2018-05-15T13:17:07-05:00 2017-12-31 810385940 ANDERSON ZURMUEHLEN & CO PC PO BOX 748 BUTTE MT 59703 990 2017-01-01 364016275 WISCONSIN ILLINOIS SENIOR HOUSING INC WISC 3039800611 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 ANDREW KERWIN CHAIR 2627288167 2018-05-14 1 JAMES E WOY P00102054 4067820451 2018-05-14 2017 2022-09-23 18:48:47Z ANDREW KERWIN 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 50936269 0 X WWW.WISCONSINILLINOISSENOIRHOUSING.ORG X 1994 IL SKILLED NURSING AND ASSISTED LIVING FACILITIES. 6 6 1727 0 -7360 0 4215853 53891 47573897 50240855 67201 210927 8217 -7360 51865168 50498313 0 0 0 0 29330599 30785400 0 0 0 19573094 19769798 48903693 50555198 2961475 -56885 69016970 69861271 58194659 58623398 10822311 11237873 THE PRIMARY PURPOSE IS TO PROVIDE SKILLED NURSING AND ASSISTED LIVING FACILITIES FOR AGED INDIVIDUALS. 0 0 38832400 44535192 WISCONSIN ILLINOIS SENIOR HOUSING, INC.(WISH) OWNS AND OPERATES SKILLED NURSING AND ASSISTED LIVING FACILITIES. THE ORGANIZATION CONSISTS 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--100 BED SKILLED NURSING AND 22 BED COMMUNITY BASED RESIDENTIAL FACILITY, MONTELLO CARE CENTER--50 BED SKILLED NURSING AND 14 BED COMMUNITY BASED RESIDENTIAL FACILITY, AND MAPLE RIDGE CARE CENTER--75 BED SKILLED NURSING FACILITY. 4797594 5705663 WELLINGTON HOMES OF WISCONSIN WAS ORGANIZED TO OPERATE SIX RESIDENTIAL ASSISTED LIVING FACILITIES OF THE BENEFIT OF THE ELDERLY. THE FACILITES HAVE A COMBINED TOTAL OF 160 BEDS. ALL HOMES ARE LOCATED IN THE FOLLOWING WISCONSIN LOCATIONS: FORT ATKINSON, HARTFORD, STEVENS POINT, WAUSAU, AND WISCONSIN RAPIDS. WELLINGTON HOMES OF WISCONSIN, LLC IS A LIMITED LIABILITY CORPORATION OPERATING AS A DISREGARDED ENTITY. THE FEDERAL ID NUMBER IS 26-0564338. THE SOLE MEMBER OF THE LLC IS WISCONSIN ILLINOIS SENIOR HOUSING, INC. THE ASSISTED LIVING FACILITY OPERATIONS BEGAN IN SEPTEMBER 2007. 43629994 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 1 130 0 1 1727 1 0 0 0 0 0 1 1 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 JOYCE SURDICK ADMINISTRATOR 40.00 X 120629 0 0 DONNA KRUTCHEN ADMINISTRATOR 40.00 X 113216 0 0 MARY SIBBING ADMINISTRATOR 40.00 X 129167 0 0 363012 0 0 3 0 0 0 MARTIN BROTHERS PO BOX 69 CEDAR FALLS IA 50613 FOOD SERVICES 883605 OMNICARE PO BOX 78000 DETROIT MI 482781668 PHARMACY 672963 MEDLINE DEPT CH 14400 PALATINE IL 60055 MEDICAL SUPPLIES 386154 FORUM EXTENDED CARE 4201 W VICTORIA ST CHICAGO IL 60646 PHARMACY 314071 MCKESSON MEDICAL-SURGICAL MINNESOTA SUPP PO BOX 204786 DALLAS TX 75320 MEDICAL SUPPLIES 290542 6 53891 53891 RESIDENT CARE REVENUE 623000 34342063 34342063 ANCILLARY REVENUE 623000 8560792 8560792 ASSISTED LIVING REVENUE 623000 7002772 7002772 MISC PATIENT BENEFIT REVENUE 623000 305979 305979 OTHER 623000 29249 29249 50240855 60210 60210 58326 65686 -7360 -7360 -7360 522987 372270 150717 150717 150717 50498313 50240855 -7360 210927 25075769 24522384 553385 79785 59775 20010 3438664 3141854 296810 2191182 2176525 14657 1914127 1914127 72233 72233 260159 260159 22768 22768 59956 6682 53274 166384 53718 112666 2107470 1976408 131062 74564 68595 5969 21020 21020 2932803 55797 2877006 2301844 2301844 374465 372285 2180 SUPPLIES 4148993 4148993 PURCHASED SERVICES AND 2593788 2197154 396634 BUSINESS TAXES 1087307 1087307 OTHER EXPENSES 704217 269049 435168 927700 364804 562896 50555198 43629994 6925204 0 5952 3843928 3257400 355311 4700058 4665288 0 50000 495812 245151 69745568 19170233 51198551 50575335 2022918 2219118 452100 7041671 7076950 294608 378090 69016970 69861271 6777092 7450734 223321 51301272 49852578 28868 936836 87427 159929 58194659 58623398 X 10822311 11237873 10822311 11237873 69016970 69861271 X -56885 20347 452100 X X 0 1 X 1 0 X 35682 43456 2858251 5567789 53981 8559159 41187684 41723958 45724959 47435440 50525114 226597155 41223366 41767414 48583210 53003229 50579095 235156314 0 0 0 235156314 112430 132848 94375 124098 269253 733004 112430 132848 94375 124098 269253 733004 41335796 41900262 48677585 53127327 50848348 235889318 0.99690 0.99540 0.00310 0.00460 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4037774 4037774 65707794 19170233 46537561 50575335 RESTRICTED BOND RESERVES 