riverview a sr lvg community-2002-0041178 - illinois · 2015-10-13 · state of illinois page 2...

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: 0041178 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

Facility Name: RIVERVIEW, A SR LVG COMMUNITY I have examined the contents of the accompanying report to the

Address: 500 Centennial Dr East Peoria 61611 State of Illinois, for the period from 06/01/01 to 05/31/02Number 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: Tazwell applicable instructions. Declaration of preparer (other than provider)

is based on all information of which preparer has any knowledge.Telephone Number: (309) 694-0022 Fax # ( 309) 694-3655

Intentional misrepresentation or falsification of any informationIDPA ID Number: 520886946023 in this cost report may be punishable by fine and/or imprisonment.

Date of Initial License for Current Owners: 10/03/95 (Signed)Officer or (Date)

Type of Ownership: Administrator (Type or Print Name) Barry Lazarusof Provider

VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title) Vice President - ReimbursementCharitable Corp. Individual StateTrust Partnership County (Signed)

IRS Exemption Code X Corporation Other (Date)"Sub-S" Corp. Paid (Print NameLimited Liability Co. Preparer and Title)TrustOther (Firm Name

& Address)

(Telephone) ( ) 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 Dekany Telephone Number: ( 419) 252-5740 201 S. Grand Avenue East

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

STATE OF ILLINOIS Facility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02

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)

N/A 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 55 Skilled (SNF) 55 20,075 1 investments not directly related to patient care?2 Skilled Pediatric (SNF/PED) 2 YES NO X3 Intermediate (ICF) 34 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?5 4 Sheltered Care (SC) 4 1,460 5 YES NO X6 ICF/DD 16 or Less 6

I. On what date did you start providing long term care at this location?7 59 TOTALS 59 21,535 7 Date started 10/03/95

J. Was the facility purchased or leased after January 1, 1978?B. Census-For the entire report period. YES X Date 10/03/95 NO

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 X NO If YES, enter numberRecipient Private Pay Other Total of beds certified 16 and days of care provided 4,458

8 SNF 0 332 5,142 5,474 8 9 SNF/PED 9 Medicare Intermediary CareFirst of Maryland, Inc.10 ICF 1,528 11,596 1,117 14,241 1011 ICF/DD 11 IV. ACCOUNTING BASIS12 SC 12 MODIFIED13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH*

14 TOTALS 1,528 11,928 6,259 19,715 14 Is your fiscal year identical to your tax year? YES NO X

C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: 12/31/02 Fiscal Year: 05/31/02 bed days on line 7, column 4.) 91.55% * All facilities other than governmental must report on the accrual basis.

STATE OF ILLINOIS Facility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02V. 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 270,536 (89) 270,447 792 271,239 271,239 12 Food Purchase (32) (32) (32) (16) (48) 23 Housekeeping 66,688 4,926 698 72,312 72,312 72,312 34 Laundry 22,049 8,599 1,059 31,707 31,707 31,707 45 Heat and Other Utilities 77,276 77,276 3,766 81,042 (2,166) 78,876 56 Maintenance 29,273 8,234 24,215 61,722 61,722 61,722 67 Other (specify):* 322 322 322 322 7

8 TOTAL General Services 388,546 21,638 103,570 513,754 4,558 518,312 (2,182) 516,130 8B. Health Care and Programs

9 Medical Director 3,450 3,450 3,450 3,450 910 Nursing and Medical Records 833,823 66,026 11,544 911,393 17,522 928,915 928,915 10

10a Therapy 302,485 3,406 28,317 334,208 334,208 334,208 10a11 Activities 26,383 1,224 1,952 29,559 29,559 29,559 1112 Social Services 64,591 69 1,732 66,392 66,392 66,392 1213 Nurse Aide Training 1314 Program Transportation 1415 Other (specify):* 15

16 TOTAL Health Care and Programs 1,227,282 70,725 46,995 1,345,002 17,522 1,362,524 1,362,524 16C. General Administration

