 8B. Health Care and Programs

9 Medical Director 5,650 5,650 5,650 5,650 910 Nursing and Medical Records 1,662,189 64,967 8,464 1,735,620 1,735,620 1,735,620 10

10a Therapy 307,104 272,542 579,646 (582,527) (2,881) 224,263 221,382 10a11 Activities 74,834 1,316 76,150 76,150 76,150 1112 Social Services 49,463 17 3,495 52,975 52,975 52,975 1213 Nurse Aide Training 16,593 10,332 26,925 26,925 2,876 29,801 1314 Program Transportation 1415 Other (specify):* 15

16 TOTAL Health Care and Programs 1,803,079 383,736 290,151 2,476,966 (582,527) 1,894,439 227,139 2,121,578 16C. General Administration

17 Administrative 77,537 77,537 77,537 133,711 211,248 1718 Directors Fees 7,097 7,097 1819 Professional Services 354,563 354,563 354,563 (341,202) 13,361 1920 Dues, Fees, Subscriptions & Promotions 102,929 102,929 (82,673) 20,256 (3,546) 16,710 2021 Clerical & General Office Expenses 91,781 14,248 22,671 128,700 128,700 281,246 409,946 2122 Employee Benefits & Payroll Taxes 417,594 417,594 417,594 36,776 454,370 2223 Inservice Training & Education 4,985 4,985 4,985 1,155 6,140 2324 Travel and Seminar 7,573 7,573 7,573 (5,574) 1,999 2425 Other Admin. Staff Transportation 2526 Insurance-Prop.Liab.Malpractice 54,802 54,802 54,802 2,709 57,511 2627 Other (specify):* 105,977 105,977 105,977 (105,635) 342 27

28 TOTAL General Administration 169,318 14,248 1,071,094 1,254,660 (82,673) 1,171,987 6,737 1,178,724 28TOTAL Operating Expense

29 (sum of lines 8, 16 & 28) 2,397,027 724,487 1,469,473 4,590,987 (665,200) 3,925,787 253,726 4,179,513 29*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.NOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification.

STATE OF ILLINOIS Facility Name & ID Number Heritage Manor-Pana #0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002

#V. COST CENTER EXPENSES (continued)

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

30 Depreciation 155,786 155,786 155,786 13,213 168,999 3031 Amortization of Pre-Op. & Org. 3132 Interest 197,629 197,629 197,629 291 197,920 3233 Real Estate Taxes 55,833 55,833 55,833 55,833 3334 Rent-Facility & Grounds 10,147 10,147 3435 Rent-Equipment & Vehicles 6,074 6,074 6,074 20,023 26,097 3536 Other (specify):* 36

37 TOTAL Ownership 415,322 415,322 415,322 43,674 458,996 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3839 Ancillary Service Centers 582,527 582,527 582,527 3940 Barber and Beauty Shops 782 19,900 20,682 20,682 20,682 4041 Coffee and Gift Shops 4142 Provider Participation Fee 82,673 82,673 82,673 4243 Other (specify):* 43

44 TOTAL Special Cost Centers 782 19,900 20,682 665,200 685,882 685,882 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 2,397,027 725,269 1,904,695 5,026,991 5,026,991 297,400 5,324,391 45

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

STATE OF ILLINOIS Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7.

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

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

1 Day Care $ $ 1 1 22 Other Care for Outpatients 2 Amount Reference3 Governmental Sponsored Special Programs 3 31 Non-Paid Workers-Attach Schedule* $ 314 Non-Patient Meals 4 32 Donated Goods-Attach Schedule* 325 Telephone, TV & Radio in Resident Rooms (48) 35 5 Amortization of Organization &6 Rented Facility Space 34 6 33 Pre-Operating Expense 337 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization8 Laundry for Non-Patients 8 34 Costs (Schedule VII) 430,840 349 Non-Straightline Depreciation 30 9 35 Other- Attach Schedule 35

10 Interest and Other Investment Income (40) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ 430,840 3611 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ 297,400 3713 Sales Tax (857) 2 1314 Non-Care Related Interest 32 14 *These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions 33 15 licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation) 24 16 on these lines.17 Non-Care Related Fees (725) 20 1718 Fines and Penalties 18 C. Are the following expenses included in Sections A to D of pages 319 Entertainment (14,561) 24 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions (1,139) 27 20 reference the line on which they appear before reclassification.21 Owner or Key-Man Insurance 21 (See instructions.) 1 2 3 422 Special Legal Fees & Legal Retainers (3,250) 19 22 Yes No Amount Reference23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. $ 3824 Bad Debt (104,496) 27 24 39 3925 Fund Raising, Advertising and Promotional (8,324) 20 25 40 Gift and Coffee Shops 40

Income Taxes and Illinois Personal 41 Barber and Beauty Shops 4126 Property Replacement Tax 26 42 Laboratory and Radiology 4227 Nurse Aide Training for Non-Employees 27 43 Prescription Drugs 4328 Yellow Page Advertising 28 44 Exceptional Care Program 4429 Other-Attach Schedule Real estate taxes 33 29 45 Other-Attach Schedule 4530 SUBTOTAL (A): (Sum of lines 1-29) $ (133,440) $ 30 46 Other-Attach Schedule 46

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

48 49 50 51 52

STATE OF ILLINOIS Page 5AHeritage Manor-Pana

ID# 0041533Report Period Beginning: 1/01/2002

Ending: 12/31/2002Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference1 $ 0 0 12 0 0 23 0 0 34 0 0 45 (48) 35 56 0 34 67 0 78 0 89 0 30 9

10 32 1011 0 1112 0 1213 (857) 2 1314 0 32 1415 0 33 1516 0 24 1617 (725) 20 1718 0 1819 24 1920 (1,139) 27 2021 0 2122 (3,250) 19 2223 0 2324 (104,496) 27 2425 (8,324) 20 2526 0 0 2627 0 0 2728 0 0 2829 0 0 2930 0 0 3031 0 0 3132 3233 0 33 3334 3435 3536 3637 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 Total (118,839) 49

STATE OF ILLINOIS Summary AFacility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

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

1 Dietary 0 0 5,174 0 0 0 0 0 0 0 0 5,174 12 Food Purchase (857) 0 0 0 0 0 0 0 0 0 0 (857) 23 Housekeeping 0 0 0 0 0 0 0 0 0 0 0 0 34 Laundry 0 0 0 0 0 0 0 0 0 0 0 0 45 Heat and Other Utilities 0 0 1,610 0 0 0 0 0 0 0 0 1,610 56 Maintenance 0 0 13,923 0 0 0 0 0 0 0 0 13,923 67 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 78 TOTAL General Services (857) 0 20,707 0 0 0 0 0 0 0 0 19,850 8

B. Health Care and Programs9 Medical Director 0 0 0 0 0 0 0 0 0 0 0 0 910 Nursing and Medical Records 0 0 0 0 0 0 0 0 0 0 0 0 10

10a Therapy 0 224,263 0 0 0 0 0 0 0 0 0 224,263 10a11 Activities 0 0 0 0 0 0 0 0 0 0 0 0 1112 Social Services 0 0 0 0 0 0 0 0 0 0 0 0 1213 Nurse Aide Training 0 0 2,876 0 0 0 0 0 0 0 0 2,876 1314 Program Transportation 0 0 0 0 0 0 0 0 0 0 0 0 1415 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 15

16 TOTAL Health Care and Programs 0 224,263 2,876 0 0 0 0 0 0 0 0 227,139 16C. General Administration

17 Administrative 0 0 133,711 0 0 0 0 0 0 0 0 133,711 1718 Directors Fees 0 0 7,097 0 0 0 0 0 0 0 0 7,097 1819 Professional Services (3,250) (351,313) 13,361 0 0 0 0 0 0 0 0 (341,202) 1920 Fees, Subscriptions & Promotions (9,049) 0 5,503 0 0 0 0 0 0 0 0 (3,546) 2021 Clerical & General Office Expenses 0 0 281,246 0 0 0 0 0 0 0 0 281,246 2122 Employee Benefits & Payroll Taxes 0 0 36,776 0 0 0 0 0 0 0 0 36,776 2223 Inservice Training & Education 0 0 1,155 0 0 0 0 0 0 0 0 1,155 2324 Travel and Seminar (14,561) 0 8,987 0 0 0 0 0 0 0 0 (5,574) 2425 Other Admin. Staff Transportation 0 0 0 0 0 0 0 0 0 0 0 0 2526 Insurance-Prop.Liab.Malpractice 0 0 2,709 0 0 0 0 0 0 0 0 2,709 2627 Other (specify):* (105,635) 0 0 0 0 0 0 0 0 0 0 (105,635) 27

