2019-06-27T18:26:35-05:00 2018-12-31 810385940 ANDERSON ZURMUEHLEN & CO PC PO BOX 748 BUTTE MT 59703 990 2018-01-01 364016275 WISCONSIN ILLINOIS SENIOR HOUSING INC WISC 3039800611 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 ANDREW KERWIN CHAIR 2627288167 2019-06-25 1 JAMES E WOY P00102054 4067820451 2019-06-25 71.92.235.236 2019-06-25 17:27:06 MD P 5727D1DA74CF4B61FEE95BC2BA0C3E581832611A 8DCF2240B8CD86C89BB56158B8CC38DC0440B69A 2018 2019-02-21 02:37:17Z ANDREW KERWIN 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 50734628 0 X WWW.WISCONSINILLINOISSENOIRHOUSING.ORG X 1994 IL SKILLED NURSING AND ASSISTED LIVING FACILITIES. 6 6 1393 0 4436 -2349 53891 52097 50240855 50364399 210927 134010 -7360 4436 50498313 50554942 0 0 0 0 30785400 31599354 0 0 0 19769798 21681937 50555198 53281291 -56885 -2726349 69861271 69284306 58623398 61397745 11237873 7886561 THE PRIMARY PURPOSE IS TO PROVIDE SKILLED NURSING AND ASSISTED LIVING FACILITIES FOR AGED INDIVIDUALS. 0 0 40704393 42546145 WISCONSIN ILLINOIS SENIOR HOUSING, INC.(WISH) OWNS AND OPERATES SKILLED NURSING FACILITIES. THE SKILLED NURSING FACILITIES CONSIST OF: EAST TROY MANOR--50 BED FACILITY, EDGERTON CARE CENTER--61 BED FACILITY, FAIR OAKS HEALTH CENTER--51 BED FACILITY, GENEVA LAKE MANOR--60 BED FACILITY, WILD ROSE MANOR--50 BED FACILITY, HOLTON MANOR--60 BED FACILITY, INGLESIDE MANOR--70 BED SKILLED NURSING, MONTELLO CARE CENTER--50 BED FACILITY, AND MAPLE RIDGE CARE CENTER--75 BED FACILITY. 5640544 7819472 WISH ALSO OWNS AND OPERATES ASSISTED AND INDEPENDENT LIVING FACILITIES. THESE FACILITIES CONSIST OF: INGLEHAVEN--16 BED COMMUNITY BASED RESIDENTIAL FACILITY, INGLEWOOD--24 BED RESIDENTIAL CARE APARTMENT COMPLEX, THE RESIDENCES ON FOREST LANGE--14 BED COMMUNITY BASED RESIDENTIAL FACILITY, THE VILLAS AT MAPLE RIDGE--14 BED COMMUNITY BASED RESIDENTIAL FACILITY, AND AND THE WELLINGTON HOMES WHICH CONSIST OF SIX COMMUNITY BASED RESIDENTIAL FACILITIES WITH A COMBINED TOTAL OF 160 BEDS. 46344937 1 1 0 0 0 0 0 0 0 0 1 0 1 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 120 0 1 1393 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 X 6 6 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X CINDY DEMOYE 3039800611 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 X LORRIE DUPONT TREASURER 1.00 X X 0 0 0 ANDREW KERWIN CHAIR 1.00 X X 0 0 0 MIRIAM GEHLER SECRETARY 1.00 X X 0 0 0 NICHOLAS LYNN MEMBER 1.00 X 0 0 0 RAJEEV KUMAR MEMBER 1.00 X 0 0 0 KAREN CARRIG MEMBER 1.00 X 0 0 0 KERI GERLACH MEMBER 1.00 X 0 0 0 ALISA PALMER DIRECTOR OF NURSING 40.00 X 107796 0 0 CYNTHIA ANDERSON ADMINISTRATOR 40.00 X 105000 0 0 ALLISON JOHNSON PHYSICAL THERAPIST 40.00 X 104473 0 0 MARY SIBBING DIRECTOR OF FACILITY OPERATIONS 40.00 X 124000 0 0 JOYCE SURDICK CLINICAL COORDINATOR 40.00 