17 Administrative 73,343 151,013 224,356 (48,115) 176,241 176,241 1718 Directors Fees 1819 Professional Services 1920 Dues, Fees, Subscriptions & Promotions 32,707 32,707 32,707 (21,138) 11,569 2021 Clerical & General Office Expenses 72,304 28,797 38,180 139,281 139,281 (31,331) 107,950 2122 Employee Benefits & Payroll Taxes 261,875 261,875 5,829 267,704 267,704 2223 Inservice Training & Education 1,406 1,406 1,406 1,406 2324 Travel and Seminar 7,886 7,886 7,886 7,886 2425 Other Admin. Staff Transportation 2526 Insurance-Prop.Liab.Malpractice 53,227 53,227 53,227 53,227 2627 Other (specify):* 27

28 TOTAL General Administration 145,647 28,797 546,294 720,738 (42,286) 678,452 (52,469) 625,983 28TOTAL Operating Expense

29 (sum of lines 8, 16 & 28) 1,761,475 121,160 696,859 2,579,494 (20,206) 2,559,288 (54,651) 2,504,637 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 RIVERVIEW, A SR LVG COMMUNITY #0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02

#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 162,353 162,353 20,206 182,559 182,559 3031 Amortization of Pre-Op. & Org. 3132 Interest 35,234 35,234 35,234 (1,088) 34,146 3233 Real Estate Taxes 60,489 60,489 60,489 (16,363) 44,126 3334 Rent-Facility & Grounds 3435 Rent-Equipment & Vehicles 2,784 2,784 2,784 2,784 3536 Other (specify):* 36

37 TOTAL Ownership 260,860 260,860 20,206 281,066 (17,451) 263,615 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3839 Ancillary Service Centers 124,935 2,436 127,371 127,371 127,371 3940 Barber and Beauty Shops 13 17,940 17,953 17,953 17,953 4041 Coffee and Gift Shops 4142 Provider Participation Fee 30,114 30,114 30,114 30,114 4243 Other (specify):* 15,679 15,679 15,679 15,679 43

44 TOTAL Special Cost Centers 140,627 50,490 191,117 191,117 191,117 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 1,761,475 261,787 1,008,209 3,031,471 3,031,471 (72,102) 2,959,369 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 RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02VI. 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 (16) 2 4 32 Donated Goods-Attach Schedule* 325 Telephone, TV & Radio in Resident Rooms (2,166) 5 5 Amortization of Organization &6 Rented Facility Space 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) 349 Non-Straightline Depreciation 9 35 Other- Attach Schedule 35

10 Interest and Other Investment Income (1,088) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ 3611 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ (72,102) 3713 Sales Tax (334) 21 1314 Non-Care Related Interest 14 *These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions 15 licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation) (2,034) 21 16 on these lines.17 Non-Care Related Fees 1718 Fines and Penalties 18 C. Are the following expenses included in Sections A to D of pages 319 Entertainment 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions (20) 21 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 22 Yes No Amount Reference23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. X $ 3824 Bad Debt (28,943) 21 24 39 3925 Fund Raising, Advertising and Promotional (21,138) 20 25 40 Gift and Coffee Shops X 40

Income Taxes and Illinois Personal 41 Barber and Beauty Shops X 4126 Property Replacement Tax (16,363) 33 26 42 Laboratory and Radiology X 4227 Nurse Aide Training for Non-Employees 27 43 Prescription Drugs X 4328 Yellow Page Advertising 28 44 Exceptional Care Program X 4429 Other-Attach Schedule 29 45 Other-Attach Schedule 4530 SUBTOTAL (A): (Sum of lines 1-29) $ (72,102) $ 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 5ARIVERVIEW, A SR LVG COMMUNITY

ID# 0041178Report Period Beginning: 06/01/01

Ending: 05/31/02Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference1 $ 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 3435 3536 3637 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 Total 0 49

STATE OF ILLINOIS Summary AFacility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02SUMMARY 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 0 0 0 0 0 0 0 0 0 0 12 Food Purchase (16) 0 0 0 0 0 0 0 0 0 0 (16) 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 (2,166) 0 0 0 0 0 0 0 0 0 0 (2,166) 56 Maintenance 0 0 0 0 0 0 0 0 0 0 0 0 67 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 78 TOTAL General Services (2,182) 0 0 0 0 0 0 0 0 0 0 (2,182) 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 0 0 0 0 0 0 0 0 0 0 0 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 0 0 0 0 0 0 0 0 0 0 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 0 0 0 0 0 0 0 0 0 0 0 16C. General Administration