28 TOTAL General Administration (132,495) (351,313) 490,545 0 0 0 0 0 0 0 0 6,737 28TOTAL Operating Expense

29 (sum of lines 8,16 & 28) (133,352) (127,050) 514,128 0 0 0 0 0 0 0 0 253,726 29

STATE OF ILLINOIS Summary BFacility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002

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

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

30 Depreciation 0 0 0 13,213 0 0 0 0 0 0 0 13,213 3031 Amortization of Pre-Op. & Org. 0 0 0 0 0 0 0 0 0 0 0 0 3132 Interest (40) 0 0 331 0 0 0 0 0 0 0 291 3233 Real Estate Taxes 0 0 0 0 0 0 0 0 0 0 0 0 3334 Rent-Facility & Grounds 0 0 0 10,147 0 0 0 0 0 0 0 10,147 3435 Rent-Equipment & Vehicles (48) 0 0 20,071 0 0 0 0 0 0 0 20,023 3536 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 36

37 TOTAL Ownership (88) 0 0 43,762 0 0 0 0 0 0 0 43,674 37 Ancillary ExpenseE. Special Cost Centers

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

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

45 (sum of lines 29, 37 & 44) (133,440) (127,050) 514,128 43,762 0 0 0 0 0 0 0 297,400 45

STATE OF ILLINOIS Page 6Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002

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

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of Business

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

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

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

Ownership Organization Costs (7 minus 4)1 V $ $ $ 12 V 10a Adjustment for Related Organization 246,316 GreenTree Therapy 100.00% 218,395 (27,921) 23 V 34 V 19 Adjustment for Related Organization 351,313 Heritage Enterprises, Inc. 100.00% (351,313) 45 V 56 V 10a Adjustment for Related Organization 306,079 GreenTree Pharmacy 100.00% 558,263 252,184 67 V 78 V 89 V 910 V 1011 V 1112 V 1213 V 1314 Total $ 903,708 $ 776,658 $ * (127,050) 14

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

STATE OF ILLINOIS Page 6AFacility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002

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

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



Ownership Organization Costs (7 minus 4)15 V 1 Dietary $ Heritage Enterprises, Inc. 100.00% $ 5,174 $ 5,174 1516 V 2 Food Purchase 0 1617 V 3 Housekeeping 0 1718 V 4 Laundry 0 1819 V 5 Heat & Other Utilities 1,610 1,610 1920 V 6 Maintenance 13,923 13,923 2021 V 7 Other 0 2122 V 9 Medical Director 0 2223 V 10 Nursing & Medical Records 0 2324 V 11 Activities 0 2425 V 12 Social Service 0 2526 V 13 Nurse Aide Training 2,876 2,876 2627 V 14 Program Transportation 0 2728 V 15 Other 0 2829 V 17 Administrative 133,711 133,711 2930 V 18 Directors Fees 7,097 7,097 3031 V 19 Professional Services 13,361 13,361 3132 V 20 Fees, Subscription, Promotions 5,503 5,503 3233 V 21 Clerical & General Office Expenses 281,246 281,246 3334 V 22 Employee Benefits & Payroll Taxes 36,776 36,776 3435 V 23 Inservice Training & Education 1,155 1,155 3536 V 24 Travel and Seminar 8,987 8,987 3637 V 25 Other Admin. Staff Transportation 0 3738 V 26 Insurance-Prop.Liab.Malpract 2,709 2,709 38

39 Total $ $ 514,128 $ * 514,128 39


STATE OF ILLINOIS Page 6BFacility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002

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

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



Ownership Organization Costs (7 minus 4)15 V 27 Other $ Heritage Enterprises, Inc. 100.00% $ 0 $ 1516 V 30 Depreciation 13,213 13,213 1617 V 31 Amortization of Pre-Op & Org 0 1718 V 32 Interest 331 331 1819 V 33 Real Estate Taxes 0 1920 V 34 Rent-Facility & Grounds 10,147 10,147 2021 V 35 Rent-Equipment & Vehicles 20,071 20,071 2122 V 36 Other 0 2223 V 38 Medically Nec Transportation 0 2324 V 39 Ancillary Service Centers 0 2425 V 40 Barber and Beauty Shops 0 2526 V 41 Coffee and Gift Shops 0 2627 V 42 Other 0 2728 V 2829 V 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 38

39 Total $ $ 43,762 $ * 43,762 39



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

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

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

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

1 Bill Froelich Chairman of Board Management 26.00 397,396 5 100.00 Director/Salary$ 24,993 line 17/18, col 7 12 Tom Jefferson Asst Secretary/TreasuManagement 10.00 390,860 5 100.00 Director/Salary 24,581 line 17/18, col 7 23 Craig Hart Secretary/Treasurer Management 20.00 343,058 10 100.00 Director/Salary 21,575 line 17/18, col 7 34 Joe Warner President Management 2.50 370,366 40 100.00 Director/Salary 23,292 line 17/18, col 7 45 Bob Dickson Executive Vice PresidManagement 0.80 92,266 40 100.00 Salary 5,803 line 17, col 7 56 Cheryl Lowney Executive Vice PresidManagement 0.30 186,564 50 100.00 Director/Salary 11,733 line 17/18, col 7 67 Steve Wannemacher Executive Vice PresidManagement 0.30 175,068 50 100.00 Director/Salary 11,010 line 17/18, col 7 78 Connie Hoselton Sr Vice President Management 0.17 140,191 40 100.00 Salary 8,817 line 17, col 7 89 Craig Ater Sr Vice President Management 0.21 143,176 50 100.00 Salary 9,004 line 17, col 7 910 1011 1112 12

13 TOTAL $ 140,808 13

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

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


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization

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

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

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

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

1 1 Dietary Beds 2,401 24 $ 82,266 $ 82,266 151 $ 5,174 12 2 Food Purchase Beds 2,401 24 0 0 151 0 23 3 Housekeeping Beds 2,401 24 0 0 151 0 34 4 Laundry Beds 2,401 24 0 0 151 0 45 5 Heat & Other Utilities Beds 2,401 24 25,593 0 151 1,610 56 6 Maintenance Beds 2,401 24 221,381 58,785 151 13,923 67 7 Other Beds 2,401 24 0 0 151 0 78 9 Medical Director Beds 2,401 24 0 0 151 0 89 10 Nursing & Medical Records Beds 2,401 24 0 0 151 0 9

10 11 Activities Beds 2,401 24 0 0 151 0 1011 12 Social Service Beds 2,401 24 0 0 151 0 1112 13 Nurse Aide Training Beds 2,401 24 45,737 39,267 151 2,876 1213 14 Program Transportation Beds 2,401 24 0 0 151 0 1314 15 Other Beds 2,401 24 0 0 151 0 1415 17 Administrative Beds 2,401 24 2,126,096 2,126,096 151 133,711 1516 18 Directors Fees Beds 2,401 24 112,849 0 151 7,097 1617 19 Professional Services Beds 2,401 24 212,454 0 151 13,361 1718 20 Fees, Subscription, Promotions Beds 2,401 24 87,500 0 151 5,503 1819 21 Clerical & General Office ExpenseBeds 2,401 24 4,472,002 4,183,145 151 281,246 1920 22 Employee Benefits & Payroll TaxeBeds 2,401 24 584,769 0 151 36,776 2021 23 Inservice Training & Education Beds 2,401 24 18,362 0 151 1,155 2122 24 Travel and Seminar Beds 2,401 24 142,902 0 151 8,987 2223 25 Other Admin. Staff TransportationBeds 2,401 24 0 0 151 0 2324 26 Insurance-Prop.Liab.Malpract Beds 2,401 24 43,070 0 151 2,709 2425 TOTALS $ 8,174,981 $ 6,489,559 $ 514,128 25


