st claras manor 2016 0050724 - Illinois · Facility Name: St Claras Manor I have examined the contents of the accompanying report to the Address: 200 Fifth Street Lincoln 62656 State

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

THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY2016 PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE

STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDEDEPARTMENT OF HEALTHCARE AND FAMILY SERVICES ANY INFORMATION ON OR BEFORE THE DUE DATE WILLFINANCIAL AND STATISTICAL REPORT (COST REPORT) RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM

FOR LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.(FISCAL YEAR 2016)

I. IDPH License ID Number: 0050724 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

Facility Name: St Claras Manor I have examined the contents of the accompanying report to the

Address: 200 Fifth Street Lincoln 62656 State of Illinois, for the period from 01/01/16 to 12/31/16Number 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: Logan applicable instructions. Declaration of preparer (other than provider)

is based on all information of which preparer has any knowledge.Telephone Number: 217-735-1507 Fax # ( )

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

Date of Initial License for Current Owners: 2010 (Signed)Officer or (Date)

Type of Ownership: Administrator (Type or Print Name) David M Underwoodof Provider

x VOLUNTARY,NON-PROFIT PROPRIETARY GOVERNMENTAL (Title) EVP & CFOx Charitable Corp. Individual State

Trust Partnership County (Signed)IRS Exemption Code 501 Corporation Other (Date)

"Sub-S" Corp. Paid (Print NameLimited Liability Co. Preparer and Title)TrustOther (Firm Name

& Address)

(Telephone) ( ) Fax # ( ) MAIL TO: BUREAU OF HEALTH FINANCE

In the event there are further questions about this report, please contact: ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICESName:Dave Underwood Telephone Number: 309 823-7135 201 S. Grand Avenue East

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

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 2Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16

III. STATISTICAL DATA D. How many bed-hold days during this year were paid by the Department?A. Licensure/certification level(s) of care; enter number of beds/bed days, 0 (Do not include bed-hold days in Section B.) (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 140 Skilled (SNF) 140 51,240 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 Sheltered Care (SC) 5 YES NO x6 ICF/DD 16 or Less 6

I. On what date did you start providing long term care at this location?7 140 TOTALS 140 51,240 7 Date started 2010

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

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?

Medicaid YES x NO If YES, enter numberRecipient Private Pay Other Total of beds certified and days of care provided 1,771

8 SNF 17,857 8,593 1,771 28,221 8 9 SNF/PED 9 Medicare Intermediary WPS10 ICF 1011 ICF/DD 11 IV. ACCOUNTING BASIS12 SC 12 MODIFIED13 DD 16 OR LESS 13 ACCRUAL x CASH* CASH*

14 TOTALS 17,857 8,593 1,771 28,221 14 Is your fiscal year identical to your tax year? YES x NO

C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: Fiscal Year: bed days on line 7, column 4.) 55.08% * All facilities other than governmental must report on the accrual basis.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 3Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)

Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF 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 274,340 8,946 283,286 283,286 283,286 12 Food Purchase 233,192 233,192 233,192 233,192 23 Housekeeping 127,364 22,480 149,844 149,844 149,844 34 Laundry 64,516 14,021 78,537 78,537 78,537 45 Heat and Other Utilities 102,485 102,485 102,485 102,485 56 Maintenance 42,551 78,357 79,641 200,549 200,549 200,549 67 Other (specify):* 7

8 TOTAL General Services 508,771 356,996 182,126 1,047,893 1,047,893 1,047,893 8B. Health Care and Programs

9 Medical Director 24,976 24,976 24,976 24,976 910 Nursing and Medical Records 1,565,914 192,302 247,576 2,005,792 2,005,792 2,005,792 10

10a Therapy 164,907 21,597 186,504 (185,758) 746 746 10a11 Activities 67,214 5,651 72,865 72,865 72,865 1112 Social Services 44,050 17 3,772 47,839 47,839 47,839 1213 CNA Training 5,506 205 5,711 5,711 5,711 1314 Program Transportation 1415 Other (specify):* 15

16 TOTAL Health Care and Programs 1,682,684 363,082 297,921 2,343,687 (185,758) 2,157,929 2,157,929 16C. General Administration

17 Administrative 77,183 77,183 77,183 77,183 1718 Directors Fees 1819 Professional Services 278,336 278,336 278,336 (16,535) 261,801 1920 Dues, Fees, Subscriptions & Promotions 291,938 291,938 (240,413) 51,525 (30,051) 21,474 2021 Clerical & General Office Expenses 155,003 16,720 6,730 178,453 178,453 178,453 2122 Employee Benefits & Payroll Taxes 660,129 660,129 660,129 660,129 2223 Inservice Training & Education 4,248 4,248 4,248 4,248 2324 Travel and Seminar 5,103 5,103 5,103 (104) 4,999 2425 Other Admin. Staff Transportation 2526 Insurance-Prop.Liab.Malpractice 74,698 74,698 74,698 74,698 2627 Other (specify):* Lost Items-Residents 62,321 62,321 62,321 (62,321) 27

28 TOTAL General Administration 232,186 16,720 1,383,503 1,632,409 (240,413) 1,391,996 (109,011) 1,282,985 28TOTAL Operating Expense

29 (sum of lines 8, 16 & 28) 2,423,641 736,798 1,863,550 5,023,989 (426,171) 4,597,818 (109,011) 4,488,807 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.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 4Facility Name & ID Number St Claras Manor #0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16

#V. COST CENTER EXPENSES (continued)

Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF 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 82,699 82,699 3031 Amortization of Pre-Op. & Org. 3132 Interest (1,467) (1,467) 3233 Real Estate Taxes 3334 Rent-Facility & Grounds 459,900 459,900 459,900 (459,900) 3435 Rent-Equipment & Vehicles 4,340 4,340 4,340 4,340 3536 Other (specify):* 36

37 TOTAL Ownership 464,240 464,240 464,240 (378,668) 85,572 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3839 Ancillary Service Centers 517,082 517,082 185,758 702,840 702,840 3940 Barber and Beauty Shops 12,026 12,026 12,026 12,026 4041 Coffee and Gift Shops 4142 Provider Participation Fee 240,413 240,413 240,413 4243 Other (specify):* 43

44 TOTAL Special Cost Centers 529,108 529,108 426,171 955,279 955,279 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 2,423,641 736,798 2,856,898 6,017,337 6,017,337 (487,679) 5,529,658 45

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

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16VI. 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- BHF 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 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) (377,201) 349 Non-Straightline Depreciation 9 35 Other- Attach Schedule 35

10 Interest and Other Investment Income (1,467) 10 36 SUBTOTAL (B): (sum of lines 31-35) $ (377,201) 3611 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ (487,679) 3713 Sales Tax 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) 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 (104) 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions (25) 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 (16,535) 22 Yes No Amount Reference23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. $ 3824 Bad Debt (62,296) 24 39 3925 Fund Raising, Advertising and Promotional (30,051) 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 CNA Training for Non-Employees 27 43 Prescription Drugs 4328 Yellow Page Advertising 28 44 4429 Other-Attach Schedule 29 45 Other-Attach Schedule 4530 SUBTOTAL (A): (Sum of lines 1-29) $ (110,478) $ 30 46 Other-Attach Schedule 46