17 Administrative 0 0 0 0 0 0 0 0 0 0 0 0 1718 Directors Fees 0 0 0 0 0 0 0 0 0 0 0 0 1819 Professional Services 0 0 0 0 0 0 0 0 0 0 0 0 1920 Fees, Subscriptions & Promotions (21,138) 0 0 0 0 0 0 0 0 0 0 (21,138) 2021 Clerical & General Office Expenses (31,331) 0 0 0 0 0 0 0 0 0 0 (31,331) 2122 Employee Benefits & Payroll Taxes 0 0 0 0 0 0 0 0 0 0 0 0 2223 Inservice Training & Education 0 0 0 0 0 0 0 0 0 0 0 0 2324 Travel and Seminar 0 0 0 0 0 0 0 0 0 0 0 0 2425 Other Admin. Staff Transportation 0 0 0 0 0 0 0 0 0 0 0 0 2526 Insurance-Prop.Liab.Malpractice 0 0 0 0 0 0 0 0 0 0 0 0 2627 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 27

28 TOTAL General Administration (52,469) 0 0 0 0 0 0 0 0 0 0 (52,469) 28TOTAL Operating Expense

29 (sum of lines 8,16 & 28) (54,651) 0 0 0 0 0 0 0 0 0 0 (54,651) 29

STATE OF ILLINOIS Summary BFacility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02

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 0 0 0 0 0 0 0 0 0 3031 Amortization of Pre-Op. & Org. 0 0 0 0 0 0 0 0 0 0 0 0 3132 Interest (1,088) 0 0 0 0 0 0 0 0 0 0 (1,088) 3233 Real Estate Taxes (16,363) 0 0 0 0 0 0 0 0 0 0 (16,363) 3334 Rent-Facility & Grounds 0 0 0 0 0 0 0 0 0 0 0 0 3435 Rent-Equipment & Vehicles 0 0 0 0 0 0 0 0 0 0 0 0 3536 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 36

37 TOTAL Ownership (17,451) 0 0 0 0 0 0 0 0 0 0 (17,451) 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) (72,102) 0 0 0 0 0 0 0 0 0 0 (72,102) 45

STATE OF ILLINOIS Page 6Facility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02

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 BusinessManor Care Inc. 100 Health Care & Retirement Corporation Toledo, OH

of America(See H.O. Cost Report)

B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,management fees, purchase of supplies, and so forth. X 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 See Home Office Allocation $ 151,013 HCR Manor Care, Inc. 100.00% $ 151,013 $ 12 V Page 23 V 8 34 V 45 V 56 V 10a Therapy Management 27,000 Heartland Management Services 100.00% 27,000 67 V 78 V 89 V 910 V 1011 V 1112 V 1213 V 1314 Total $ 178,013 $ 178,013 $ * 14

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


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 N/A $ 12 23 34 45 56 67 78 89 910 1011 1112 12

13 TOTAL $ 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 HCR Manor Care, Inc.

A. Are there any costs included in this report which were derived from allocations of central office Street Address 333 North Summit St. or parent organization costs? (See instructions.) YES X NO City / State / Zip Code Toledo, OH 43604

Phone Number ( 419) 252-5500 B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( 419) 254-5494

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 - Direct Accumulated Cost 2,026,840,883 357 Nurs. Fac $ $ $ 0 12 1 Dietary - Pooled Accumulated Cost 2,425,139,746 357 Nurs. Fac 680,609 406,990 2,822,253 792 23 5 Utilities - Direct Accumulated Cost 2,026,840,883 357 Nurs. Fac 154,435 2,822,253 215 34 5 Utilities - Pooled Accumulated Cost 2,425,139,746 357 Nurs. Fac 3,051,710 2,822,253 3,551 45 10 Nursing - Direct Accumulated Cost 2,026,840,883 357 Nurs. Fac 10,993,908 2,822,253 15,308 56 10 Nursing - Pooled Accumulated Cost 2,425,139,746 357 Nurs. Fac 1,902,166 1,264,589 2,822,253 2,214 67 17 General & Admin - Direct Accumulated Cost 2,026,840,883 357 Nurs. Fac 14,112,784 2,822,253 19,651 78 17 General & Admin - Pooled Accumulated Cost 2,425,139,746 357 Nurs. Fac 71,533,109 46,622,737 2,822,253 83,247 89 22 Employee Benefits - Direct Accumulated Cost 2,026,840,883 357 Nurs. Fac 2,156,484 2,822,253 3,003 9