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization

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

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

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

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

1 27 Other Beds 2,401 24 $ $ 151 $ 12 30 Depreciation Beds 2,401 24 210,090 151 13,213 23 31 Amortization of Pre-Op & Org Beds 2,401 24 151 34 32 Interest Beds 2,401 24 5,270 151 331 45 33 Real Estate Taxes Beds 2,401 24 151 56 34 Rent-Facility & Grounds Beds 2,401 24 161,349 151 10,147 67 35 Rent-Equipment & Vehicles Beds 2,401 24 319,142 151 20,071 78 36 Other Beds 2,401 24 151 89 38 Medically Nec Transportation Beds 2,401 24 151 9

10 39 Ancillary Service Centers Beds 2,401 24 151 1011 40 Barber and Beauty Shops Beds 2,401 24 151 1112 41 Coffee and Gift Shops Beds 2,401 24 151 1213 42 Other Beds 2,401 24 151 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ 695,851 $ $ 43,762 25


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

1 2 3 4 5 6 7 8 9 10Reporting

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

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

1 National City XX Mortage $28,143.00 03/01/96 $ 4,072,322 $ 3,225,849 01/15/06 variable $ 160,397 12 National City Loan Amortization XX Mortgage 6,540 23 Central Office Allocation XX Interest Income 34 Alpha Community Bank xx 05/01/01 113,849 91,080 4,554 45 5

Working Capital6 Central Office Allocation xx Working Capital 26,138 67 Central Office Allocation xx Working Capital 331 78 8

9 TOTAL Facility Related $28,143.00 $ 4,186,171 $ 3,316,929 $ 197,960 9B. Non-Facility Related*

10 Interest Income (40) 1011 1112 1213 13

14 TOTAL Non-Facility Related $ $ $ (40) 14

15 TOTALS (line 9+line14) $ 4,186,171 $ 3,316,929 $ 197,920 15

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

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

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


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

1. Real Estate Tax accrual used on 2001 report. $ 54,530 1

2. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 53,836 2

3. Under or (over) accrual (line 2 minus line 1). $ (694) 3

4. Real Estate Tax accrual used for 2002 report. (Detail and explain your calculation of this accrual on the lines below.) $ 56,527 4

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

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

7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. $ 55,833 7

Real Estate Tax History:

Real Estate Tax Bill for Calendar Year: 1997 8 FOR OHF USE ONLY1998 91999 10 13 FROM R. E. TAX STATEMENT FOR 2001 $ 132000 112001 12 14 PLUS APPEAL COST FROM LINE 5 $ 14

15 LESS REFUND FROM LINE 6 $ 15

16 AMOUNT TO USE FOR RATE CALCULATION $ 16

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

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

Important , please see the next worksheet, "RE_Tax". The real estate tax statement and bill must accompany the cost report.

2001 LONG TERM CARE REAL ESTATE TAX STATEMENTFACILITY NAME Heritage Manor-Pana COUNTY MONTGOMERY

FACILITY IDPH LICENSE NUMBER 0041533

CONTACT PERSON REGARDING THIS REPORT Craig Ater

TELEPHONE ( 309 )823-7135 FAX #: ( )

A. Summary of Real Estate Tax Cost

Enter the tax index number and real estate tax assessed for 2001 on the lines provided below. Enter only the portion of thecost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursinghome property which is vacant, rented to other organizations, or used for purposes other than long term care must not beentered in Column D. Do not include cost for any period other than calendar year 2001.

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

Applicable toTax Index Number Property Description Total Tax Nursing Home

1. 112522223013 Nursing Home $ 568.00 $ 568.00

2. 112522223014 Nursing Home $ 53,268.00 $ 53,268.00

3. $ $

4. $ $

5. $ $

6. $ $

7. $ $

8. $ $

9. $ $

10. $ $

TOTALS $ 53,836.00 $ 53,836.00

B. Real Estate Tax Cost Allocations

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

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

C. Tax Bills

Attach a copy of the 2001 tax bills which were listed in Section A to this statement. Be sure to use the 2001 tax bill whichis normally paid during 2002.

Page 10A

IMPORTANT NOTICE

TO: Long Term Care Facilities with Real Estate Tax Rates RE: 2001 REAL ESTATE TAX COST DOCUMENTATION

In order to set the real estate tax portion of the capital rate, it is necessary that we obtain additional information regarding your calendar 2001 real estate tax costs, as well as copies of your real estate tax bills for calendar 2001.

Please complete the Real Estate Tax Statement below and forward with a copy of your 2001 real estate tax bill to the Department of Public Aid, Office of Health Finance, 201 South Grand Avenue East, Springfield, Illinois 62763.

Please send these items in with your completed 2002 cost report. The cost report will not be considered complete and timely filed until this statement and the corresponding real estate tax bills are filed. If you have any questions, please call the Office of Health Finance at (217) 782-1630.

STATE OF ILLINOIS Page 11Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002X. BUILDING AND GENERAL INFORMATION:

A. Square Feet: 33,800 B. General Construction Type: Exterior Brick/Wood Frame Number of Stories

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

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

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

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

E. List all other business entities owned by this operating entity or related to the operating entity that are located on or adjacent to this nursing home's grounds(such as, but not limited to, apartments, assisted living facilities, day training facilities, day care, independent living facilities, nurse aide training facilities, etc.)List entity name, type of business, square footage, and number of beds/units available (where applicable).

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

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

3. Current Period Amortization: 4. Dates Incurred:

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

XI. OWNERSHIP COSTS: 1 2 3 4

A. Land. Use Square Feet Year Acquired Cost1 Land $ 51,055 12 23 TOTALS $ 51,055 3


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

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

Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation4 151 $ 3,943,054 $ $ $ $ 45 56 67 78 8

Improvement Type**9 910 Smoke Detectors 1997 1,113 1011 1112 Seal BlackTop/Parking Lot 1996 2,680 1213 Heritage Manor Sign 1996 2,192 1314 Laundry Room Central A/C 1996 3,019 1415 1516 Generator Repair 1998 1,559 1617 Roof 1998 26,420 1718 1819 roof 1999 113,936 1920 2021 Heat / Cool Unit 2000 1,170 2122 Roof Repair Walkway 2000 1,715 2223 2324 2425 Tile Floor 2001 1,646 2526 Heat/Cool Unit 2001 1,180 2627 2728 Day Room Carpet 2002 1,225 2829 Hot Water Heater 2002 2,224 2930 Sewar repair 2002 1,965 3031 3132 3233 3334 C/O Allocation 13,213 13,213 3435 Book Depreciation 103,224 103,224 692,198 3536 36

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



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

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation37 $ $ $ $ $ 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 4950 5051 5152 5253 5354 5455 5556 5657 5758 5859 5960 6061 6162 6263 6364 6465 6566 6667 6768 6869 6970 TOTAL (lines 4 thru 69) $ 4,105,098 $ 103,224 $ 116,437 $ 13,213 $ 692,198 70

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

STATE OF ILLINOIS Page 12BFacility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002


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

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12A, Carried Forward $ 4,105,098 $ 103,224 $ 116,437 $ 13,213 $ 692,198 12 23 34 45 56 67 78 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 4,105,098 $ 103,224 $ 116,437 $ 13,213 $ 692,198 34

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

STATE OF ILLINOIS Page 13Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002XI. OWNERSHIP COSTS (continued)

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

71 Purchased in Prior Years $ 349,477 $ 52,562 $ 52,562 $ $ 326,946 7172 Current Year Purchases 39,083 7273 Fully Depreciated Assets 7374 7475 TOTALS $ 388,560 $ 52,562 $ 52,562 $ $ 326,946 75

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

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

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

81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 4,544,713 8182 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 155,786 8283 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 168,999 83 **84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ 13,213 8485 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 1,019,144 85

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

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

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

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


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

001 2 3 4 5 6

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

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

** 8. List separately any amortization of lease expense included on page 4, line 34. Fiscal Year Ending Annual Rent This amount was calculated by dividing the total amount to be amortized by the length of the lease . 12. /2003 $

13. /2004 $ 9. Option to Buy: YES NO Terms: * 14. /2005 $

B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.) 15. Is Movable equipment rental included in building rental? YES NO 16. Rental Amount for movable equipment: $ 26,097 Description: pager, computer equipment

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

1 2 3 4Model Year Monthly Lease Rental Expense

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

STATE OF ILLINOIS Page 15Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002XIII. EXPENSES RELATING TO NURSE AIDE TRAINING PROGRAMS (See instructions.)