X 103959 0 0 545228 0 0 5 0 0 0 CARRIAGE HEALTHCARE COMPANIES INC 13185 WEST GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 MANAGEMENT FEES AND REIMBURSABLE EXPENSE 1778731 OMNICARE PO BOX 78000 DETROIT MI 482781668 PHARMACY, MEDICAL SUPPLIES, & CONSULTATI 1078742 MARTIN BROTHERS PO BOX 69 CEDAR FALLS IA 50613 FOOD SERVICES 1047919 WISCONSIN DEPARTMENT OF HEALTH SERVICES PO BOX 93970 MILWAUKEE WI 53293 MEDICAL SUPPLIES & CONSULTATIONS 854050 MEDLINE DEPT CH 14400 PALATINE IL 60055 MEDICAL SUPPLIES 654200 7 52097 52097 RESIDENT CARE REVENUE 623000 40461332 40461332 ASSISTED LIVING REVENUE 623000 7819472 7819472 ANCILLARY REVENUE 623000 1840393 1840393 MISC. PATIENT BENEFIT REVENUE 623000 243202 243202 50364399 132792 132792 147462 143026 4436 4436 4436 37878 36660 1218 1218 1218 50554942 50365617 4436 132792 26192666 25592356 600310 84243 64484 19759 3116454 2828403 288051 2205991 2183304 22687 1976811 1976811 27185 27185 283019 283019 12710 12710 77419 4645 72774 171528 63454 108074 2088124 1981348 106776 94695 84817 9878 1276 1276 2875431 105061 2770370 4335676 4335676 400423 399975 448 SUPPLIES 4161762 4161762 PURCHASED SERVICES AND 1809691 1809691 BUSINESS TAXES 1097832 1097832 OTHER EXPENSE 820931 330016 490915 1447424 423134 1024290 53281291 46344937 6936354 0 3843928 2204275 355311 1120308 4665288 4554358 50000 141895 245151 234159 70150991 21394266 50575335 48756725 2219118 2852737 452100 0 7076950 6206899 378090 3212950 69861271 69284306 7450734 6615384 223321 0 49852578 33570000 936836 21156470 159929 55891 58623398 61397745 X 11237873 7886561 11237873 7886561 69861271 69284306 X -2726349 -172855 -452108 X X 0 1 X 1 0 X 43456 2858251 5567789 53981 52097 8575574 41723958 45724959 47435440 50525114 50324523 235733994 41767414 48583210 53003229 50579095 50376620 244309568 0 0 0 244309568 132848 94375 124098 269253 280254 900828 132848 94375 124098 269253 280254 900828 41900262 48677585 53127327 50848348 50656874 245210396 0.99630 0.99690 0.00370 0.00310 X 4059467 4059467 66091524 21394266 44697258 48756725 RESTRICTED BOND RESERVES 6206899 F 6206899 RESIDENT TRUST ACCOUNTS 55891 55891 X 47734100 -172900 -2647800 -2820700 50554800 142 142 50554942 50633000 -491 -491 50633491 2647800 2647800 53281291 PART X, LINE 2: FOOTNOTE 1 TO THE FINANCIAL STATEMENTS STATES MANAGEMENT HAS REVIEWED ITS OPERATIONS FOR UNCERTAIN TAX POSITIONS AND HAS DETERMINED NO UNCERTAIN TAX POSITIONS EXIST. PART XI, LINE 2D ADJUSTMENT (1) -$609,700 - PROVISION FOR BAD DEBT IS PRESENTED IN PATIENT REVENUES FOR FINANCIAL REPORTING PRESENTATION. ADJUSTMENT (2) -$24,300 - INVESTMENT FEES INCLUDED IN INVESTMENT INCOME FOR FINANCIAL REPORTING PRESENTATION. ADJUSTMENT (3) -$2,013,800 - AMORTIZATION OF REFINANCED COSTS OF ISSUANCE INCLUDED IN OTHER INCOME FOR