10 22 Employee Benefits - Pooled Accumulated Cost 2,425,139,746 357 Nurs. Fac 2,428,174 2,822,253 2,826 1011 30 Depreciation - Direct Accumulated Cost 2,026,840,883 357 Nurs. Fac 101,489 2,822,253 141 1112 30 Depreciation - Pooled Accumulated Cost 2,425,139,746 357 Nurs. Fac 17,241,472 2,822,253 20,065 1213 1314 32 Interest 12,439,256 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ 136,795,596 $ 48,294,316 $ 151,013 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 Bankers Trust Co. X Facility $ 8,240,000 $ 7,490,000 $ 35,234 12 23 34 45 5

Working Capital6 67 78 Interest Income (1,088) 8

9 TOTAL Facility Related $ 8,240,000 $ 7,490,000 $ 34,146 9B. Non-Facility Related*

10 1011 1112 1213 13

14 TOTAL Non-Facility Related $ $ $ 14

15 TOTALS (line 9+line14) $ 8,240,000 $ 7,490,000 $ 34,146 15

16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ N/A 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. $ 70,208 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.) $ 57,167 2

3. Under or (over) accrual (line 2 minus line 1). $ (13,041) 3

4. Real Estate Tax accrual used for 2002 report. (Detail and explain your calculation of this accrual on the lines below.) $ 57,167 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. $ 44,126 7

Real Estate Tax History:

Real Estate Tax Bill for Calendar Year: 1997 64,798 8 FOR OHF USE ONLY1998 71,570 91999 75,148 10 13 FROM R. E. TAX STATEMENT FOR 2001 $ 132000 70,208 112001 57,167 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 RIVERVIEW, A SR LVG COMMUNITY COUNTY Tazwell

FACILITY IDPH LICENSE NUMBER 0041178

CONTACT PERSON REGARDING THIS REPORT Craig Dekany

TELEPHONE (419) 252-5740 FAX #: ( 419) 254-5495

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. 01-01-23-200-025 See Attached (16%) $ 372,710.72 $ 59,633.72

2. $ $

3. $ $

4. $ $

5. $ $

6. $ $

7. $ $

8. $ $

9. $ $

10. $ $

TOTALS $ 372,710.72 $ 59,633.72

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 X 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 RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02X. BUILDING AND GENERAL INFORMATION:

A. Square Feet: 18,156 B. General Construction Type: Exterior Masonry Frame Steel Number of Stories 1

C. Does the Operating Entity? X (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? X (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 X 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 Facility 1995 $ 335,515 12 23 TOTALS $ 335,515 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 59 1995 $ 2,170,148 $ 54,763 $ 54,763 $ $ 356,455 45 Audit Adj. 2002 (802,552) (20,064) (20,064) (341,084) 56 67 78 8

Improvement Type**9 BUILDING IMPROVEMENTS (Current Year Depreciation) 36,389 36,389 123,149 910 FLOORING/CARPETING 1997 2,228 1011 ELECTRICAL 1997 4,089 1112 KICKPLATES 1997 2,838 1213 HOT WATER TANK 1997 2,744 1314 FLOORING 1997 1,825 1415 MOTOR 1997 2,305 1516 GAZEBO IMPROVEMENTS 1997 1,737 1617 WALL COVERING 1997 5,337 1718 ROOM UPGRADES 1997 37,321 1819 SIGNS 1997 1,179 1920 STEAMER 1997 2,587 2021 ROOFING 1998 1,117 2122 FLOORING 1998 4,963 2223 CARPENTRY 1998 3,150 2324 PLUMBING 1998 10,659 2425 WALLCOVERING 1998 9,932 2526 DOOR/WINDOW 1998 658 2627 RENOVATION-PATIENT ROOMS 1998 41,798 2728 FINISH /STUD 1998 4,351 2829 CARPENTRY 1998 4,953 2930 DOOR/WINDOW 1998 14,573 3031 FLOORING 1998 6,859 3132 PLUMBING 1998 757 3233 ELECTRICAL 1998 7,844 3334 PAINTING/WALLCOVERING 1998 12,790 3435 GENERAL CONTRACTOR FEES 1998 11,007 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.