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

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

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

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

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

FacilityDrop-outs Completed Contract Total $

1 Community College Tuition $ $ $ $2 Books and Supplies 10,332 10,332 D. NUMBER OF AIDES TRAINED3 Classroom Wages (a) 16,593 16,5934 Clinical Wages (b) COMPLETED5 In-House Trainer Wages (c) 1. From this facility6 Transportation 2. From other facilities (f)7 Contractual Payments DROP-OUTS8 Nurse Aide Competency Tests 1. From this facility9 TOTALS $ $ 26,925 $ $ 26,925 2. From other facilities (f)

10 SUM OF line 9, col. 1 and 2 (e) $ 26,925 TOTAL TRAINED

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


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

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

Reference Service Units Cost Allocated) (Column 2 + 4) (Col. 3 + 5 + 6)1 Licensed Occupational Therapist 10a/3 hrs $ $ 103,934 $ $ 103,934 1

Licensed Speech and Language2 Development Therapist 10a/3 hrs 14,223 14,223 23 Licensed Recreational Therapist hrs 34 Licensed Physical Therapist 10a/3 hrs 100,238 2,987 103,225 45 Physician Care visits 56 Dental Care visits 67 Work Related Program hrs 78 Habilitation hrs 8

# of9 Pharmacy 39/3 prescrpts 556,301 556,301 9

Psychological Services (Evaluation and Diagnosis/

10 Behavior Modification) hrs 1011 Academic Education hrs 1112 Exceptional Care Program 12

13 Other (specify): x-ray 39/3 26,226 26,226 13

14 TOTAL $ $ 244,621 $ 559,288 $ 803,909 14

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


XV. BALANCE SHEET - Unrestricted Operating Fund. As of 12/31/2002 (last day of reporting year) This report must be completed even if financial statements are attached.

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

A. Current Assets C. Current Liabilities1 Cash on Hand and in Banks $ 7,384 $ 1 26 Accounts Payable $ 50,355 $ 262 Cash-Patient Deposits 13,152 2 27 Officer's Accounts Payable 27

Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits 13,152 283 Patients (less allowance ) 611,756 3 29 Short-Term Notes Payable 294 Supply Inventory (priced at ) 4 30 Accrued Salaries Payable 262,896 305 Short-Term Investments 5 Accrued Taxes Payable6 Prepaid Insurance 11,158 6 31 (excluding real estate taxes) 4,304 317 Other Prepaid Expenses 7 32 Accrued Real Estate Taxes(Sch.IX-B) 56,527 328 Accounts Receivable (owners or related parties) 2,288,114 8 33 Accrued Interest Payable 15,103 339 Other(specify): 9 34 Deferred Compensation 34

TOTAL Current Assets 35 Federal and State Income Taxes 3510 (sum of lines 1 thru 9) $ 2,931,564 $ 10 Other Current Liabilities(specify):

B. Long-Term Assets 36 Security Deposits 20,838 3611 Long-Term Notes Receivable 11 37 3712 Long-Term Investments 12 TOTAL Current Liabilities13 Land 51,055 13 38 (sum of lines 26 thru 37) $ 423,175 $ 3814 Buildings, at Historical Cost 4,105,097 14 D. Long-Term Liabilities15 Leasehold Improvements, at Historical Cost 15 39 Long-Term Notes Payable 3916 Equipment, at Historical Cost 388,560 16 40 Mortgage Payable 3,316,929 4017 Accumulated Depreciation (book methods) (1,019,144) 17 41 Bonds Payable 4118 Deferred Charges 18 42 Deferred Compensation 4219 Organization & Pre-Operating Costs 19 Other Long-Term Liabilities(specify):

Accumulated Amortization - 43 4320 Organization & Pre-Operating Costs 20 44 4421 Restricted Funds 21 TOTAL Long-Term Liabilities22 Other Long-Term Assets (specify): 22 45 (sum of lines 39 thru 44) $ 3,316,929 $ 4523 Other(specify): Deferred Tax Asset 19,620 23 TOTAL LIABILITIES

TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 3,740,104 $ 4624 (sum of lines 11 thru 23) $ 3,545,188 $ 24

47 TOTAL EQUITY(page 18, line 24) $ 2,736,648 $ 47TOTAL ASSETS TOTAL LIABILITIES AND EQUITY

25 (sum of lines 10 and 24) $ 6,476,752 $ 25 48 (sum of lines 46 and 47) $ 6,476,752 $ 48

*(See instructions.)


XVI. STATEMENT OF CHANGES IN EQUITY1

Total1 Balance at Beginning of Year, as Previously Reported $ 1,999,879 12 Restatements (describe): 23 Audit Adjustment 9,000 34 45 56 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ 2,008,879 6

A. Additions (deductions):7 NET Income (Loss) (from page 19, line 43) 727,769 78 Aquisitions of Pooled Companies 89 Proceeds from Sale of Stock 910 Stock Options Exercised 1011 Contributions and Grants 1112 Expenditures for Specific Purposes 1213 Dividends Paid or Other Distributions to Owners ( ) 1314 Donated Property, Plant, and Equipment 1415 Other (describe) 1516 Other (describe) 1617 TOTAL Additions (deductions) (sum of lines 7-16) $ 727,769 17

B. Transfers (Itemize):18 1819 1920 2021 2122 2223 TOTAL Transfers (sum of lines 18-22) $ 2324 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ 2,736,648 24 *

* This must agree with page 17, line 47.


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

1 2Revenue Amount Expenses Amount

A. Inpatient Care A. Operating Expenses1 Gross Revenue -- All Levels of Care $ 5,780,725 1 31 General Services 859,361 312 Discounts and Allowances for all Levels (1,055,884) 2 32 Health Care 2,476,966 323 SUBTOTAL Inpatient Care (line 1 minus line 2) $ 4,724,841 3 33 General Administration 1,254,660 33

B. Ancillary Revenue B. Capital Expense4 Day Care 4 34 Ownership 415,322 345 Other Care for Outpatients 5 C. Ancillary Expense6 Therapy 464,874 6 35 Special Cost Centers 20,682 357 Oxygen 7 36 Provider Participation Fee 368 SUBTOTAL Ancillary Revenue (lines 4 thru 7) $ 464,874 8 D. Other Expenses (specify):

C. Other Operating Revenue 37 Loss from Non-Nursing property 379 Payments for Education 9 38 3810 Other Government Grants 10 39 3911 Nurses Aide Training Reimbursements 2,038 1112 Gift and Coffee Shop 4,321 12 40 TOTAL EXPENSES (sum of lines 31 thru 39)* $ 5,026,991 4013 Barber and Beauty Care 22,276 1314 Non-Patient Meals 14 41 Income before Income Taxes (line 30 minus line 40)** 727,769 4115 Telephone, Television and Radio 1516 Rental of Facility Space 16 42 Income Taxes 4217 Sale of Drugs 535,755 1718 Sale of Supplies to Non-Patients 18 43 NET INCOME OR LOSS FOR THE YEAR (line 41 minus line 42) $ 727,769 4319 Laboratory 1920 Radiology and X-Ray 2021 Other Medical Services 615 2122 Laundry 2223 SUBTOTAL Other Operating Revenue (lines 9 thru 22)$ 565,005 23

D. Non-Operating Revenue24 Contributions 24 * This must agree with page 4, line 45, column 4.25 Interest and Other Investment Income*** 40 2526 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 40 26 ** Does this agree with taxable income (loss) per Federal Income

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

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

30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 5,754,760 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.