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

48 49 50 51 52

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5ASt Claras Manor

ID# 0050724Report Period Beginning: 01/01/16

Ending: 12/31/16Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference1 $ 12 23 34 45 56 67 78 89 910 1011 1112 1213 1314 1415 0 33 1516 24 1617 0 20 1718 1819 24 1920 (25) 27 2021 2122 (16,535) 19 2223 2324 (62,296) 27 2425 (30,051) 20 2526 2627 0 22 2728 2829 2930 3031 3132 3233 3334 3435 3536 3637 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 Total (108,907) 49

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary AFacility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16SUMMARY 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 0 0 0 0 0 0 0 0 0 0 0 0 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 0 0 0 0 0 0 0 0 0 0 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 0 0 0 0 0 0 0 0 0 0 0 0 8

B. Health Care and Programs9 Medical Director 0 0 0 0 0 0 0 0 0 0 0 0 9

10 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 CNA 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 (16,535) 0 0 0 0 0 0 0 0 0 0 (16,535) 1920 Fees, Subscriptions & Promotions (30,051) 0 0 0 0 0 0 0 0 0 0 (30,051) 2021 Clerical & General Office Expenses 0 0 0 0 0 0 0 0 0 0 0 0 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 (104) 0 0 0 0 0 0 0 0 0 0 (104) 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):* (62,321) 0 0 0 0 0 0 0 0 0 0 (62,321) 27

28 TOTAL General Administration (109,011) 0 0 0 0 0 0 0 0 0 0 (109,011) 28TOTAL Operating Expense

29 (sum of lines 8,16 & 28) (109,011) 0 0 0 0 0 0 0 0 0 0 (109,011) 29

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary BFacility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16

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 82,699 0 0 0 0 0 0 0 0 0 82,699 3031 Amortization of Pre-Op. & Org. 0 0 0 0 0 0 0 0 0 0 0 0 3132 Interest (1,467) 0 0 0 0 0 0 0 0 0 0 (1,467) 3233 Real Estate Taxes 0 0 0 0 0 0 0 0 0 0 0 0 3334 Rent-Facility & Grounds 0 (459,900) 0 0 0 0 0 0 0 0 0 (459,900) 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 (1,467) (377,201) 0 0 0 0 0 0 0 0 0 (378,668) 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) (110,478) (377,201) 0 0 0 0 0 0 0 0 0 (487,679) 45

HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES A. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of BusinessNFP-Board of Directors List Attached St Clara's Senior Servi Lincoln Sponsor Org

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 34 Adjustment for Related Organization 459,900 (459,900) 23 V 30 St Clara's Senior Services Inc. 0.00% 82,699 82,699 34 V 45 V 56 V 67 V 78 V 89 V 9

10 V 1011 V 1112 V 1213 V 1314 Total $ 459,900 $ 82,699 $ * (377,201) 14

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

HFS 3745 (N-4-99) IL478-2471


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 None $ 12 23 34 45 56 67 78 89 9

10 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

HFS 3745 (N-4-99) IL478-2471


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 x 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 $ $ $ 12 23 34 45 56 67 78 89 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ $ $ 25

HFS 3745 (N-4-99) IL478-2471


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 $ $ $ 12 23 34 45 5

Working Capital6 67 78 8

9 TOTAL Facility Related $ $ $ 9B. Non-Facility Related*

10 Interest Income (1,467) 1011 1112 1213 13

14 TOTAL Non-Facility Related $ $ $ (1,467) 14

15 TOTALS (line 9+line14) $ $ $ (1,467) 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.)

HFS 3745 (N-4-99) IL478-2471


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

Important, please see the next worksheet, "RE_Tax". The real estate tax 1. Real Estate Tax accrual used on 2015 report. statement and bill must accompany the cost report. $ 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.) $ 2

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

4. Real Estate Tax accrual used for 2016 report. (Detail and explain your calculation of this accrual on the lines below.) $ 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. $ 7

Real Estate Tax History:

Real Estate Tax Bill for Calendar Year: 2011 8 FOR BHF USE ONLY2012 92013 10 13 FROM R. E. TAX STATEMENT FOR 2015 $ 132014 112015 12 14 PLUS APPEAL COST FROM LINE 5 $ 14

None15 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.

HFS 3745 (N-4-99) IL478-2471

2015 LONG TERM CARE REAL ESTATE TAX STATEMENTFACILITY NAME St Claras Manor COUNTY Logan

FACILITY IDPH LICENSE NUMBER 0050724

CONTACT PERSON REGARDING THIS REPORT

TELEPHONE ( ) FAX #: ( )

A. Summary of Real Estate Tax Cost

Enter the tax index number and real estate tax assessed for 2015 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 2015.

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

Applicable toTax Index Number Property Description Total Tax Nursing Home

1. None $ $

2. $ $

3. $ $

4. $ $

5. $ $

6. $ $

7. $ $

8. $ $

9. $ $

10. $ $

TOTALS $ $

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 and 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 original 2015 tax bills which were listed in Section A to this statement. Be sure to use the 2015tax bill which is normally paid during 2016.

PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax billdocumentation . Facilities located in Cook County are required to provide copies of their original second installment tax bill.

Page 10A

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 11Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16X. BUILDING AND GENERAL INFORMATION:

A. Square Feet: 53,286 B. General Construction Type: Exterior Brick Frame Wood Number of Stories 2

C. Does the Operating Entity? (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? (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, CNA training facilities, etc.)List entity name, type of business, square footage, and number of beds/units available (where applicable).St. Clara's Senior Services - Owns real and personal property.

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 $ 12 23 TOTALS $ 3

HFS 3745 (N-4-99) IL478-2471


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

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

Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation4 140 $ 1,624,882 $ $ $ $ 45 56 67 78 8

Improvement Type**9 1976 1976 65,361 9

10 1978 1978 3,451 1011 1980 1980 8,793 1112 1981 1981 11,439 1213 1982 1982 3,826 1314 1983 1983 1,535 1415 1984 1984 4,031 1516 1985 1985 7,859 1617 1986 1986 2,541 1718 1987 1987 10,753 1819 1988 1988 1,006 1920 1989 1989 1,431 2021 1991 1991 8,799 2122 1992 1992 17,963 2223 1993 1993 15,564 2324 1994 1994 51,022 2425 1995 1995 124,932 2526 1996 1996 102,380 2627 1997 1997 39,247 2728 Fire Sprinkler 1998 22,151 2829 Transfer Switch 1998 4,819 2930 Water Line 1998 6,379 3031 Soffits 1998 3,950 3132 Generator 1998 3,164 3233 Heating, A/C Improvements 1998 8,664 3334 3435 Depreciation 57,886 57,886 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

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12AFacility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16