STATE OF ILLINOIS Page 12AFacility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02


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

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation37 ROOFING 1998 $ 500 $ $ $ $ 3738 SIGNAGE 1998 28,202 3839 HVAC 1998 4,530 3940 CONCRETE SIDEWALK 1998 1,800 4041 PAINTING/WALLCOVERING 1999 460 4142 DINING ROOM REMODEL 1999 3,196 4243 WALLCOVERING 2000 47 4344 WALLCOVERING 2000 148 4445 WALLCOVERING 2000 417 4546 DOUBLE EGRESS DOORS 2000 2,985 4647 JOCKEY PUMP FOR SPRINKER SYSTEM 2000 310 4748 OFFICE REMODELING 2000 660 4849 DINING RENOVATIONS 2000 2,169 4950 OFFICE RENO 2000 3,064 5051 CIRCULATING PUMP & PIPING 2000 2,814 5152 DINING ROOM REMODELING COST 2000 540 5253 WALLCOVERING 2000 1,689 5354 PIPING 2000 998 5455 PIPING COST 2000 22 5556 ADDTL PIPING COST 2000 274 5657 PIPING COST 2000 2,475 5758 PIPING 2000 33,529 5859 ADDTL COST OFFICE RENOVATION 2000 231 5960 COUNTERTOP-OFFICE RENOVATION 2000 795 6061 SPRINKLER WORK 2000 963 6162 SPRINKLER WORK - RETAINAGE 2000 107 6263 WALLCOVERING-BUSINESS OFFICES 2000 2,000 6364 BORDER - DON OFFICE 2000 30 6465 WALLCOVERING 2000 95 6566 CONSULTANT-DINING RM 2000 3,514 6667 FLOORING-DINING RM 2000 1,091 6768 FLOORING-DINING RM 2000 70 6869 6970 TOTAL (lines 4 thru 69) $ 1,666,921 $ 71,088 $ 71,088 $ $ 138,520 70

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

STATE OF ILLINOIS Page 12BFacility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12A, Carried Forward $ 1,666,921 $ 71,088 $ 71,088 $ $ 138,520 12 WALLCOVERING-DINING RM 2000 573 23 DINING RM RENOVATIONS 2000 1,540 34 WALLCOVERING 2000 344 45 DINING RM DEMO 2000 400 56 CONSULTING-OFFICE RENOV 2000 543 67 JOHNSON CONTROL COMPRESSOR 2000 1,189 78 ELECTRICAL 2000 3,951 89 ELECTRICAL-RETAINAGE 2000 439 9

10 PTAC UNITS & DUCKWORK-OFFICE 2000 16,375 1011 DUCTWORK & WALLS-OFFICES 2000 1,819 1112 CARPET 2000 4,652 1213 CARPET 2000 200 1314 ADDT'L DINING ROOM RENOVATION 2000 162 1415 ADDT'L COSTS OF ROOFTOP 2001 226 1516 ELECTRICAL 2000 1,919 1617 ELECTRICAL 2000 960 1718 CEILING-TILES LAUNDRY ROOM 2001 1,855 1819 CEILING TILE 2001 4,985 1920 TILE CEILING 2001 1,599 2021 CUSTOM NURSES STATION 2001 8,469 2122 CEILING TILE 2001 2,350 2223 VINYL FLOOR COVERING WITH BASE 2001 1,300 2324 RELOCATE EXHAUST FANS & GRILLE 2001 4,478 2425 RELOCATE EXHAUST FANS & GRILLE 2001 498 2526 FIRE CAULKING AND SAFING 2002 3,886 2627 PAINTING 2001 2,900 2728 BORDER 2002 75 2829 DRYVIT FOR WINDOWS 2002 7,700 2930 BORDER 2002 101 3031 Landscaping 2001 7,097 3132 AUDIT ADJUSTMENT - CAPITAL 1993 10,497 1,050 1,050 9,447 3233 3334 TOTAL (lines 1 thru 33) $ 1,760,001 $ 72,138 $ 72,138 $ $ 147,967 34