STATE OF ILLINOIS Page 20Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002XVIII. A. STAFFING AND SALARY COSTS (Please report each line separately.) (This schedule must cover the entire reporting period.) B. CONSULTANT SERVICES

1 2** 3 4 1 2 3# of Hrs. # of Hrs. Reporting Period Average Number Total Consultant Schedule VActually Paid and Total Salaries, Hourly of Hrs. Cost for Line &Worked Accrued Wages Wage Paid & Reporting Column

1 Director of Nursing 1,755 1,950 $ 53,751 $ 27.56 1 Accrued Period Reference2 Assistant Director of Nursing 3,195 3,480 59,796 17.18 2 35 Dietary Consultant $ 0 353 Registered Nurses 3,940 4,312 88,101 20.43 3 36 Medical Director 5,650 364 Licensed Practical Nurses 24,374 26,491 352,340 13.30 4 37 Medical Records Consultant 949 375 Nurse Aides & Orderlies 117,645 126,407 1,067,775 8.45 5 38 Nurse Consultant 386 Nurse Aide Trainees 2,609 2,609 16,593 6.36 6 39 Pharmacist Consultant 3,990 397 Licensed Therapist 7 40 Physical Therapy Consultant 408 Rehab/Therapy Aides 3,600 3,952 40,426 10.23 8 41 Occupational Therapy Consultant 419 Activity Director 9 42 Respiratory Therapy Consultant 4210 Activity Assistants 8,039 8,781 74,834 8.52 10 43 Speech Therapy Consultant 4311 Social Service Workers 3,495 3,956 49,463 12.50 11 44 Activity Consultant 4412 Dietician 12 45 Social Service Consultant 3,495 4513 Food Service Supervisor 13 46 Other(specify) 4614 Head Cook 14 47 4715 Cook Helpers/Assistants 22,581 24,081 198,428 8.24 15 48 4816 Dishwashers 1617 Maintenance Workers 4,601 4,985 74,312 14.91 17 49 TOTAL (lines 35 - 48) $ 14,084 4918 Housekeepers 11,494 12,142 81,073 6.68 1819 Laundry 9,377 10,033 70,817 7.06 1920 Administrator 2,080 2,080 77,537 37.28 2021 Assistant Administrator 21 C. CONTRACT NURSES22 Other Administrative 22 1 2 323 Office Manager 23 Number Schedule V24 Clerical 7,222 8,107 91,781 11.32 24 of Hrs. Total Line &25 Vocational Instruction 25 Paid & Contract Column26 Academic Instruction 26 Accrued Wages Reference27 Medical Director 27 50 Registered Nurses $ 0 5028 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 0 5129 Resident Services Coordinator 29 52 Nurse Aides 0 5230 Habilitation Aides (DD Homes) 3031 Medical Records 31 53 TOTAL (lines 50 - 52) $ 5332 Other Health Care(specify) 3233 Other(specify) 3334 TOTAL (lines 1 - 33) 226,007 243,366 $ 2,397,027 * $ 9.85 34

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

STATE OF ILLINOIS Page 21Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002XIX. SUPPORT SCHEDULES A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions

Name Function % Amount Description Amount Description AmountNancy Pryor Administrator 0 $ 77,537 Workers' Compensation Insurance $ 46,214 IDPH License Fee $ 0

Unemployment Compensation Insurance 22,415 Advertising: Employee Recruitment 1,619 FICA Taxes 183,373 Health Care Worker Background CheckEmployee Health Insurance 145,969 (Indicate # of checks performed 14 ) 259 Employee Meals Central Office Allocation 5,503 Illinois Municipal Retirement Fund (IMRF)* Promotional Advertising 3,091Employee Hepatitis Vaccine 2,508 Public Relations 5,233

TOTAL (agree to Schedule V, line 17, col. 1) Employee Benefits - 17,115 Dues and Subscriptions 9,830(List each licensed administrator separately.) $ 77,537 Employee Benefits - central office 36,776 License and Fees 224B. Administrative - Other

Less: Public Relations Expense (5,233) Description Amount Non-allowable advertising (725)

$ Yellow page advertising (3,091)

TOTAL (agree to Schedule V, $ 454,370 TOTAL (agree to Sch. V, $ 16,710 line 22, col.8) line 20, col. 8)

TOTAL (agree to Schedule V, line 17, col. 3) $ E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar**(Attach a copy of any management service agreement) to Owners or EmployeesC. Professional Services Description Amount Vendor/Payee Type Amount Description Line # AmountHeritage Enterprises Management Fees $ 351,313 $ Out-of-State Travel $

00

In-State Travel2,577

44

Seminar Expense 4,952Non Allowable (14,561)

0 Central Office Allocation 8,987Legal Fees (Adjusted to zero) 3,250

0 Entertainment Expense ( )TOTAL (agree to Schedule V, line 19, column 3) TOTAL $ (agree to Sch. V,(If total legal fees exceed $2500 attach copy of invoices.) $ 354,563 TOTAL line 24, col. 8) $ 1,999

* Attach copy of IMRF notifications **See instructions.


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

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

Improvement Improvement Total Cost UsefulType Was Made Life FY1999 FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007

1 $ $ $ $ $ $ $ $ $ $2345678910111213141516171819

20 TOTALS $ $ $ $ $ $ $ $ $ $

STATE OF ILLINOIS Page 23Facility Name & ID Number Heritage Manor-Pana # 0041533 Report Period Beginning: 1/01/2002 Ending: 12/31/2002XX. GENERAL INFORMATION:

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

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

(14) Is a portion of the building used for any function other than long term care services for(3) Did the nursing home make political contributions or payments to a political the patient census listed on page 2, Section B? no For example,

action organization? no If YES, have these costs is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attachbeen properly adjusted out of the cost report? yes a schedule which explains how all related costs were allocated to these functions.

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

related costs? yes Indicate the amount. $ 690(5) Have you properly capitalized all major repairs and equipment purchases? yes

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

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

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

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

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

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

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

Schedule VII)? YES NO no If YES, please indicate name of the facility, transportation during this reporting period. $IDPH license number of this related party and the date the present owners took over.

(17) Has an audit been performed by an independent certified public accounting firm? yesFirm Name: Sulaski & Webb The instructions for the

(11) Indicate the amount of the Provider Participation Fees paid and accrued to the Department cost report require that a copy of this audit be included with the cost report. Has this copyof Public Aid during this cost report period. $ 82,673 been attached? No If no, please explain. Not available at this dateThis amount is to be recorded on line 42 of Schedule V.

(18) Have all costs which do not relate to the provision of long term care been adjusted out(12) Are there any salary costs which have been allocated to more than one line on Schedule V out of Schedule V? yes

for an individual employee? no If YES, attach an explanation of the allocation.(19) If total legal fees are in excess of $2500, have legal invoices and a summary of services

performed been attached to this cost report? yesAttach invoices and a summary of services for all architect and appraisal fees.

