2012-11-07T10:44:24-06:00 2011-12-31 810385940 ANDERSON ZURMUEHLEN & CO PC PO BOX 748 BUTTE MT 59703 990 2011-01-01 364016275 WISCONSIN ILLINOIS SENIOR HOUSING INC WISC 2627288167 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 ANDY KERWIN 2627288167 2012-11-05 1 JAMES E WOY P00102054 4067820451 2012-11-04 2011 2016-02-24 21:20:13Z ANDY KERWIN 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 32436875 0 X WWW.WISCONSINILLINOISSENOIRHOUSING.ORG X 1994 IL SKILLED NURSING AND ASSISTED LIVING FACILITIES INCLUDING DEVELOPMENTALLY DISABLED FACILITIES. 6 6 981 0 0 0 39569 21937 30421464 31588458 228140 56396 -566 -42362 30688607 31624429 0 0 0 0 15808230 16307580 0 0 0 14091510 15054122 29899740 31361702 788867 262727 44420361 43884718 38977543 38192800 5442818 5691918 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 0 26382837 31588458 WISCONSIN ILLINOIS SENIOR HOUSING, INC. 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. 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. 26382837 1 0 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 0 1 38 0 981 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 IL X RUTH BABINEAUX 3039800611 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 CHARLES W NASON 1.00 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 0 0 0 JILL KRUEGER 1.00 X 0 0 0 NICHOLAS LYNN 1.00 X 0 0 0 MARY TELLIS-NAYAK 8.00 X 0 39375 0 0 39375 0 0 0 0 0 CARRIAGE HEALTHCARE INC 13185 W GREEN MTN DRIVE LAKEWOOD CO 80228 MANAGEMENT COMPANY 1107858 GENESIS REHAB SERVICES PO BOX 7247-6524 PHILADELPHIA PA 191706524 THERAPY SERVICES 1024125 SYSCO EASTER WI ONE SYSCO DRIVE JACKSON WI 53037 FOOD SERVICES 278317 REINHART 2655 EAST RICHMOND STREET SHWNO WI 51466 FOOD SERVICES 266632 OMNICARE PHARMACIES OF WI PO BOX 715268 COLUMBUS OH 432715268 PHARMACY SERVICES 257717 5 21937 21937 RESIDENT CARE REVENUE 623000 18972404 18972404 ANCILLIARY REVENUE 623000 7076749 7076749 ASSISTED LIVING REVENU 623000 5433151 5433151 MISC PATIENT BENEFIT R 623000 106154 106154 31588458 139265 139265 5914 6326 -412 -412 -412 722014 1237 779975 26145 -57961 -24908 -82869 -82869 MISC. REVENUE 623000 49167 49167 MISC. REVENUE: HEALTH 623000 1694 1694 PRIOR YEAR ADJUSTMENTS 623000 -29027 -29027 -63784 -63784 -41950 31624429 31588046 0 14446 13961003 13806671 154332 972307 874749 97558 1374270 1266319 107951 1107858 1107858 83063 83063 200373 200373 28734 28734 85227 12645 72582 121932 21980 99952 1156855 1067931 88924 109309 16696 92613 2164852 2164852 1258877 1258877 245532 245432 100 PURCHASED SERVICES AND 3542989 3542989 SUPPLIES 2690801 2690801 BUSINESS TAXES 922278 922278 BAD DEBT EXPENSE 536514 536514 798928 469889 329039 31361702 26382837 4978865 0 4850 4850 2524154 3045050 4748839 4928500 52086 56054 137086 44273 34056022 9271522 24979045 24784500 2084515 1680692 7878594 7488606 2011192 1852193 44420361 43884718 4300194 4233500 230445 164700 34395002 33705100 51902 89500 38977543 38192800 X 5442818 5691918 5442818 5691918 44420361 43884718 X 262727 -13627 X X 0 0 0 X 9563 7633 19999 39569 21937 98701 20196628 24701607 28822103 30421464 31588458 135730260 20206191 24709240 28842102 30461033 31610395 135828961 0 0 0 135828961 199562 200161 83860 190842 139265 813690 199562 200161 83860 190842 139265 813690 20405753 24909401 28925962 30651875 31749660 136642651 0.99400 0.99270 0.00600 0.00730 X 3185843 3185843 30870179 9271522 21598657 24784500 RESTRICTED BOND RESERVES 7488606 F 7488606 RESIDENT TRUST ACCOUNTS 53200 OTHER LIABILITIES 36300 89500 31624429 31361702 262727 -9993 -426 -3208 -13627 249100 31633800 13160 13160 31620640 3789 3789 31624429 31384700 23511 23511 31361189 513 513 31361702 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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 8 - OTHER ADJUSTMENTS: ROUNDING -300. DEPRECIATION -2,908. TOTAL TO SCHEDULE D, PART XI, LINE 8: -3,208. PART X: RESIDENT TRUST ACCOUNTS BALANCE $53,064 CARRIAGE HEALTHCARE,INC. MANAGEMENT AGENT PAYABLE $369,100 DUE TO THIRD PARTY PAYORS $0 PART XII LINE 2D ROUNDED FINANCIAL STATEMENT ADJUSTMENT RENTAL EXPENSES -PG 9 LINE 6B NET ADJUSTMENT - LINE 2D PART XIII LINE 2D ROUNDEND FINANCIAL STATEMENT ADJUSTMENT RENTAL EXPENSES - PG 9 LINE 6B NET ADJUSTMENT 6,942 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VJ84 2006-07-19 330000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VH92 2006-07-19 345000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VJ66 2003-07-19 2020000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VJ74 2006-07-19 2655000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 2006 0 0 0 0 345000 2006 0 0 0 0 2006 0 0 0 0 2006 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VJ82 2006-07-19 7170000 DEBT PREVIOUSLY FINANCED FOR ACQUISITION OF FIVE NURSING HOME FACILITIES 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4B1 2007-09-07 585000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V460 2007-09-17 1130000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710V4H8 2007-09-17 3605000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 2006 0 0 0 0 180000 2007 0 0 0 0 2007 0 0 0 0 2007 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 9771044J4 2007-09-17 7935000 ACQUISITION OF SIX ASSISTED LIVING FACILITIES LOCATED IN WISCONSIN 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 977108VD1 2010-08-01 980000 REFINANCE AND IMPROVEMENTS OF LIVIING FACILITIES 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710BVE9 2010-08-01 1275000 REFINANCE AND IMPROVEMENTS OF LIVIING FACILITIES 0 0 0 WISCONSIN HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 977108BG4 2010-08-01 6910000 REFINANCE AND IMPROVEMENTS OF LIVIING FACILITIES 0 0 0 2007 0 0 0 0 180000 2010 0 0 0 0 2010 0 0 0 0 2010 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 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, 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -9,993. PRIOR PERIOD ADJUSTMENTS: -426. ROUNDING -300. DEPRECIATION -2,908. TOTAL TO FORM 990, PART XI, LINE 5: -13,627. 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 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WELLINGTON HOMES OF WISCONSIN B 211600 FIAR VALUE