STATE OF ILLINOIS Page 12CFacility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12B, Carried Forward $ 1,760,001 $ 72,138 $ 72,138 $ $ 147,967 12 AUDIT ADJUSTMENT - CAPITAL 1994 975 97 97 780 23 AUDIT ADJUSTMENT - CAPITAL 1995 3,969 397 397 2,778 34 AUDIT ADJUSTMENT - CAPITAL 1996 2,279 228 228 1,367 45 AUDIT ADJUSTMENT - CAPITAL 1994 3,509 351 351 2,807 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) $ 1,770,732 $ 73,210 $ 73,210 $ $ 155,699 34


STATE OF ILLINOIS Page 13Facility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02XI. 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 $ 708,639 $ 89,143 $ 89,143 $ $ 484,631 7172 Current Year Purchases 84,524 7273 Fully Depreciated Assets 7374 Home Office 20,206 20,206 7475 TOTALS $ 793,162 $ 89,143 $ 109,349 $ 20,206 $ 484,631 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) $ 2,899,409 8182 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 162,353 8283 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 182,559 83 **84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ 20,206 8485 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 640,330 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: N/A 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 X 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: N/A $ 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 X NO 16. Rental Amount for movable equipment: $ 2,784 Description: O2 Concentrators, Wheelchairs, Gerichairs, Elect. Beds, Etc.

(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 N/A $ $ 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 RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02XIII. 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? X 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 D. NUMBER OF AIDES TRAINED3 Classroom Wages (a)4 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 $ $ $ $ 2. From other facilities (f)

10 SUM OF line 9, col. 1 and 2 (e) $ 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 4589 hrs $ 98,203 422 $ 10,556 $ 334 5,011 $ 109,093 1

Licensed Speech and Language2 Development Therapist 10a 925 hrs 19,788 142 3,557 1,067 23,345 23 Licensed Recreational Therapist hrs 34 Licensed Physical Therapist 10a 8621 hrs 184,494 565 14,122 3,072 9,186 201,688 45 Physician Care visits 56 Dental Care visits 67 Work Related Program hrs 78 Habilitation hrs 8

# of9 Pharmacy 39 prescrpts 124,935 124,935 9

Psychological Services (Evaluation and Diagnosis/

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

13 Other (specify): Inhalation, X-Ray 10,39 Col 3 2,518 2,518 13

14 TOTAL $ 302,485 1,129 $ 30,753 $ 128,341 15,264 $ 461,579 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 05/31/02 (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 $ 13,540 $ 1 26 Accounts Payable $ 15,544 $ 262 Cash-Patient Deposits 2 27 Officer's Accounts Payable 27

Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits 283 Patients (less allowance (81,363) ) 407,656 3 29 Short-Term Notes Payable 294 Supply Inventory (priced at ) 3,734 4 30 Accrued Salaries Payable 133,201 305 Short-Term Investments 5 Accrued Taxes Payable6 Prepaid Insurance 6 31 (excluding real estate taxes) 317 Other Prepaid Expenses 1,603 7 32 Accrued Real Estate Taxes(Sch.IX-B) 57,167 328 Accounts Receivable (owners or related parties) 8 33 Accrued Interest Payable 339 Other(specify): 9 34 Deferred Compensation 34

TOTAL Current Assets 35 Federal and State Income Taxes 3510 (sum of lines 1 thru 9) $ 426,533 $ 10 Other Current Liabilities(specify):

B. Long-Term Assets 36 Other Accrued Expenses 14,701 3611 Long-Term Notes Receivable 11 37 3712 Long-Term Investments 12 TOTAL Current Liabilities13 Land 335,515 13 38 (sum of lines 26 thru 37) $ 220,613 $ 3814 Buildings, at Historical Cost 1,770,733 14 D. Long-Term Liabilities15 Leasehold Improvements, at Historical Cost 15 39 Long-Term Notes Payable 3916 Equipment, at Historical Cost 793,162 16 40 Mortgage Payable 4017 Accumulated Depreciation (book methods) (640,330) 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) $ $ 4523 Other(specify): 23 TOTAL LIABILITIES

TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 220,613 $ 4624 (sum of lines 11 thru 23) $ 2,259,080 $ 24

47 TOTAL EQUITY(page 18, line 24) $ 2,465,000 $ 47TOTAL ASSETS TOTAL LIABILITIES AND EQUITY

25 (sum of lines 10 and 24) $ 2,685,613 $ 25 48 (sum of lines 46 and 47) $ 2,685,613 $ 48

*(See instructions.)


XVI. STATEMENT OF CHANGES IN EQUITY1

Total1 Balance at Beginning of Year, as Previously Reported $ 3,017,845 12 Restatements (describe): 23 34 45 56 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ 3,017,845 6

A. Additions (deductions):7 NET Income (Loss) (from page 19, line 43) 755,043 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) $ 755,043 17

B. Transfers (Itemize):18 Change in Interdivision (1,307,888) 1819 1920 2021 2122 2223 TOTAL Transfers (sum of lines 18-22) $ (1,307,888) 2324 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ 2,465,000 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 $ 3,029,414 1 31 General Services 513,754 312 Discounts and Allowances for all Levels (81,419) 2 32 Health Care 1,345,002 323 SUBTOTAL Inpatient Care (line 1 minus line 2) $ 2,947,995 3 33 General Administration 720,738 33

B. Ancillary Revenue B. Capital Expense4 Day Care 4 34 Ownership 260,860 345 Other Care for Outpatients 5 C. Ancillary Expense6 Therapy 673,060 6 35 Special Cost Centers 191,117 357 Oxygen 7 36 Provider Participation Fee 368 SUBTOTAL Ancillary Revenue (lines 4 thru 7) $ 673,060 8 D. Other Expenses (specify):

C. Other Operating Revenue 37 379 Payments for Education 9 38 3810 Other Government Grants 10 39 3911 Nurses Aide Training Reimbursements 1112 Gift and Coffee Shop 64 12 40 TOTAL EXPENSES (sum of lines 31 thru 39)* $ 3,031,471 4013 Barber and Beauty Care 19,421 1314 Non-Patient Meals 16 14 41 Income before Income Taxes (line 30 minus line 40)** 755,043 4115 Telephone, Television and Radio 2,166 1516 Rental of Facility Space 16 42 Income Taxes 4217 Sale of Drugs 121,388 1718 Sale of Supplies to Non-Patients 18 43 NET INCOME OR LOSS FOR THE YEAR (line 41 minus line 42) $ 755,043 4319 Laboratory 16,005 1920 Radiology and X-Ray 3,281 2021 Other Medical Services 2,030 2122 Laundry 2223 SUBTOTAL Other Operating Revenue (lines 9 thru 22)$ 164,371 23

D. Non-Operating Revenue24 Contributions 24 * This must agree with page 4, line 45, column 4.25 Interest and Other Investment Income*** 2526 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 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 1,088 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) $ 1,088 29 detailed explanation.

30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 3,786,514 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.