Account G/L Cost Rpt Sch 5 pg 3/4Sch 5 pg 3/4Sch 6 pg 5AdjustmentNumber Description Balance Grouping Line # Col # Line # Amount1009 PETTY CASH 7,384 1,009 1,009 PETTY CA 7,3841010 CASH IN BANK 1,100 1,100 ACCTS RE 611,7561040 CASH IN BANK-PAYROLL 1,101 1,101 ALLOW. FOR UNCOLLECTIBLES1100 ACCOUNTS RECEIVABLE 611,756 1,110 1,110 ACCTS RECEIV-M/C1110 MEDICARE RECEIVABLES 1,125 1,125 ACCTS RECEIV-IPA1125 IPA INCOME RECEIVABLE 1,135 1,135 ACCTS RECEIV-IC1130 MEDICARE COST REPORT 1,140 1,140 UNAPPLIED CASH RECEIPTS1135 ACCOUNTS RECEIVABLE-IC 1,145 1,145 A/R SUSPENSE-REFUNDS1140 UNAPPLIED CASH RECEIPTS 1,200 1,200 PREPAID I 11,1581145 A/R SUSPENSE-REFUNDS 1,220 1,220 OTHER PREPAID EXPENSES1190 ACCRUED INTEREST REC 1,300 1,300 DIETARY INVENTORY1200 PREPAID INSURANCE 11,158 1,310 1,310 SUPPLIES INVENTORY1220 OTHER PREPAID EXPENSES 1,320 1,320 LINEN INVENTORY1300 FOOD INVENTORY 1,409 1,409 LAND 51,0551310 SUPPLIES INVENTORY 1,450 1,450 FURNITUR 388,5601409 LAND 51,055 1,460 -326,9461450 FURNITURE & EQUIPMENT 388,560 1,475 1,475 CODE ALE 4,105,0971460 ACCUM DEPR-FURN & EQUIP -326,946 1,490 1,490 ACCUM DE -692,1981475 BUILDING & IMPROVEMENTS 4,105,097 1,530 1,530 RESIDENT 13,1521490 ACCUM DEPR-BUILDING -692,198 1,550 1,550 LOAN FEE 19,6201530 RESIDENT FUNDS 13,152 1,551 1,551 LOAN FEES ADDED1550 LOAN FEES 19,620 1,850 1,850 INTERCOM 2,288,1141560 REAL ESTATE TAX ESCROW 2,010 2,010 ACCOUNT -50,3551575 REIMBURSABLE PURCHASES 2,100 2,095 BONUSES PAYABLE1850 INTRACOMPANY 2,288,114 2,100 2,100 ACCRUED -130,3992010 ACCOUNTS PAYABLE -50,355 2,100 2,100 PR CLEARING-BENEFITS2095 BONUSES PAYABLE 2,100 2,100 PR CLEARING-LABOR2100 ACCRUED PAYROLL -130,399 2,110 2,110 ACCRUED -132,4972110 ACCRUED VACATION PAY -132,497 2,120 2,120 U.C. TAXES PAYABLE2120 UC TAXES PAYABLE 2,125 2,125 FICA TAXE -4,3042125 FICA TAX PAYABLE -4,304 -4,304 2,130 2,130 FEDERAL W/H TAX PAYABLE2130 FIT PAYABLE 2,140 2,140 STATE W/H TAX PAYABLE2140 STATE W/H PAYABLE 0 2,152 2,152 WORKERS COMP ACCRUAL2145 EARNED INCOME CREDIT 2,225 2,225 EMPLOYEEE INSURANCE REFUND2150 UC FED CREDIT REDUCTION 2,230 2,230 PAYROLL SAVINGS2230 PAYROLL SAVINGS 2,235 2,240 UNITED FUND2235 IRA W/HOLDINGS 2,240 2,246 GROUP INSURANCE - CAFETERIA2240 UNITED WAY 2,246 2,250 401K W/H2245 GROUP INSURANCE PAYABLE 2,2502246 GROUP INSURANCE PAYABLE-CAFETERIA 2,260 2,260 WAGE GARNISHMENT2260 WAGE GARNISHMENTS 2,300 2,300 ACCRUED -15,1032280 MISC PAYROLL DEDUCTIONS 2,320 2,320 IPA PAYM -20,8382300 ACCRUED INTEREST PAYABLE -15,103 2,350 2,350 REAL ESTA -56,5272310 SALES TAX PAYABLE 2,3852320 IPA PAYMENTS PAYABLE -20,838 2,400 2,400 CURRENT PORTION OF LT DEBT2350 REAL ESTATE TAX PAYABLE -56,527 2,512 2,512 DUE TO RE -13,1522385 ACTIVITY FUND 0 2,600 2,600 LASALLE -3,225,8492390 SECURITY DEPOSITS 2,6002391 VOLUNTEER FUND 2,625 2,625 LASALLE -91,0802393 HEART FUND/BAZAAR 2,6252395 DEFERRED INC EMP & MEM 2,695 2,695 CURRENT PORTION OF LT DEBT2400 CURRENT PORTION LT DEBT 2,720 2,720 RETAINED -2,008,8792460 INCOME TAXES PAYABLE net income -727,7692512 DUE TO RESIDENTS -13,1522600 MORTGAGE PAYABLE -3,316,9292650 EQUIPMENT LOAN PAYABLE balance 02695 CURRENT PORTION LT DEBT2696 DEFERRED INCOME TAXES2710 COMMON STOCK2720 RETAINED EARNINGS -2,008,8792970 PROFIT/LOSS FOR PERIOD -727,7693007.1 PATIENT DAYS-PRIVATE 12,664 3,007 3,007 PATIENT D 12,6643007.2 PATIENT DAYS-IPA 34,295 3,007 3,007 PATIENT D 34,2953007.3 PATIENT DAYS-MEDICARE 4,955 3,007 3,007 PATIENT D 4,9553007.4 PATIENT DAYS-CONVERSION 3,0073007.5 PATIENT DAYS-LICENSED 3,0073007.6 PATIENT DAYS-TOTAL 3,0073010 1 BASIC CHARGE-PRIVATE & VA -1,365,466 0 0 0 0 3,0073015 1 PRIVATE ASSESSMENT TAX INCOME 0 0 0 0 3,010 3,010 BASIC CHA -1,365,4663020 1 BASIC CHARGE-IPA -2,689,131 0 0 0 0 3,020 3,020 BASIC CHA -2,689,1313030 1 BASIC CHARGE-MEDICARE -1,293,763 0 0 0 0 3,030 3,030 BASIC CHA -1,293,7633035 4 DAY CARE/HOME CARE 0 0 0 0 3,040 3,040 LIGHT NU -3,2973040 1 LIGHT NURSING CARE -118,237 0 0 0 0 3,050 3,050 MEDIUM N -17,2083050 1 MEDIUM NURSING CARE 0 0 0 0 3,060 3,060 HEAVY NU -30,9523060 1 HEAVY NURSING CARE 0 0 0 0 3,061 3,061 SKILLED N -66,7803061 1 SKILLED NURSING CARE 3,080 3,080 NURSING -11,3623080 1 NURSING SUPPLIES-PRIVATE -213,737 0 0 0 0 3,081 3,081 NURSING -114,1503081 1 NURSING SUPPLIES-IPA 0 0 0 0 3,082 3,082 NURSING -75,6203082 1 NURSING SUPPLIES MED PT A 0 0 0 0 3,083 3,083 NURSING -12,6053083 1 NURSING SUPPLIES MED PT B 3,100 3,100 DRUGS-ME -296,2163100 17 DRUGS -535,755 0 0 0 0 3,101 3,101 DRUGS-OT -239,5393101 17 DRUGS-OTHER 3,110 3,110 PHYSICAL -4,4803110 6 PT-PRIVATE -464,874 0 0 0 0 3,1113111 6 PT-IPA 0 0 0 0 3,112 3,112 PHYSICAL -171,7833112 6 PT-MEDICARE PART A 0 0 0 0 3,113 3,113 PHYSICAL -14,1883113 6 PT-MEDICARE PART B 0 0 0 0 3,140 3,140 RESPIRAT -7,8553130 1 PUBLIC AID ASSESSMENT INC 3,150 3,150 ST/OT THE -7,6853140 19 LABORATORY