7076950 F 7076950 RESIDENT TRUST ACCOUNTS 61929 INTERCOMPANY PAYABLES 98000 159929 X 49956900 20347 -562900 -542553 50499453 -1140 -1140 50498313 49993200 902 902 49992298 562900 562900 50555198 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) -$562,700 - PROVISION FOR BAD DEBT IS PRESENTED IN PATIENT REVENUES FOR FINANCIAL REPORTING PRESENTATION. PART XI, LINE 4B ADJUSTMENT (1) -$1,140 ROUNDING DIFFERENCE. PART XII, LINE 2D ADJUSTMENT (1) $902 - ROUNDING TO THE AUDITED FINANCIAL STATEMENTS. PART XII, LINE 4B ADJUSTMENT (1) $562,900 - THE PROVISION FOR BAD DEBT IS INCLUDED IN EXPENSES ON THE FORM 990. A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4B1 2007-09-07 585000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V460 2007-09-17 1130000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4H8 2007-09-17 3605000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 9771044J4 2007-09-17 7935000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 A 2007 0 0 0 0 B 2007 0 0 0 0 C 2007 0 0 0 0 D 2007 0 0 0 0 A 0 0 0 0 0 1 0 0 B 0 0 0 0 0 1 0 0 C 0 0 0 0 0 1 0 0 D 0 0 0 0 0 1 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 A 0 B 0 C 0 D 0 A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 977108VD1 2010-08-01 980000 REFINANCE AND IMPROVEMENTS OF LIVING FACILITIES 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710BVE9 2010-08-01 1275000 REFINANCE AND IMPROVEMENTS OF LIVING FACILITIES 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 977108BG4 2010-08-01 6910000 REFINANCE AND IMPROVEMENTS OF LIVING FACILITIES 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2H4 2012-08-07 2070000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 A 2010 0 0 0 0 B 2010 0 0 0 0 C 2010 0 0 0 0 D 2012 0 0 0 0 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 A 0 B 0 C 0 D 0 A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2J0 2012-08-07 3440000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2K7 2012-08-07 6070000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710BZ96 2012-08-07 225000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2A9 2012-08-07 230000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 A 2012 0 0 0 0 B 2012 0 0 0 0 C 2012 0 0 0 0 D 2012 0 0 0 0 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 A 0 B 0 C 0 D 0 A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2B7 2012-08-07 235000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2C5 2012-08-07 245000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2D3 2012-08-07 255000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2E1 2012-08-07 265000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 A 2012 0 0 0 0 B 2012 0 0 0 0 C 2012 0 0 0 0 D 2012 0 0 0 0 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 A 0 B 0 C 0 D 0 A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2F8 2012-08-07 275000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B2G6 2012-08-07 290000 ACQUISITION OF 1 FACILITY LOCATED IN WISCONSIN AND IMPROVEMENTS OF LIVING FA 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DDD5 2013-11-06 430000 IMPROVEMENTS OF 1 FACILITY LOCATED IN WISCONSIN. 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DDJ2 2013-11-06 7525000 IMPROVEMENTS OF 1 FACILITY LOCATED IN WISCONSIN. 0 0 0 A 2012 0 0 0 0 B 2012 0 0 0 0 C 2014 0 0 0 0 D 2014 0 0 0 0 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 A 0 B 0 C 0 D 0 A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 2014-12-01 10330000 REFINANCE DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOMES 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 2014-12-01 3450000 IMPROVEMENTS OF 1 FACILITY LOCATED IN WISCONSIN. 0 0 0 A 2014 1 0 0 0 B 2017 0 0 0 0 A 0 0 0 0 0 0 0 B 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 A 0 B 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 AND SECRETARY TO REVIEW AND SIGN THE 990 ON BEHALF OF THE BOARD. ALL BOARD MEMBERS RECEIVE A COPY OF 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: EQUITY IN WELLINGTON LLC - SHELTEERED VILLAGE 452,100. 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 WEST GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 260564338 ASSISTED LIVING FACILITY WI N/A