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

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation37 Windows 1998 $ 3,422 $ $ $ $ 3738 Sidewalks 1998 2,963 3839 Fixtures 1999 224 3940 Faucets 1999 1,532 4041 Water System Improvements 1999 7,920 4142 Windows 1999 23,400 4243 Fixtures 1999 2,812 4344 Faucets 1999 1,404 4445 Heating & Cooling Unit 2000 4,050 4546 Water System 2000 37,203 4647 Glass Doors 2000 1,145 4748 Remodeling 2000 4,581 4849 Plumbing 2000 4,128 4950 Windows 2000 600 5051 Plumbing 2000 1,702 5152 4 Ton Condensing Unit 2000 4,453 5253 Windows 2000 5,400 5354 Exhaust Fan 2000 1,100 5455 Heating & Cooling Units 2000 4,050 5556 Doors 2000 4,081 5657 Porch Ceiling 2000 4,050 5758 Exhaust Fan 2000 2,046 5859 Concrete Pad 2000 5,398 5960 Fire Sprinkler 2001 1,304 6061 Faucets 2001 3,432 6162 Patio Roof 2001 1,532 6263 Exhaust Fan 2001 1,000 6364 A/C Unit 2001 16,312 6465 A/C Kitchen 2001 6,850 6566 6667 6768 6869 6970 TOTAL (lines 4 thru 69) $ 2,314,036 $ 57,886 $ 57,886 $ $ 70

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

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12BFacility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12A, Carried Forward $ 2,314,036 $ 57,886 $ 57,886 $ $ 12 23 Code Alert Alarm 2002 5,600 34 Ceiling Fan 2002 996 45 Heat Cool Units 2002 4,550 56 Carpet 2002 2,361 67 Seal Coat Parking Lot 2002 3,342 78 Walk-In Cooler 2002 17,518 89 Roof Replacement 2002 92,577 9

10 Door 2002 824 1011 Wide Area Network Wiring 2002 3,167 1112 1213 Roof Replacement 2003 53,524 1314 Facility Wiring 2003 11,041 1415 Remodel Bathrooms 2003 33,616 1516 Closet Doors 2003 4,188 1617 Water Heaters and Storage Tank 2003 38,929 1718 Capital Report Adj 2003 (10,796) 1819 Furnace 2004 1,800 1920 Remodel Activity room-- carpet 2004 2,624 2021 Heat Cool Units 2004 8,094 2122 Remodel Employee Lounge 2004 2,955 2223 Electric Door opener 2004 1,598 2324 Drain Grate 2004 2,350 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 2,594,894 $ 57,886 $ 57,886 $ $ 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12CFacility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12B, Carried Forward $ 2,594,894 $ 57,886 $ 57,886 $ $ 12 23 Code Alert System 2005 726 34 Kitchen Hood 2005 1,662 45 Wander System 2005 2,543 56 Hallway remode -- Paint and carpet 2005 20,919 67 A/C Units 2005 1,187 78 Fire Supression 2005 1,845 89 9

10 A/C Units 2006 1,843 1011 Security Camera 2006 1,059 1112 PTAC Units 2006 1,287 1213 A/C Units 2006 1,207 1314 1415 1516 1617 Simplex Fire Alarm 2008 8,105 1718 1819 Otis elevator 2008 183,160 1920 Fire Alarm 2008 18,587 2021 2122 Fire Sprinkler 2009 4,477 2223 2324 Masonry --building exterior 2010 11,260 2425 2526 Water heater & conditioner 2011 19,115 2627 Roof 2011 88,421 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 2,962,297 $ 57,886 $ 57,886 $ $ 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12DFacility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12C, Carried Forward $ 2,962,297 $ 57,886 $ 57,886 $ $ 12 23 Rooftop Heating & Cooling Unit 2013 21,000 34 Lighting Retrofit 2013 4,482 45 Water Temperature Control & Mixing Valve 2013 4,370 56 A/C Unit 2013 2,540 67 Sprinkler Installation-Exterior Canopies 2013 5,580 78 89 New Generator 2014 43,875 9

10 Installation of Electrical Outlets 2014 4,432 1011 Replace Condensing Unit 2014 4,528 1112 Upgrade Tankless Water Heater 2014 26,198 1213 1314 Hot water boiler for laundry room 2015 5,680 1415 PTAC installation 2015 2,563 1516 Replace HVAC pump 2015 3,393 1617 Install new hot water tank 2015 3,883 1718 New 5 ton condensing unit 2015 3,300 1819 Improve parking lot - sealcoat & stripe 2015 7,500 1920 2021 Install new grease trap 2016 8,002 2122 Replace steps 2016 4,228 2223 Replace sewer pump 2016 2,691 2324 Install new water heaters 2016 9,180 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 3,129,722 $ 57,886 $ 57,886 $ $ 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 13Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16XI. OWNERSHIP COSTS (continued)

C. Equipment Costs-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 $ 1,238,681 $ 20,138 $ 20,138 $ $ 7172 Current Year Purchases 7273 Fully Depreciated Assets 7374 7475 TOTALS $ 1,238,681 $ 20,138 $ 20,138 $ $ 75

D. Vehicle Costs. (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 2015 Grand Caravan 2015 $ 32,723 $ 4,675 $ 4,675 $ $ 7677 7778 7879 7980 TOTALS $ 32,723 $ 4,675 $ 4,675 $ $ 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) $ 4,401,126 8182 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 86,083 8283 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 86,083 83 **84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ 8485 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 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.

HFS 3745 (N-4-99) IL478-2471


XII. RENTAL COSTSA. Building and Fixed Equipment (See instructions.) 1. Name of Party Holding Lease: St. Clara's Senior Services 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 Original Rental Total Years Total YearsConstructed of Beds Lease Date Amount of Lease Renewal Option*

Original 10. Effective dates of current rental agreement:3 Building: $ 459,900 3 Beginning4 Additions 4 Ending5 56 6 11. Rent to be paid in future years under the current7 TOTAL $ 459,900 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. /2017 $ 459,900

13. /2018 $ 459,900 9. Option to Buy: YES NO Terms: * 14. /2019 $ 459,900

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: $ 4,340 Description: Copiers and televisions

(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 None $ $ 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.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 15Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.)

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

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

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

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

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

FacilityDrop-outs Completed Contract Total $

1 Community College Tuition $ $ $ $2 Books and Supplies 205 205 D. NUMBER OF CNAs TRAINED3 Classroom Wages (a) 5,506 5,5064 Clinical Wages (b) COMPLETED5 In-House Trainer Wages (c) 1. From this facility6 Transportation 2. From other facilities (f)7 Contractual Payments DROP-OUTS8 CNA Competency Tests 1. From this facility9 TOTALS $ $ 5,711 $ $ 5,711 2. From other facilities (f)10 SUM OF line 9, col. 1 and 2 (e) $ 5,711 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 CNAs 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 CNA is from your facility or is being contracted to be trained in of those facilities for which you trained CNAs. your facility. Drop-out costs can only be for costs incurred by your own CNAs.