INCOME 0 0 0 0 3,151 3,151 ST/OT THE -14,1963150 6 SPEECH/OT-PRIVATE 0 0 0 0 3,152 3,152 ST/OT THE -176,6003151 6 SPEECH/OT-IPA 0 0 0 0 3,153 3,153 ST/OT THE -16,9163152 6 SPEECH/OT-MED PART A 0 0 0 0 3,160 3,185 REHAB/ISO -51,1713153 6 SPEECH/OT MED PART B 3,410 3,410 IPA/OTHER 309,7573410 2 IPA DISCOUNTS 1,055,884 0 0 0 0 3,411 3,411 MEDICARE 17,0773411 2 MEDICAID PART B DISCOUNT 0 0 0 0 3,420 3,420 MEDICARE 726,5153420 2 MEDICARE DISCOUNTS 0 0 0 0 3,5003440 36 ASSESSMENT TAX EXPENSE 42 3 0 0 3,5203520 16 RENT INCOME 0 6 0 6 0 3,530 3,530 BEAUTY S -22,2763530 13 BEAUTY SHOP -22,276 0 0 0 0 3,560 3,560 ACTIVITY 5603560 12 ACTIVITY FUND INCOME 560 0 0 0 0 3,570 3,570 VENDING -4,8813570 12 VENDING INCOME/EXPENSE -4,881 0 0 0 0 3,590 3,590 EQUIPMEN -100,3913580 12 MANAGEMENT FEES 0 0 0 0 3,5953590 1 EQUIPMENT RENTAL -100,391 0 0 0 0 3,600 3,600 MISC INCO -6153595 21 RESIDENT TRANSPORTATION 0 0 0 0 0 4,110 4,110 G&A WAG 84,2413600 21 MISC INCOME -615 0 0 0 0 4,111 4,111 ADMINIST 77,5374110 GENERAL & ADMINIST WAGES 84,241 91,781 21 1 17 0 4,115 4,115 G&A PTO & 7,5404111 ADMINISTRATOR WAGES 77,537 77,537 17 1 0 0 4,120 4,120 EMPLOYE 17,0074115 VACATION & SICK - G&A 7,540 21 1 0 0 4,125 4,125 EMPLOYE 2,5084120 4475 EMPLOYEE BENEFITS 17,115 417,594 22 3 0 0 4,1304125 EMPLOYEE HEPETITIS VACCIN 2,508 22 3 0 0 4,1354130 EMPLOYEE SCHOLORSHIP WAG 0 21 1 0 0 4,250 4,250 OFFICE SU 10,2964135 EMPLOYEE SCHOLORSHIP COS 0 23 3 0 0 4,255 4,255 POSTAGE 3,7284220 DIRECTORS FEES 18 3 0 0 4,260 4,260 TELEPHON 22,6714250 4255 OFFICE SUPPLIES 14,248 14,248 21 2 0 0 4,275 4,275 TRAINING 4,9854260 TELEPHONE 22,671 22,671 21 3 0 0 4,276 4,276 INJURY PR 4,5804275 TRAINING & EMPLOYEE DEVL 4,985 4,985 23 3 16 0 4,280 4,280 GENERAL 2,5774280 GENERAL TRAVEL 2,577 7,573 24 3 16 0 4,281 4,281 MEAL EXP 444281 MEAL EXPENSE FOR TRAVEL 44 24 3 19 0 4,285 4,285 EDUCATIO 4,9524285 EDUCATION & SEMINAR 4,952 24 3 19 -14,561 *** 4,2894290 HELP WANTED ADVERTISING 1,619 102,929 20 3 0 0 -82,673 4,290 4,290 HELP WAN 1,6194291 PROMOTIONAL ADVERTISING 3,091 20 3 25 -3,091 4,291 4,291 PROMOTIO 3,0914292 PUBLIC RELATIONS 5,233 20 3 25 -5,233 4,292 4,292 PUBLIC RE 5,2334300 LICENSES & FEES 82,897 20 3 17 0 4,300 4,300 LICENSE & 82,8974310 DUES & SUBSCRIPTIONS 9,830 20 3 17 -725 4,310 4,310 DUES & SU 9,8304320 CONTRIBUTIONS 1,139 27 3 20 -1,139 4,320 4,350 PROFESSIO 1,1394350 PROFESSIONAL FEES 3,250 354,563 19 3 22 -3,250 4,350 4,355 MEDICAL 3,2504355 MEDICAL DIRECTOR 5,650 5,650 9 3 0 0 4,355 4,360 UTILIZATI 5,6504360 UTILIZATION REVIEW 0 10 3 0 0 4,362 4,362 MEDICAL 9494361 OTHER PHYSICIAN FEES 39 3 0 0 4,363 4,363 PHARMAC 3,9904362 MEDICAL RECORDS CONSULT 949 10 3 0 0 4,364 4,364 SOCIAL SE 3,4954363 PHARMACIST FEES 3,990 10 3 0 0 4,370 4,370 TV RENTA 484364 SOC SERV/ACT CONSULT 3,495 3,495 12 3 0 0 4,383 4,383 BACKGRO 2594370 TV RENTAL 48 35 3 5 -48 ** 4,3904380 INCOME TAXES 0 105,977 27 3 26 0 4,400 4,400 PAYROLL 197,7404383 BACKGROUND CHECKS 259 20 3 26 0 4,401 4,401 PAYROLL 8,0484400 PAYROLL TAXES 197,740 22 3 0 0 4,410 4,410 GROUP IN 145,9694401 PAYROLL TAXES ADMINIST 8,048 22 3 0 0 4,420 4,420 LIABILITY 54,8024410 GROUP INSURANCE 145,969 22 3 0 0 4,430 4,430 WORKMAN 36,3434420 LIABILITY INSURANCE 54,802 54,802 26 3 0 0 4,435 4,435 W/C-FIRST 4,4954425 INSURANCE-OWNERS 22 3 21 0 4,436 4,436 DRUG TES 7964430 WORKMENS COMP INSURANCE 46,214 22 3 0 0 4,450 4,450 CENTRAL 351,3134450 CENTRAL OFFICE FEES 351,313 19 3 34 -351,313 4,460 4,460 BAD DEBT 104,4964460 BAD DEBTS 104,496 27 3 24 -104,496 4,461 4,461 BAD DEBT 2,5354470 LOST ITEMS-RESIDENTS 342 27 3 0 4,470 4,470 LOST ITEM 3424490 MISCELLANEOUS 0 27 3 0 0 4,475 4,475 UNIFORM 1084510 REAL ESTATE TAXES 55,833 55,833 33 3 0 0 4,486 4,486 SERVICE C 5,0914600 LEASED EQUIPMENT 6,026 6,074 35 3 16 0 4,490 4,490 MISC EXPE -1,1245110 MAINTENANCE SALARIES 69,409 74,312 6 1 0 0 4,496 4,496 MISC. M.I. 2245120 MAINTENANCE SICK & VAC 4,903 6 1 0 0 4,510 4,510 REAL ESTA 55,8335130 ELECTRIC 52,502 87,595 5 3 0 0 4,600 4,600 LEASED E 6,0265131 NATURAL GAS 12,484 5 3 0 0 5,110 5,110 MAINTENA 69,4095132 HEATING & DEISEL OIL 5 3 0 0 5,120 5,120 MAINTENA 4,9035133 WATER & SEWER 22,609 5 3 0 0 5,130 5,130 ELECTRIC 52,5025134 TRASH COLLECTION 3,935 20,633 6 3 0 0 5,131 5,131 NATURAL 12,4845140 PROPERTY PLANT REPLACEMN 9,212 41,518 6 2 0 0 5,133 5,133 WATER & 22,6095160 GENERAL REPAIR & MAINT 32,306 6 2 0 0 5,134 5,134 TRASH CO 3,9355165 MAINTENANCE CONTRACTS 16,698 6 3 0 0 5,140 5,140 PROP/PLAN 9,2125210 DIETARY WAGES 183,477 198,428 1 1 0 0 5,160 5,160 GENERAL 32,3065220 DIETARY SICK & VAC 14,951 1 1 0 0 5,165 5,165 MAINTENA 11,6075240 SALES TAX 2 3 13 -857 5,210 5,210 DIETARY W 183,4775248 FOOD PURCHASES 222,097 221,407 2 2 0 0 5,220 5,220 DIETARY P 14,9515250 SUPPLIES-DISHWASHING 6,241 22,212 1 2 0 0 5,248 5,248 FOOD PUR 