STATE OF ILLINOIS Page 20Facility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02XVIII. 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 2,168 2,382 $ 49,486 $ 20.77 1 Accrued Period Reference2 Assistant Director of Nursing 2,995 3,291 64,788 19.69 2 35 Dietary Consultant $ 353 Registered Nurses 4,134 4,543 86,038 18.94 3 36 Medical Director Monthly 3,450 5,9,3 364 Licensed Practical Nurses 13,118 14,414 239,943 16.65 4 37 Medical Records Consultant Monthly 1,040 5,10,3 375 Nurse Aides & Orderlies 35,208 38,687 376,199 9.72 5 38 Nurse Consultant 386 Nurse Aide Trainees 6 39 Pharmacist Consultant 397 Licensed Therapist 12,847 14,132 302,485 21.40 7 40 Physical Therapy Consultant 408 Rehab/Therapy Aides 8 41 Occupational Therapy Consultant 419 Activity Director 9 42 Respiratory Therapy Consultant 4210 Activity Assistants 2,550 2,792 26,383 9.45 10 43 Speech Therapy Consultant 4311 Social Service Workers 3,790 4,168 64,591 15.50 11 44 Activity Consultant Monthly 1,952 5,11,3 4412 Dietician 12 45 Social Service Consultant Monthly 1,732 5.12.3 4513 Food Service Supervisor 13 46 Other(specify) 4614 Head Cook 14 47 4715 Cook Helpers/Assistants 27,629 27,629 270,536 9.79 15 48 4816 Dishwashers 1617 Maintenance Workers 1,920 2,116 29,273 13.83 17 49 TOTAL (lines 35 - 48) $ 8,174 4918 Housekeepers 7,756 8,519 66,688 7.83 1819 Laundry 3,056 3,346 22,049 6.59 1920 Administrator 2,710 2,710 73,343 27.06 2021 Assistant Administrator 21 C. CONTRACT NURSES22 Other Administrative 22 1 2 323 Office Manager 23 Number Schedule V24 Clerical 4,938 5,863 72,304 12.33 24 of Hrs. Total Line &25 Vocational Instruction 25 Paid & Contract Column26 Academic Instruction 26 Accrued Wages Reference27 Medical Director 27 50 Registered Nurses $ 5028 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 5129 Resident Services Coordinator 29 52 Nurse Aides 5230 Habilitation Aides (DD Homes) 3031 Medical Records 1,935 2,127 17,369 8.17 31 53 TOTAL (lines 50 - 52) $ 5332 Other Health Care(specify) 3233 Other(specify) 3334 TOTAL (lines 1 - 33) 126,754 136,719 $ 1,761,475 * $ 12.88 34

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

STATE OF ILLINOIS Page 21Facility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02XIX. SUPPORT SCHEDULES A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions

Name Function % Amount Description Amount Description AmountLinda Van Meter Administrator 0 $ 73,343 Workers' Compensation Insurance $ 35,704 IDPH License Fee $ 565

Unemployment Compensation Insurance 15,496 Advertising: Employee Recruitment 6,695 FICA Taxes 108,780 Health Care Worker Background CheckEmployee Health Insurance 89,980 (Indicate # of checks performed 48 ) 958

Employee Meals Dues & Subscriptions 1,385 Illinois Municipal Retirement Fund (IMRF)* Association Dues 2,863Other Employee Benefits 3,121 Advertising 20,241

TOTAL (agree to Schedule V, line 17, col. 1) Payroll Overhead Allocated 890(List each licensed administrator separately.) $ 73,343 401K / SMSP Match 3,097B. Administrative - Other Disability Payments 4,620 Less: Non-Allowable Association Dues (897)

Employee Uniform 187 Less: Public Relations Expense ( ) Description Amount Home Office Allocation 5,829 Non-allowable advertising (20,241) Management Fees $ 151,013 Yellow page advertising ( )

TOTAL (agree to Schedule V, $ 267,704 TOTAL (agree to Sch. V, $ 11,569 line 22, col.8) line 20, col. 8)

TOTAL (agree to Schedule V, line 17, col. 3) $ 151,013 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 # AmountN/A $ $ Out-of-State Travel $

In-State Travel 7,191Includes travel expense to the HomeOffice in Toledo, OH for regional meeting Seminar Expense 695

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.) $ TOTAL line 24, col. 8) $ 7,886

* 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 N/A $ $ $ $ $ $ $ $ $ $2345678910111213141516171819

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

STATE OF ILLINOIS Page 23Facility Name & ID Number RIVERVIEW, A SR LVG COMMUNITY # 0041178 Report Period Beginning: 06/01/01 Ending: 05/31/02XX. 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. IHCA $ 2863

(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? Yes 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. $ N/A Has any meal income been offset against

related costs? Yes Indicate the amount. $ (16)(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? 5-10 (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. $ 24,698 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? N/Ad. Have vehicle usage logs been maintained? N/A

(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? N/A

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

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 X 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? NoFirm Name: 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. $ 30,114 been attached? If no, please explain.This 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? N/AAttach invoices and a summary of services for all architect and appraisal fees.

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