HFS 3745 (N-4-99) IL478-2471


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 hrs $ $ 203,589 $ $ 203,589 1

Licensed Speech and Language2 Development Therapist hrs 124,246 124,246 23 Licensed Recreational Therapist hrs 34 Licensed Physical Therapist hrs 189,247 746 189,993 45 Physician Care visits 56 Dental Care visits 67 Work Related Program hrs 78 Habilitation hrs 8

# of9 Pharmacy prescrpts 164,161 164,161 9

Psychological Services (Evaluation and Diagnosis/

10 Behavior Modification) hrs 1011 Academic Education hrs 1112 Other (specify): 12

13 Other (specify): 21,597 21,597 13

14 TOTAL $ $ 538,679 $ 164,907 $ 703,586 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 CNAs, who help with the above activities should not be listed on this schedule.

HFS 3745 (N-4-99) IL478-2471


XV. BALANCE SHEET - Unrestricted Operating Fund. As of 12/31/16 (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 $ 70,341 $ 1 26 Accounts Payable $ 197,698 $ 262 Cash-Patient Deposits 27,433 2 27 Officer's Accounts Payable 27

Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits 27,433 283 Patients (less allowance ) 1,111,291 3 29 Short-Term Notes Payable 294 Supply Inventory (priced at ) 16,952 4 30 Accrued Salaries Payable 174,240 305 Short-Term Investments 5 Accrued Taxes Payable6 Prepaid Insurance 19,052 6 31 (excluding real estate taxes) 2,380 317 Other Prepaid Expenses 7 32 Accrued Real Estate Taxes(Sch.IX-B) 328 Accounts Receivable (owners or related parties) 488,838 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) $ 1,733,907 $ 10 Other Current Liabilities(specify):

B. Long-Term Assets 36 Bed Tax 27,406 3611 Long-Term Notes Receivable 11 37 3712 Long-Term Investments 12 TOTAL Current Liabilities13 Land 13 38 (sum of lines 26 thru 37) $ 429,157 $ 3814 Buildings, at Historical Cost 14 D. Long-Term Liabilities15 Leasehold Improvements, at Historical Cost 15 39 Long-Term Notes Payable 3916 Equipment, at Historical Cost 16 40 Mortgage Payable 4017 Accumulated Depreciation (book methods) 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) $ 429,157 $ 4624 (sum of lines 11 thru 23) $ $ 24

47 TOTAL EQUITY(page 18, line 24) $ 1,304,750 $ 47TOTAL ASSETS TOTAL LIABILITIES AND EQUITY

25 (sum of lines 10 and 24) $ 1,733,907 $ 25 48 (sum of lines 46 and 47) $ 1,733,907 $ 48

*(See instructions.)

HFS 3745 (N-4-99) IL478-2471


XVI. STATEMENT OF CHANGES IN EQUITY1

Total1 Balance at Beginning of Year, as Previously Reported $ 1,857,452 12 Restatements (describe): 23 34 45 56 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ 1,857,452 6

A. Additions (deductions):7 NET Income (Loss) (from page 19, line 43) (552,702) 78 Aquisitions of Pooled Companies 89 Proceeds from Sale of Stock 9

10 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) $ (552,702) 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) $ 1,304,750 24 *

* This must agree with page 17, line 47.

HFS 3745 (N-4-99) IL478-2471


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 2I. Revenue Amount II. Expenses Amount

A. Inpatient Care A. Operating Expenses1 Gross Revenue -- All Levels of Care $ 4,873,244 1 31 General Services 1,047,893 312 Discounts and Allowances for all Levels (1,607,764) 2 32 Health Care 2,343,687 323 SUBTOTAL Inpatient Care (line 1 minus line 2) $ 3,265,480 3 33 General Administration 1,632,409 33

B. Ancillary Revenue B. Capital Expense4 Day Care 4 34 Ownership 464,240 345 Other Care for Outpatients 5 C. Ancillary Expense6 Therapy 1,809,845 6 35 Special Cost Centers 529,108 357 Oxygen 7 36 Provider Participation Fee 368 SUBTOTAL Ancillary Revenue (lines 4 thru 7) $ 1,809,845 8 D. Other Expenses (specify):

C. Other Operating Revenue 37 379 Payments for Education 9 38 38

10 Other Government Grants 10 39 3911 CNA Training Reimbursements 1112 Gift and Coffee Shop 582 12 40 TOTAL EXPENSES (sum of lines 31 thru 39)* $ 6,017,337 4013 Barber and Beauty Care 13,935 1314 Non-Patient Meals 14 41 Income before Income Taxes (line 30 minus line 40)** (552,702) 4115 Telephone, Television and Radio 1516 Rental of Facility Space 16 42 Income Taxes 4217 Sale of Drugs 268,900 1718 Sale of Supplies to Non-Patients 18 43 NET INCOME OR LOSS FOR THE YEAR (line 41 minus line 42) $ (552,702) 4319 Laboratory 1920 Radiology and X-Ray 20 III. Net Inpatient Revenue detailed by Payer Source21 Other Medical Services (574) 21 44 Medicaid - Net Inpatient Revenue $ 4422 Laundry 22 45 Private Pay - Net Inpatient Revenue 4523 SUBTOTAL Other Operating Revenue (lines 9 thru 22) $ 282,843 23 46 Medicare - Net Inpatient Revenue 46

D. Non-Operating Revenue 47 Other-(specify) 4724 Contributions 105,000 24 48 Other-(specify) 4825 Interest and Other Investment Income*** 1,467 25 49 TOTAL Inpatient Care Revenue (This total must agree to Line 3) $ 4926 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 106,467 26

E. Other Revenue (specify):**** * This must agree with page 4, line 45, column 4.27 Settlement Income (Insurance, Legal, Etc.) 27 ** Does this agree with taxable income (loss) per Federal Income28 28 Tax Return? If not, please attach a reconciliation.

28a 28a *** See the instructions. If this total amount has not been offset against interest29 SUBTOTAL Other Revenue (lines 27, 28 and 28a) $ 29 expense on Schedule V, line 32, please include a detailed explanation.

30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 5,464,635 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 20Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16XVIII. 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 1,832 1,928 $ 64,583 $ 33.50 1 Accrued Period Reference2 Assistant Director of Nursing 0 2 35 Dietary Consultant $ 0 353 Registered Nurses 9,798 10,314 313,253 30.37 3 36 Medical Director 24,976 364 Licensed Practical Nurses 15,951 16,790 416,413 24.80 4 37 Medical Records Consultant 2,291 375 CNAs & Orderlies 49,374 51,973 707,411 13.61 5 38 Nurse Consultant 386 CNA Trainees 598 630 5,506 8.74 6 39 Pharmacist Consultant 5,170 397 Licensed Therapist 7 40 Physical Therapy Consultant 408 Rehab/Therapy Aides 2,120 2,232 64,254 28.79 8 41 Occupational Therapy Consultant 419 Activity Director 9 42 Respiratory Therapy Consultant 42

