2013-07-08T15:26:26-05:00 2012-12-31 810385940 ANDERSON ZURMUEHLEN & CO PC PO BOX 748 BUTTE MT 59703 990 2012-01-01 364016275 WISCONSIN ILLINOIS SENIOR HOUSING INC WISC 2627288167 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 ANDY KERWIN 2627288167 2013-06-28 1 JAMES E WOY P00102054 4067820451 2013-06-28 2012 2016-02-24 21:20:13Z ANDY KERWIN 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 34484166 0 X WWW.WISCONSINILLINOISSENOIRHOUSING.ORG X 1994 IL SKILLED NURSING AND ASSISTED LIVING FACILITIES INCLUDING DEVELOPMENTALLY DISABLED FACILITIES. 7 7 1173 0 0 0 21937 864446 31588458 33464363 56396 221403 -42362 -754905 31624429 33795307 0 0 0 0 16307580 18375806 0 0 0 15054122 15902066 31361702 34277872 262727 -482565 43884718 58536875 38192800 53327400 5691918 5209475 X THE PRIMARY PURPOSE IS TO PROVIDE SKILLED NURSING AND ASSISTED LIVING FACILITIES FOR AGED INDIVIDUALS INCLUDING ONE HOME DEDICATED TO INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES. 0 1 24089947 28062863 WISCONSIN ILLINOIS SENIOR HOUSING, INC.(WISH) OWNS AND OPERATES SKILLED NURSING AND ASSISTED LIVING FACILITIES INCLUDING DEVELOPMENTALLY DISABLED FACILITIES. THE ORGANIZATION CONSISTS OF: FAIR OAKS HEALTH CENTER--46 BED FACILITY, GENEVA LAKE MANOR--60 BED FACILITY, WILD ROSE MANOR--78 BED FACILITY, SHELTERED VILLAGE OF RIPON--50 BED DEVELOPMENTALLY DISABLED FACILITY, HOLTON MANOR--60 BED FACILITY, AND MONTELLO CARE CENTER--46 BED SKILLED NURSING AND 7 BED COMMUNITY BASED RESIDENTIAL FACILITY. 4448639 5401500 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, SEEVENS 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. 28538586 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 1 0 0 0 1 40 0 1 1173 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL X CINDY DEMOYE 3039800611 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 X CHARLES W NASON 1.00 X X 0 0 0 KEN DEVITO 1.00 X 0 0 0 MIRIAM GEHLER 1.00 X 0 0 0 ANDREW KERWIN 1.00 X X 0 0 0 JILL KRUEGER 1.00 X X 0 0 0 NICHOLAS LYNN 1.00 X 0 0 0 RAJEEV KUMAR 1.00 X 0 0 0 0 0 0 0 0 0 0 GENESIS REHAB SERVICES PO BOX 7247-6524 PHILADELPHIA PA 191706524 THERAPY SERVICES 2481047 CARRIAGE HEALTHCARE INC 13185 W GREEN MTN DRIVE LAKEWOOD CO 80228 MANAGEMENT COMPANY 1107858 REINHART 2655 EAST RICHMOND STREET SHWNO WI 51466 FOOD SERVICES 542880 SYSCO EASTER WI ONE SYSCO DRIVE JACKSON WI 53037 FOOD SERVICES 328379 SYNERTX 7540 N 19TH AVE PHOENIX AZ 85021 THERAPY SERVICES 251906 5 864446 864446 RESIDENT CARE REVENUE 623000 21121632 21121632 ASSISTED LIVING REVENUE 623000 6154893 6154893 ANCILLIARY REVENUE 623000 6063070 6063070 MISC PATIENT BENEFIT REVENUE 623000 124768 124768 33464363 126853 126853 407950 6241 401709 401709 401709 777168 682618 94550 94550 94550 PRIOR YEAR ADJUSTMENTS ALL LOC 623000 7324 7324 IMPAIRMENT OF SHELTERED VILLAGE F 623000 -1163938 -1163938 -1156614 33795307 33464363 0 -533502 15400329 15234479 165850 1423666 1172847 250819 1551811 1454215 97596 1171324 1171324 116112 116112 270372 270372 30768 30768 48964 10659 38305 197959 47437 150522 1216233 1131013 85220 81928 20389 61539 2331372 2331372 1321452 1321452 304358 303958 400 PURCHASED SERVICES AND 3567509 3403362 164147 SUPPLIES 2748492 2747727 765 BUSINESS TAXES 1031885 1031885 BAD DEBT EXPENSE 489022 489022 974316 519724 454592 34277872 28538586 5739286 0 X 4850 5722 3045050 3528961 4928500 6041589 0 56054 85640 44273 44229 42145727 9490927 24784500 32654800 1680692 1849368 7488606 12313567 1852193 2012999 43884718 58536875 4233500 6645636 164700 33705100 46570057 89500 111707 38192800 53327400 X 5691918 5209475 5691918 5209475 43884718 58536875 X -482565 382 -260 X X 0 1 X 1 0 X 7633 19999 39569 21937 57422 146560 24701607 28822103 30421464 31588458 33464363 148997995 24709240 28842102 30461033 31610395 33521785 149144555 0 0 0 149144555 200161 83860 190842 139265 534803 1148931 200161 83860 190842 139265 534803 1148931 24909401 28925962 30651875 31749660 34056588 150293486 0.99240 0.99400 0.00760 0.00600 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3146437 3146437 38999290 9490927 29508363 32654800 RESTRICTED BOND RESERVES 12313567 F 12313567 RESIDENT TRUST ACCOUNTS 111707 111707 X 37167900 382 4630939 4631321 32536579 1258728 1258728 33795307 37650100 6300008 6300008 31350092 2927780 2927780 34277872 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 2D - ADJUSTMENT (1) $612- CLASSIFICATION DIFFERENCE BETWEEN REVENUE AND EXPENSE. 2D - ADJUSTMENT (2) $489,022 - PROVISION FOR BAD DEBT IS PRESENTED IN PATIENT REVENUES FOR FINANCIAL REPORTING PRESENTATION. 2D - ADJUSTMENT (3) $5,120,573 - FINANCIAL STATEMENTS INCLUDED THIS MUCH OF EDGERTON CARE CENTER INC REVENUES. 4B - ADJUSTMENT (1) -$6,241 - RENTAL EXPENSE IS REPORTED IN REVENUES ON THE FORM 990. 4B - ADJUSTMENT (2) $2,027,047 - DISCONTINUED SEGMENT'S OPERATING INCOME WAS INCLUDED IN REVENUES ON THE FORM 990. 