FINANCIAL REPORTING PRESENTATION. PART XI, LINE 4B ADJUSTMENT (1) $142 ROUNDING DIFFERENCE. PART XII, LINE 2D ADJUSTMENT (1) -$491 - ROUNDING TO THE AUDITED FINANCIAL STATEMENTS. PART XII, LINE 4B ADJUSTMENT (1) $609,700 - PROVISION FOR BAD DEBT IS PRESENTED IN PATIENT REVENUES FOR FINANCIAL REPORTING PRESENTATION. ADJUSTMENT (2) $24,300 - INVESTMENT FEES INCLUDED IN INVESTMENT INCOME FOR FINANCIAL REPORTING PRESENTATION. ADJUSTMENT (3) $2,013,800 - AMORTIZATION OF REFINANCED COSTS OF ISSUANCE INCLUDED IN OTHER INCOME FOR FINANCIAL REPORTING PRESENTATION. A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DP42 2018-08-30 3695000 REFINANCE AND IMPROVEMENTS OF ASSISTED LIVING FACILITIES 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DP59 2018-08-30 3735000 REFINANCE AND IMPROVEMENTS OF ASSISTED LIVING FACILITIES 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DP67 2018-08-30 4780000 REFINANCE AND IMPROVEMENTS OF ASSISTED LIVING FACILITIES 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DP75 2018-08-30 21360000 REFINANCE AND IMPROVEMENTS OF ASSISTED LIVING FACILITIES 0 0 0 A 2018 1 0 0 1 B 2018 1 0 0 1 C 2018 1 0 0 1 D 2018 1 0 0 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 D 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 0 0 D 0 0 0 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS ENGAGED CARRIAGE HEALTHCARE INC. (CHC) TO PROVIDE MANAGEMENT SERVICES THROUGH JUNE 30, 2018. CHC IS AN INDEPENDENT "FOR PROFIT ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD HAS DESIGNATED THE CHAIRMAN SIGN THE 990 ON BEHALF OF THE BOARD. ALL BOARD MEMBERS REVIEW AND APPROVE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY IS MONITORED THROUGH THE CORPORATE COMPLIANCE PROGRAM. REPORTS ARE PROVIDED TO THE BOARD ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION AND MANAGEMENT COMPANY AGREEMENTS ARE REVIEW BY INDEPENDENT BOARD MEMBERS ON AN ANNUAL BASIS. COMPARABLE DATA IS OBTAINED IN ORDER TO ESTABLISH REASONABLE AMOUNTS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION WILL PROVIDE DOCUMENTS UPON WRITTEN REQUEST TO THE COMPANY. FORM 990, PART XI, LINE 9: MERGED IN EQUITY FROM INVESTMENT IN WELLINGTON HOMES OF WISCONSIN, LLC -452,108. FORM 990 - LINE 2C SCHEDULE XI THE ENTIRE BOARD REVIEWS AND HAS RESPONSIBILITY FOR THE FINANCIAL STATEMENTS. THIS POLICY IS UNCHANGED FROM PRIOR YEARS. WELLINGTON HOMES OF WISCONSIN LLC 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 260564338 ASSISTED LIVING FACILITIES WI N/A TRANSITIONS AT HOME INC 13185 W GREEN MOUNTAIN ROAD LAKEWOOD CO 80228 205835453 HOME HEALTH CARE WI 501(C)(3) LINE 10 N/A 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 TRANSITIONS AT HOME INC D 51490 REVIEW OF GENERAL LEDGER TRANSITIONS AT HOME INC L 152796 REVIEW OF GENERAL LEDGER