10 Activity Assistants 5,743 6,045 67,214 11.12 10 43 Speech Therapy Consultant 4311 Social Service Workers 1,796 1,890 44,050 23.31 11 44 Activity Consultant 4412 Dietician 12 45 Social Service Consultant 3,772 4513 Food Service Supervisor 13 46 Other(specify) 4614 Head Cook 14 47 4715 Cook Helpers/Assistants 23,708 24,956 274,340 10.99 15 48 4816 Dishwashers 1617 Maintenance Workers 3,171 3,338 42,551 12.75 17 49 TOTAL (lines 35 - 48) $ 36,209 4918 Housekeepers 9,240 9,726 127,364 13.10 1819 Laundry 5,271 5,548 64,516 11.63 1920 Administrator 1,984 2,088 77,183 36.97 2021 Assistant Administrator 21 C. CONTRACT NURSES22 Other Administrative 22 1 2 323 Office Manager 23 Number Schedule V24 Clerical 6,991 7,359 155,003 21.06 24 of Hrs. Total Line &25 Vocational Instruction 25 Paid & Contract Column26 Academic Instruction 26 Accrued Wages Reference27 Medical Director 27 50 Registered Nurses $ 3,633 5028 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 36,797 5129 Resident Services Coordinator 29 52 Certified Nurse Assistants/Aides 199,397 5230 Habilitation Aides (DD Homes) 3031 Medical Records 31 53 TOTAL (lines 50 - 52) $ 239,827 5332 Other Health Care(specify) 3233 Other(specify) 3334 TOTAL (lines 1 - 33) 137,577 144,817 $ 2,423,641 * $ 16.74 34

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

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 21Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16XIX. SUPPORT SCHEDULES A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions

Name Function % Amount Description Amount Description AmountMike Eads $ 77,183 Workers' Compensation Insurance $ 75,869 IDPH License Fee $

Unemployment Compensation Insurance 13,551 Advertising: Employee Recruitment 5,541 FICA Taxes 185,409 Health Care Worker Background Check Employee Health Insurance 354,365 (Indicate # of checks performed ) 3,546 Employee Meals Illinois Municipal Retirement Fund (IMRF)*

PR 7,422TOTAL (agree to Schedule V, line 17, col. 1) Other Benefits 30,935 Dues & Subscriptions 11,896(List each licensed administrator separately.) $ 77,183 License & Fees 5,717B. Administrative - Other

Less: Public Relations Expense (7,422) Description Amount Non-allowable advertising (5,226)

$ Yellow page advertising ( )

TOTAL (agree to Schedule V, $ 660,129 TOTAL (agree to Sch. V, $ 21,474 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 Operations Group Mgmt $ 256,433 $ Out-of-State Travel $ADP Payroll tax processing 1,183JM Abbott Audit 9,329Principal Financial 401 k consulting 1,500 In-State Travel

4,04415

Seminar Expense 1,044

(104)Legal adj to Zero 9,891

Entertainment Expense ( )TOTAL (agree to Schedule V, line 19, column 3) TOTAL $ (agree to Sch. V,(For legal fee disclosure, see page 39 of instructions) $ 278,336 TOTAL line 24, col. 8) $ 4,999

* Attach copy of IMRF notifications **See instructions.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 22Facility Name & ID Number St Claras Manor # 0050724 Report Period Beginning: 01/01/16 Ending: 12/31/16XX. 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, 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. HCCI

(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? No on Schedule V. $ 0 Has any meal income been offset against

related costs? Yes Indicate the amount. $ 4,059(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 Yrs (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? 100%d. 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 x 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 x If YES, please indicate name of the facility, transportation during this reporting period. $ 0IDPH 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: JM Abbott

(11) Indicate the amount of the Provider Participation Fees paid and accrued to the Departmentduring this cost report period. $ 240,413 (18) Have all costs which do not relate to the provision of long term care been adjusted outThis amount is to be recorded on line 42 of Schedule V. out of Schedule V? Yes

(12) Are there any salary costs which have been allocated to more than one line on Schedule V (19) Has a schedule for the legal fees reported on the cost report been provided by the facility?for an individual employee? No If YES, attach an explanation of the allocation. See page 39 of the instructions for details. None Claimed