4B - ADJUSTMENT (3) -$1,163,938 - LOSS ON DISPOSAL OF FIXED ASSETS FOR THE DISCONTINUED SEGMENT IS REPORTED IN REVENUE ON THE FORM 990. 4B - ADJUSTMENT (4) $402,000 - RENTAL INCOME WAS ELIMINATED UPON CONSOLIDATION IN THE AUDITED FINANCIAL STATEMENTS. 4B - ADJUSTMENT (5) -$140 ROUNDING DIFFERENCE. PART XII 2D - ADJUSTMENT (1) $1,163,900 - LOSS ON DISPOSAL OF FIXED ASSETS FOR THE DISCONTINUED SEGMENT IS INCLUDED IN THE DISCONTINUED OPERATIONS SECTION OF THE AUDITED FINANCIAL STATEMENTS. 2D - ADJUSTMENT (2) $411,800 - NET LOSS FROM DISCONTINUED SEGMENT IS INCLUDED IN THE DISCONTINUED OPERATIONS SECTION OF THE AUDITED FINANCIAL STATEMENTS. 2D - ADJUSTMENT (3) -$612 - CLASSIFICATION DIFFERENCE BETWEEN REVENUE AND EXPENSE. 2D - ADJUSTMENT (4) $79 - ROUNDING TO THE AUDITED FINANCIAL STATEMENTS. 2D - ADJUSTMENT (5) $6,241 - RENTAL EXPENSE IS REPORTED IN REVENUE ON THE FORM 990. 2D - ADJUSTMENT (6) $4,718,600 - THE FINANCIAL STATEMENTS INCLUDE EDGERTON CARE CENTER EXPENSES OF THIS AMOUNT. 4B - ADJUSTMENT (1) $489,022 - THE PROVISION FOR BAD DEBT IS INCLUDED IN EXPENSES ON THE FORM 990. 4B - ADJUSTMENT (2) $2,438,728 - THE DISCONTINUED SEGMENT'S TOTAL EXPENSES ARE INCLUDED IN EXPENSES ON THE FORM 990. A WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VJ84 2006-07-19 330000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VH92 2006-07-19 345000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VJ66 2003-07-19 2020000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VJ74 2006-07-19 2655000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 A 2006 0 0 0 0 B 2006 0 0 0 0 C 2006 0 0 0 0 D 2006 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 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VJ82 2006-07-19 7170000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4B1 2007-09-07 585000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V460 2007-09-17 1130000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4H8 2007-09-17 3605000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 A 2006 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 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 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 9771044J4 2007-09-17 7935000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 B WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 977108VD1 2010-08-01 980000 REFINANCE AND IMPROVEMENTS OF LIVIING FACILITIES 0 0 0 C WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710BVE9 2010-08-01 1275000 REFINANCE AND IMPROVEMENTS OF LIVIING FACILITIES 0 0 0 D WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 977108BG4 2010-08-01 6910000 REFINANCE AND IMPROVEMENTS OF LIVIING FACILITIES 0 0 0 A 2007 0 0 0 0 B 2010 0 0 0 0 C 2010 0 0 0 0 D 2010 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 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 B 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 C 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 D 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 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 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 B 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 C 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 D 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 A 2012 0 0 0 0 B 2012 0 0 0 0 C 2012 0 0 0 0 D 2015 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 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 B 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 C 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 A 2012 0 0 0 0 B 2012 0 0 0 0 C 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 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 CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 AS OF YEAR END, THE ORGANIZATION HAS DISCONTINUED ITS PROGRAM SERVICES REGARDING THE DEVELOPMENTALLY DISABLED. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS ENGAGED CARRIAGE HEALTHCARE INC. (CHC) TO PROVIDE MANAGEMENT SERVICES THROUGH JUNE 30, 2012. CHC IS AN INDEPENDENT "FOR PROFIT" ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 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. CONTRIBUTION OF EDGERTON CARE CENTER, INC. ASSETS AND LIABILITIES: FORM 990 - PART X, LINE 16 AND 26 EFFECTIVE DECEMBER 31, 2012 AT 12:00 A.M., EDGERTON CARE CENTER, INC. CONTRIBUTED ALL ITS ASSETS AND LIABILITIES TO WISH. THE BALANCE SHEET IN THIS RETURN INCLUDES THESE ASSETS AND LIABILITIES ACCORDINGLY. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: ROUNDING -260. BOARD RESPONSIBILITY 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 EDGERTON CARE CENTER INC 313 STOUGHTON ROAD EDGERTON WI 53534 205835453 LONG-TERM CARE FACILITY WI 501(C) LINE 3 WISCONSIN ILLINIOS SENIOR HOUSING INC 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 EDGERTON CARE CENTER INC C 807024 FAIR MARKET VALUE EDGERTON CARE CENTER INC J 402000 LEASE AGREEMENT