223,2215260 DIETARY REPLACEMENT 3,148 1 2 0 0 5,250 5,250 SUPPLIES 6,2415270 KITCHEN SUPPLIES-PAPER 12,823 1 2 0 0 5,260 5,260 REPLACEM 3,1485295 MEAL CREDIT -690 2 2 0 0 5,270 5,270 KITCHEN 12,8235310 LAUNDRY WAGES 66,395 70,817 4 1 0 0 5,295 5,295 MEAL INC -6905340 LAUNDRY SICK & VAC 4,422 4 1 0 0 5,310 5,310 LAUNDRY 66,3955370 LAUNDRY REPLACEMENT 13,158 23,646 4 2 0 0 5,340 5,340 LAUNDRY 4,4225380 LAUNDRY REIMBURSEMENT 4 3 0 0 5,370 5,370 REPLACEM 13,1585390 LAUNDRY SUPPLIES 10,488 4 2 0 0 5,380 5,380 OUTSIDE L 4355410 HOUSEKEEPING WAGES 77,317 81,073 3 1 0 0 5,390 5,390 SUPPLIES 10,0535440 HOUSEKEEPING SICK & VAC 3,756 3 1 0 0 5,410 5,410 HOUSEKE 77,3175480 HOUSEKEEPING SUPPLIES 7,497 17,720 3 2 0 0 5,440 5,440 HOUSEKE 3,7565490 HOUSEKEEPING SUPPLIES-PPR 10,223 3 2 0 0 5,480 5,480 SUPPLIES- 7,4976010 RN WAGES-MEDICARE 1,662,189 10 1 0 0 5,490 5,490 SUPPLIES- 10,2236020 RN WAGES-NON MEDICARE 73,649 10 1 0 0 6,020 6,020 RN WAGE 73,6496030 DON WAGES 53,751 10 1 0 0 6,030 6,030 DON WAG 53,7516035 ADON 59,796 10 1 0 0 6,035 6,035 ADON WA 59,7966040 RN SICK & VACATION 14,452 10 1 0 0 6,040 6,040 RN PTO & 14,4526110 LPN WAGES-MEDICARE 10 1 0 0 6,120 6,120 LPN WAGE 328,4986120 LPN WAGES-NON MEDICARE 328,498 10 1 0 0 6,140 6,140 LPN PTO & 23,8426130 LPN WAGES OTHER 10 1 0 0 6,220 6,220 AIDES WA 983,4706140 LPN SICK & VACATION 23,842 10 1 0 0 6,240 6,240 AIDES PTO 84,3056210 AIDE WAGES-MEDICARE 10 1 0 0 6,2456220 AIDE WAGES-NON MEDICARE 983,470 10 1 0 0 6,2466230 WARD CLERKS 10 1 0 0 6,2476240 AIDE VACATION & SICK 84,305 10 1 0 0 6,250 6,250 NURSE AID 16,5936245 CONTRACT NURSES-RN 0 10 3 0 0 6,255 6,255 NURSE AID 10,3326246 CONTRACT NURSES-LPN 0 10 3 0 0 6,260 6,260 NURSE AID -2,0386247 CONTRACT NURSES-AIDES 0 10 3 0 0 6,270 6,270 REHAB WA 37,0636250 NURSE AIDE TRAINING WAGES 16,593 16,593 13 1 0 0 6,275 6,275 REHAB PT 3,3636255 NURSE AID TRAINING EXP 10,332 10,332 13 2 0 0 6,290 6,290 NURSING 52,5286260 NURSE AIDE TRAINING REIMB -2,038 0 0 0 0 6,295 6,295 NURSING 9,9976270 REHAB WAGES 37,063 10 1 0 0 6,390 6,390 REPLACEM 2,4426275 REHAB SICK & VAC 3,363 10 1 0 0 6,490 6,490 OTHER 3,5256280 NURSING DEPT EDUCATION 23 3 0 0 7,280 7,280 DRUG PUR 160,0626290 NURSING SUPPLIES 52,528 64,967 10 2 0 0 7,281 7,281 DRUG PUR 144,0556295 NURSING SUPPLIES 9,997 10 2 0 0 7,380 7,380 LABORAT 15,7716390 REPLACEMENT-NURSING 2,442 10 2 0 0 7,391 7,391 AMBULAN 8,4936490 NURSING OTHER 3,525 8,464 10 3 0 0 7,393 7,392 HOSPITAL 1,9627280 DRUG PURCHASES 160,062 307,104 39 2 0 252,184 *** 7,510 7,510 ACTIVITIE 71,4567281 DRUG PURCHASES-OTHER 144,055 39 2 7,540 7,540 ACTIVITIE 3,3787380 LABORATORY SERVICES 26,226 272,542 39 3 0 0 7,590 7,590 ACTIVITIE 1,3167410 HOME HEALTH SALARY 39 1 0 0 7,620 7,620 PHYSICAL 121,2127440 HOME HEALTH SICK & VAC 39 1 0 0 7,660 7,660 P.T. SUPPL 2,9877450 HOME HEALTH EXPENSES 39 3 0 0 7,710 7,710 SOCIAL SE 45,6487510 ACTIVITES WAGES 71,456 74,834 11 1 0 0 7,720 7,720 SOCIAL SE 3,8157540 ACTIVITIES SICK & VAC 3,378 11 1 0 0 7,730 7,730 SOCIAL SE 177590 ACTIVITIES SUPPLIES 1,316 1,316 11 2 0 0 7,740 7,740 OCCUPAT 117,5447595 ACTIVITIES FEES 0 0 11 3 0 0 7,7507610 PT WAGES 39 1 0 0 7,770 7,770 SPEECH TH 7,5607611 PT SICK & VACATION 39 1 0 0 7,820 7,820 BEAUTICIA 19,9007620 PT FEES 121,212 39 3 0 -20,974 *** 7,890 7,890 BEAUTY S 7827660 PT SUPPLIES 2,987 39 2 0 0 7,9607710 SOCIAL SERVICE WAGES 45,648 49,463 12 1 0 0 8,120 8,120 INTEREST 164,9517720 SOCIAL SERVICE SICK & VAC 3,815 12 1 0 0 8,125 8,125 ALLOCAT 26,1387730 SOCIAL SERVICE EXPENSES 17 17 12 2 0 0 8,130 8,130 DEPRECIA 155,7867740 OT FEE 117,544 39 3 0 -13,610 *** 8,150 8,150 LOAN FEE 6,5407750 SOCIAL THERAPIST FEE 0 0 12 3 0 0 9,510 9,510 INTEREST -407770 SPEECH THERAPY FEE 7,560 39 3 0 6,663 *** 9,5207800 BEAUTICIAN WAGES 0 40 1 0 0 9,5307810 BEAUTICIAN SICK & VAC 40 1 0 07820 BEAUTICIAN FEES 19,900 19,900 40 3 0 07890 BEAUTY SHOP SUPPLIES 782 782 40 2 0 07910 VOLUNTEER COORDINATOR 0 0 21 1 0 07940 VOL COORD SICK & VAC 21 1 0 07960 VOL COORD SUPPLIES 0 21 2 0 08100 RENT 0 0 34 3 0 0 -727,7698120 INTEREST EXPENSE 191,089 197,629 32 3 14 -408130 DEPRECIATION 155,786 155,786 30 3 9 08150 LOAN FEE AMORTIZATION 6,540 32 3 0 0 60,7739510 INTEREST INCOME -40 32 0 10 09520 MISC NON-OPERATING INCOM 0 0 0 0 09700 INCOME TAXES 0 0 0 0

5,024,913 5,026,9912,078

GRAND TOTALS -727,769 -260,490(NET INCOME)

0FACILITY NAME:FACILITY ID: 0

FACILITY UNITS: 89

BALANCE SHEET TOTAL 0173,113

G/L RECAP CENSUSPP 12,664 12,383IPA 34,295 33,967medicare 4,955 4,955

51,914 51,305

IPA BEDHOLDS 328PP BEDHOLDS 281PP CONVERS 0

FOR OHF USE LL1 THIS AGENCY IS REQUESTING … Laundry 70,817 23,646 94,463 94,463 94,463 4 5 Heat...

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Transcript of FOR OHF USE LL1 THIS AGENCY IS REQUESTING … Laundry 70,817 23,646 94,463 94,463 94,463 4 5 Heat...