Attach invoices and a summary of services for all architect and appraisal fees

HFS 3745 (N-4-99) IL478-2471

Account G/L Cost Rpt Sch 5 pg 3 Sch 5 pg 3 Sch 6 pg AdjustmentNumber Description Balance Grouping Line # Col # Line # Amount1009 PETTY CASH 70,341 1,009 1,009 CASH 70,3411010 CASH IN BANK 1,100 1,100 ACCTS RE 1,361,2911040 CASH IN BANK-PAYROLL 1,101 1,101 ALLOW. F (250,000)1100 ACCOUNTS RECEIVABLE 1,111,291 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 14,6541145 A/R SUSPENSE-REFUNDS 1,220 1,220 OTHER PR 4,3981190 ACCRUED INTEREST REC 1,300 1,300 DIETARY 2,3091200 PREPAID INSURANCE 19,052 1,310 1,310 SUPPLIES 14,6431220 OTHER PREPAID EXPENSES 1,320 1,320 LINEN INVENTORY1300 FOOD INVENTORY 1,409 1,409 LAND 01310 SUPPLIES INVENTORY 16,952 1,450 1,450 FURNITU 01409 LAND 0 1,460 01450 FURNITURE & EQUIPMENT 0 1,475 1,475 BUILDING 01460 ACCUM DEPR-FURN & EQUI 0 1,490 1,490 ACCUM D 01475 BUILDING & IMPROVEMENT 0 1,530 1,530 RESIDEN 27,4331490 ACCUM DEPR-BUILDING 0 1,550 1,550 LOAN FE 01530 RESIDENT FUNDS 27,433 1,551 1,551 LOAN FEES ADDED1550 LOAN FEES 0 1,850 1,850 INTERCO 488,8381560 REAL ESTATE TAX ESCROW 2,010 2,010 ACCOUN (197,698)1575 REIMBURSABLE PURCHASES 2,100 2,095 BONUSES PAYABLE1850 INTRACOMPANY 488,838 2,100 2,100 ACCRUED (49,660)2010 ACCOUNTS PAYABLE -197,698 2,100 2,100 PR CLEARING-BENEFITS2095 BONUSES PAYABLE 2,100 2,100 PR CLEARING-LABOR2100 ACCRUED PAYROLL -49,660 2,110 2,110 ACCRUED (124,580)2110 ACCRUED VACATION PAY -124,580 2,120 2,120 U.C. TAX 02120 UC TAXES PAYABLE 2,125 2,125 FICA TAX 02125 FICA TAX PAYABLE -2,380 -2,380 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/H (1,796)2245 GROUP INSURANCE PAYABLE 2,2502246 GROUP INSURANCE PAYABLE-CAFETERIA 2,260 2,260 WAGE GA (584)2260 WAGE GARNISHMENTS 2,300 2,300 ACCRUED 02280 MISC PAYROLL DEDUCTIONS 2,320 2,320 IPA PAYM (27,406)2300 ACCRUED INTEREST PAYAB 0 2,350 2,350 REAL EST 02310 SALES TAX PAYABLE 2,385 02320 IPA PAYMENTS PAYABLE -27,406 2,400 2,400 CURRENT PORTION OF LT DEBT2350 REAL ESTATE TAX PAYABL 0 2,512 2,512 DUE TO R (27,433)2385 ACTIVITY FUND 0 2,600 2,600 LASALLE 02390 SECURITY DEPOSITS 0 2,6002391 VOLUNTEER FUND 2,625 2,625 LASALLE CONSTR. LOAN #22393 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 RETAINE (1,857,452)2460 INCOME TAXES PAYABLE net income 552,7022512 DUE TO RESIDENTS -27,4332600 MORTGAGE PAYABLE 02650 EQUIPMENT LOAN PAYABLE balance 02695 CURRENT PORTION LT DEBT2696 DEFERRED INCOME TAXES2710 COMMON STOCK2720 RETAINED EARNINGS -1,857,4522970 PROFIT/LOSS FOR PERIOD 552,7023007.1 PATIENT DAYS-PRIVATE 8,593 3,007 3,007 PATIENT D 8,5933007.2 PATIENT DAYS-IPA 17,857 3,007 3,007 PATIENT D 17,8573007.3 PATIENT DAYS-MEDICARE 1,771 3,007 3,007 PATIENT D 1,7713007.4 PATIENT DAYS-CONVERSION 3,007 03007.5 PATIENT DAYS-LICENSED 3,0073007.6 PATIENT DAYS-TOTAL 3,0073010 1 BASIC CHARGE-PRIVATE & -4,859,981 0 0 0 0 3,0073015 1 PRIVATE ASSESSMENT TAX INCOME 0 0 0 0 3,010 3,010 BASIC CHA (4,859,981)3020 1 BASIC CHARGE-IPA 0 0 0 0 0 3,020 3,020 BASIC CHA 03030 1 BASIC CHARGE-MEDICARE 0 0 0 0 0 3,030 3,030 BASIC CHA 03035 4 DAY CARE/HOME CARE 0 0 0 0 3,040 163,5533040 1 LIGHT NURSING CARE 0 0 0 0 0 3,050 03050 1 MEDIUM NURSING CARE 0 0 0 0 3,060 03060 1 HEAVY NURSING CARE 0 0 0 0 3,061 03061 1 SKILLED NURSING CARE 3,080 3,080 NURSING (4,498)3080 1 NURSING SUPPLIES-PRIVAT -20,651 0 0 0 0 3,081 3,081 NURSING (12,701)3081 1 NURSING SUPPLIES-IPA 0 0 0 0 3,082 3,082 NURSING (3,452)3082 1 NURSING SUPPLIES MED PT A 0 0 0 0 3,083 3,083 NURSING 03083 1 NURSING SUPPLIES MED PT B 3,100 3,100 DRUGS-ME (204,769)3100 17 DRUGS -268,900 0 0 0 0 3,101 (64,131)3101 17 DRUGS-OTHER 3,110 3,110 PHYSICAL (96,305)3110 6 PT-PRIVATE -1,809,845 0 0 0 0 3,111 03111 6 PT-IPA 0 0 0 0 3,112 3,112 PHYSICAL (199,375)3112 6 PT-MEDICARE PART A 0 0 0 0 3,113 3,113 PHYSICAL (344,795)3113 6 PT-MEDICARE PART B 0 0 0 0 3,140 3,140 LABORAT (99,785)3130 1 PUBLIC AID ASSESSMENT IN 163,553 3,150 (159,995)3140 19 LABORATORY INCOME 0 0 0 0 3,151 (2,365)3150 6 SPEECH/OT-PRIVATE 0 0 0 0 3,152 3,152 ST/OT THE (330,385)3151 6 SPEECH/OT-IPA 0 0 0 0 3,153 3,153 ST/OT THE (576,840)3152 6 SPEECH/OT-MED PART A 0 0 0 0 3,160 3,185 REHAB/ISOLATION/OTHER CHG3153 6 SPEECH/OT MED PART B 3,410 3,410 IPA/OTHER 226,9663410 2 IPA DISCOUNTS 1,607,764 0 0 0 0 3,411 3,411 MEDICARE 419,8753411 2 MEDICAID PART B DISCOUNT 0 0 0 0 3,420 3,420 MEDICARE 935,7423420 2 MEDICARE DISCOUNTS 0 0 0 0 3,500 (16,372)3440 36 ASSESSMENT TAX EXPENSE 42 3 0 0 3,520 3,520 RENT INCO 03520 16 RENT INCOME 0 6 0 6 0 3,530 3,530 BEAUTY S (13,935)3530 13 BEAUTY SHOP -13,935 0 0 0 0 3,560 (125)3560 12 ACTIVITY FUND INCOME -125 0 0 0 0 3,570 3,570 (457)3570 12 VENDING INCOME/EXPENSE -457 0 0 0 0 3,590 3,590 EQUIPMEN 7,3883580 12 MANAGEMENT FEES 0 0 0 0 3,595 3,595 RESIDENT 03590 1 EQUIPMENT RENTAL 7,388 0 0 0 0 3,600 3,600 MISC INCO 5743595 21 RESIDENT TRANSPORTATIO 0 0 0 0 0 4,110 4,110 G&A WAG 143,1823600 21 MISC INCOME 574 0 0 0 0 4,111 4,111 ADMINIST 77,1834110 GENERAL & ADMINIST WAG 143,182 155,003 21 1 17 0 4,115 4,115 G&A PTO & 11,8214111 ADMINISTRATOR WAGES 77,183 77,183 17 1 0 0 4,120 4,120 EMPLOYE 31,6714115 VACATION & SICK - G&A 11,821 21 1 0 0 4,1214120 4475 EMPLOYEE BENEFITS 30,935 660,129 22 3 0 0 4,130 4,130 EMPLOYE 04125 EMPLOYEE HEPETITIS VACC 0 22 3 0 0 4,135 4,135 EMPLOYE 04130 EMPLOYEE SCHOLORSHIP W 0 163,553 21 1 0 0 4,250 4,250 OFFICE SU 8,0574135 EMPLOYEE SCHOLORSHIP C 0 23 3 0 0 4,255 4,255 POSTAGE 5424220 DIRECTORS FEES 0 0 18 3 0 0 4,260 4,260 TELEPHON 6,7304250 4255 OFFICE SUPPLIES 16,720 16,720 21 2 0 0 4,275 4,275 TRAINING 4,2484260 TELEPHONE 6,730 6,730 21 3 0 0 4,2764275 TRAINING & EMPLOYEE DE 4,248 4,248 23 3 16 0 ** 4,280 4,280 GENERAL 4,0444280 GENERAL TRAVEL 4,044 5,103 24 3 16 0 4,281 4,281 MEAL EXP 154281 MEAL EXPENSE FOR TRAVE 15 24 3 19 0 4,285 4,285 EDUCATIO 8724285 EDUCATION & SEMINAR 1,044 24 3 19 -104 *** 4,289 4,289 MEETINGS 1724290 HELP WANTED ADVERTISIN 5,541 128,385 20 3 0 0 -76,860 4,290 4,290 HELP WAN 5,5414291 PROMOTIONAL ADVERTISIN 17,403 20 3 25 -17,403 4,291 4,291 PROMOTIO 17,4034292 PUBLIC RELATIONS 7,422 20 3 25 -7,422 4,292 4,292 PUBLIC RE 7,4224300 LICENSES & FEES 82,577 20 3 17 0 4,300 4,300 LICENSE & 82,5774310 DUES & SUBSCRIPTIONS 11,896 20 3 17 -5,226 4,310 4,310 DUES & SU 11,8964320 CONTRIBUTIONS 25 27 3 20 -25 4,320 4,320 CONTRIBU 254350 PROFESSIONAL FEES 21,837 278,336 19 3 22 -16,535 4,350 4,350 PROFESSIO 21,8374355 MEDICAL DIRECTOR 24,976 24,976 9 3 0 0 4,355 4,355 MEDICAL 24,9764360 UTILIZATION REVIEW 0 10 3 0 0 4,362 2,2914361 OTHER PHYSICIAN FEES 39 3 0 0 4,363 5,1704362 MEDICAL RECORDS CONSU 2,291 10 3 0 0 4,364 4,364 SOCIAL SE 3,7724363 PHARMACIST FEES 5,170 10 3 0 0 4,370 4,370 TV RENTA 1,9154364 SOC SERV/ACT CONSULT 3,772 3,772 12 3 0 0 4,383 4,383 BACKGRO 3,5464370 TV RENTAL 1,915 35 3 5 0 4,390 4,390 OTHER TA 04380 INCOME TAXES 62,321 27 3 26 0 4,400 4,400 PAYROLL 190,9494383 BACKGROUND CHECKS 3,546 20 3 26 0 4,401 4,401 PAYROLL 8,0114400 PAYROLL TAXES 190,949 22 3 0 0 4,410 4,410 GROUP IN 354,3654401 PAYROLL TAXES ADMINIST 8,011 22 3 0 0 4,420 4,420 LIABILITY 74,6984410 GROUP INSURANCE 354,365 22 3 0 0 4,430 4,430 WORKMAN 74,7424420 LIABILITY INSURANCE 74,698 74,698 26 3 0 0 4,435 4,435 W/C-FIRST 2474425 INSURANCE-OWNERS 22 3 21 0 4,436 4,436 DRUG TES 8804430 WORKMENS COMP INSURAN 75,869 22 3 0 0 4,450 4,450 MANAGEM 256,4994450 CENTRAL OFFICE FEES 256,499 19 3 34 0 ** 4,460 4,460 BAD DEBT 62,2964460 BAD DEBTS 62,296 27 3 24 -62,296 4,461 4,461 BAD DEBT 41,5534470 LOST ITEMS-RESIDENTS 0 27 3 0 4,470 4,470 LOST ITEM 04490 MISCELLANEOUS 0 27 3 0 0 4,475 4,475 UNIFORM (736)4510 REAL ESTATE TAXES 0 0 33 3 0 0 4,486 4,486 SERVICE C 24,9974600 LEASED EQUIPMENT 2,425 4,340 35 3 16 0 4,490 4,490 MISC EXPE 1875110 MAINTENANCE SALARIES 40,621 42,551 6 1 0 0 4,496 4,496 MISC. M.I. 8,1215120 MAINTENANCE SICK & VAC 1,930 6 1 0 0 4,510 4,510 REAL ESTA 05130 ELECTRIC 61,785 102,485 5 3 0 0 4,600 4,600 LEASED E 2,4255131 NATURAL GAS 9,080 5 3 0 0 5,110 5,110 MAINTENA 40,6215132 HEATING & DEISEL OIL 5 3 0 0 5,120 5,120 MAINTENA 1,9305133 WATER & SEWER 31,620 5 3 0 0 5,130 5,130 ELECTRIC 61,7855134 TRASH COLLECTION 9,387 79,641 6 3 0 0 5,131 5,131 NATURAL 9,0805140 PROPERTY PLANT REPLACE 6,136 78,357 6 2 0 0 5,133 5,133 WATER & 31,6205160 GENERAL REPAIR & MAINT 72,221 6 2 0 0 5,134 5,134 TRASH CO 9,3875165 MAINTENANCE CONTRACT 70,254 6 3 0 0 5,140 5,140 PROP/PLAN 6,1365210 DIETARY WAGES 259,922 274,340 1 1 0 0 5,160 5,160 GENERAL 72,2215220 DIETARY SICK & VAC 14,418 1 1 0 0 5,165 5,165 MAINTENA 45,2575240 SALES TAX 2 3 13 0 5,210 5,210 DIETARY W 259,9225248 FOOD PURCHASES 237,251 233,192 2 2 0 0 5,220 5,220 DIETARY P 14,4185250 SUPPLIES-DISHWASHING 4,447 8,946 1 2 0 0 5,248 5,248 FOOD PUR 237,0645260 DIETARY REPLACEMENT 2,315 1 2 0 0 5,250 5,250 SUPPLIES 4,4475270 KITCHEN SUPPLIES-PAPER 2,184 1 2 0 0 5,260 5,260 REPLACEM 2,3155295 MEAL CREDIT -4,059 2 2 0 0 5,270 5,270 KITCHEN 2,1845310 LAUNDRY WAGES 59,286 64,516 4 1 0 0 5,295 5,295 MEAL INC (4,059)5340 LAUNDRY SICK & VAC 5,230 4 1 0 0 5,310 5,310 LAUNDRY 59,2865370 LAUNDRY REPLACEMENT 9,247 14,021 4 2 0 0 5,340 5,340 LAUNDRY 5,2305380 LAUNDRY REIMBURSEMENT 4 3 0 0 5,370 5,370 REPLACEM 9,2475390 LAUNDRY SUPPLIES 4,774 4 2 0 0 5,380 05410 HOUSEKEEPING WAGES 118,499 127,364 3 1 0 0 5,390 5,390 SUPPLIES 4,7745440 HOUSEKEEPING SICK & VAC 8,865 3 1 0 0 5,410 5,410 HOUSEKE 118,4995480 HOUSEKEEPING SUPPLIES 21,573 22,480 3 2 0 0 5,440 5,440 HOUSEKE 8,8655490 HOUSEKEEPING SUPPLIES-P 907 3 2 0 0 5,480 5,480 SUPPLIES- 21,5736010 RN WAGES-MEDICARE 1,565,914 10 1 0 0 5,490 5,490 SUPPLIES- 9076020 RN WAGES-NON MEDICARE 297,769 10 1 0 0 6,020 6,020 RN WAGE 297,7696030 DON WAGES 64,583 10 1 0 0 6,030 6,030 DON WAG 64,5836035 ADON 0 10 1 0 0 6,035 6,035 ADON WA 06040 RN SICK & VACATION 15,484 10 1 0 0 6,040 6,040 RN PTO & 15,4846110 LPN WAGES-MEDICARE 392,726 10 1 0 0 6,120 6,120 LPN WAGE 392,7266120 LPN WAGES-NON MEDICAR 0 10 1 0 0 6,140 6,140 LPN PTO & 23,6876130 LPN WAGES OTHER 10 1 0 0 6,220 6,220 AIDES WA 671,2536140 LPN SICK & VACATION 23,687 10 1 0 0 6,240 6,240 AIDES PTO 36,1586210 AIDE WAGES-MEDICARE 10 1 0 0 6,245 3,6336220 AIDE WAGES-NON MEDICAR 671,253 10 1 0 0 6,246 36,7976230 WARD CLERKS 10 1 0 0 6,247 199,3976240 AIDE VACATION & SICK 36,158 10 1 0 0 6,250 5,5066245 CONTRACT NURSES-RN 3,633 10 3 0 0 6,255 2056246 CONTRACT NURSES-LPN 36,797 10 3 0 0 6,260 06247 CONTRACT NURSES-AIDES 199,397 10 3 0 0 6,270 6,270 REHAB WA 59,9716250 NURSE AIDE TRAINING WAG 5,506 5,506 13 1 0 0 6,275 6,275 REHAB PT 4,2836255 NURSE AID TRAINING EXP 205 205 13 2 0 0 6,290 6,290 NURSING 171,3286260 NURSE AIDE TRAINING REIM 0 0 0 0 0 6,295 6,295 NURSING 2,8486270 REHAB WAGES 59,971 10 1 0 0 6,390 6,390 REPLACEM 18,1266275 REHAB SICK & VAC 4,283 10 1 0 0 6,490 6,490 OTHER 2886280 NURSING DEPT EDUCATION 23 3 0 0 7,280 7,280 DRUG PUR 163,5656290 NURSING SUPPLIES 171,328 192,302 10 2 0 0 7,281 7,281 DRUG PUR 5966295 NURSING SUPPLIES 2,848 10 2 0 0 7,380 7,380 LABORAT 13,4806390 REPLACEMENT-NURSING 18,126 10 2 0 0 7,391 7,390 X-RAY SER 4,6496490 NURSING OTHER 288 247,576 10 3 0 0 7,393 3,4687280 DRUG PURCHASES 163,565 164,907 39 2 0 0 *** 7,510 7,510 ACTIVITIE 63,8067281 DRUG PURCHASES-OTHER 596 39 2 7,540 7,540 ACTIVITIE 3,4087380 LABORATORY SERVICES 21,597 21,597 39 3 0 0 7,590 7,590 ACTIVITIE 5,6517410 HOME HEALTH SALARY 39 1 0 0 7,620 7,620 PHYSICAL 189,2477440 HOME HEALTH SICK & VAC 39 1 0 0 7,660 7,660 P.T. SUPPL 7467450 HOME HEALTH EXPENSES 39 3 0 0 7,710 7,710 SOCIAL SE 40,6727510 ACTIVITES WAGES 63,806 67,214 11 1 0 0 7,720 7,720 SOCIAL SE 3,3787540 ACTIVITIES SICK & VAC 3,408 11 1 0 0 7,730 7,730 SOCIAL SE 177590 ACTIVITIES SUPPLIES 5,651 5,651 11 2 0 0 7,740 7,740 OCCUPAT 203,5897595 ACTIVITIES FEES 0 0 11 3 0 0 7,7507610 PT WAGES 39 1 0 0 7,770 7,770 SPEECH TH 124,2467611 PT SICK & VACATION 39 1 0 0 7,820 7,820 BEAUTICI 12,0267620 PT FEES 189,247 517,082 39 3 0 0 *** 7,890 07660 PT SUPPLIES 746 39 2 0 0 7,960 07710 SOCIAL SERVICE WAGES 40,672 44,050 12 1 0 0 8,120 8,120 INTEREST 07720 SOCIAL SERVICE SICK & VA 3,378 12 1 0 0 8,125 07730 SOCIAL SERVICE EXPENSES 17 17 12 2 0 0 8,130 8,130 DEPRECIA 07740 OT FEE 203,589 39 3 0 0 *** 8,150 07750 SOCIAL THERAPIST FEE 0 0 12 3 0 0 9,510 9,510 INTEREST (1,467)7770 SPEECH THERAPY FEE 124,246 39 3 0 0 *** 9,520 9,520 MISC NON (105,000)7800 BEAUTICIAN WAGES 0 40 1 0 0 9,530 4,220 07810 BEAUTICIAN SICK & VAC 40 1 0 0 8,100 459,9007820 BEAUTICIAN FEES 12,026 12,026 40 3 0 0 9,702 07890 BEAUTY SHOP SUPPLIES 0 0 40 2 0 0 5,230 07910 VOLUNTEER COORDINATOR 21 1 0 0 552,7027940 VOL COORD SICK & VAC 21 1 0 07960 VOL COORD SUPPLIES 0 21 2 0 08100 RENT 459,900 459,900 34 3 0 0 Expenses Fixed Assets8120 INTEREST EXPENSE 0 0 32 3 14 -1,467 08130 DEPRECIATION 0 0 30 3 9 08150 LOAN FEE AMORTIZATION 0 32 3 0 0 09510 INTEREST INCOME -1,467 32 0 10 09520 MISC NON-OPERATING INCO -105,000 0 0 0 0 9700 INCOME TAXES 0 0 0 0 0

5,747,317 6,017,337270,020

GRAND TOTALS 552,702 -110,478(NET INCOME)

0FACILITY NAME:FACILITY ID: 0

FACILITY UNITS: 89

BALANCE SHEET TOTAL 0

G/L RECAP CENSUSPP 8,593 8,593IPA 17,857 17,857medicare 1,771 1,771

28,221

HFS 3745 (N-4-99) IL478-2471

St. Clara's Manor Inc.HFS ID# 376075710001HFS Cost Report - December 31, 2016Board of Directors

Member Home City State

Clyde Reynolds - President Lincoln IL

Dr. Dennis Carroll Lincoln IL

Tonita Reifsteck Lincoln IL

HFS 3745 (N-4-99) IL478-2471

St. Clara's Manor Inc.HFS ID# 376075710001HFS Cost Report - December 31, 2016Schedule V - Column 5 Reclassifications

Add (Subtract)

Reclassification of Provider Participation Fees

Provider Participation Fee - $1.50 Line 20, Col 3 (76,860)Provider Assesment Fee - $6.07 Line 20, Col 3 (163,553)

(240,413)

Provider Participation Fee Line 42 240,413

Reclassification of Ancillary Services Cost

Cost of Drugs Purchased Line 10(a), Col 2 (164,161)Cost of Lab & Radiology Services Purchased Line 10(a), Col 3 (21,597)

(185,758)

Ancillary Service Centers Line 39 185,758

HFS 3745 (N-4-99) IL478-2471

Documents

st claras manor 2016 0050724 - Illinois · Facility Name: St Claras Manor I have examined the contents of the accompanying report to the Address: 200 Fifth Street Lincoln 62656 State