2011-09-29T11:19:02-05:00 2010-12-31 ANDERSON ZURMUEHLEN & CO PC PO BOX 748 BUTTE MT 59703 990 2010-01-01 364016275 WISCONSIN ILLINOIS SENIOR HOUSING INC WISC 2627288167 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 RONALD PATTERSON 2627288167 2011-09-26 1 JAMES E WOY 4067820451 2010 2016-03-07 17:11:31Z RONALD PATTERSON 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 31373442 0 X WWW.WISCONSINILLINOISSENOIRHOUSING.ORG X 1994 IL SKILLED NURSING AND ASSISTED LIVING FACILITIES INCLUDING DEVELOPMENTALLY DISABLED FACILITIES. 6 6 782 0 0 0 19999 39569 28822103 30421464 -118610 228140 -1016 -566 28722476 30688607 0 0 0 0 15094017 15808230 0 0 0 13209920 14091510 28303937 29899740 418539 788867 35934260 44420361 31444716 38977543 4489544 5442818 THE PRIMARY PURPOSE IS TO PROVIDE SKILLED NURSING AND ASSISTED LIVING FACILITIES FOR AGED INDIVIDUALS INCLUDING DEVELOPMENTALLY DISABLED FACILITIES. 0 0 24955418 30458762 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. 24955418 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 0 1 30 0 782 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 DR GLENN HOBERG 1.00 X 0 0 0 RONALD PATTERSON 1.00 X 0 0 0 ANDREW KERWIN 1.00 X 0 0 0 JILL KRUEGER 1.00 X 0 0 0 MARY TELLIS-NAYAK 8.00 X 0 50000 0 0 50000 0 0 0 0 0 GENESIS REHAB SERVICES PO BOX 7247-6524 PHILADELPHIA PA 191706524 THERAPY SERVICES 2049600 CARRIAGE QUALITY INC 13185 W GREEN MTN DRIVE LAKEWOOD CO 80228 MANAGEMENT COMPANY 903120 SYNERTEX 7540 N 19TH STE 200 PHOENIX AZ 85021 THERAPY SERVICES 400335 ROESCHEN'S OMNICARE PHARMACY PO BOX 78083 MILWAUKEE WI 53278 PHARMACY SERVICES 375698 FORUM PHARMACY 7440 N FRONTAGE ROAD SKOKIE IL 60077 PHARMACY SERVICES 137074 5 39569 39569 RESIDENT CARE REVENUE 623000 19202876 19202876 ANCILLIARY REVENUE 623000 5561577 5561577 ASSISTED LIVING REVENU 623000 5500039 5500039 MISC PATIENT BENEFIT R 623000 156972 156972 30421464 190842 190842 5761 6327 -566 -566 -566 715806 678508 37298 37298 37298 30688607 30458762 0 190276 13642760 13436666 206094 931612 841972 89640 1233858 1132914 100944 1092550 1092550 119935 119935 215350 215350 19266 19266 77378 11752 65626 147550 28856 118694 1099960 1022635 77325 100948 19924 81024 1797570 15067 1782503 1116733 1116733 310114 309844 270 PURCHASED SERVICES AND 3011584 3011584 SUPPLIES 2474992 2474992 BUSINESS TAXES 963046 963046 BAD DEBT EXPENSE 501253 501253 PURCHASED SERVICES AND 210860 210860 832421 439929 392492 29899740 24955418 4944322 0 4350 4850 1709058 2524154 3623965 4748839 475 58183 52086 133794 137086 33038401 8059356 23776886 24979045 1852459 2084515 3504166 7878594 1270924 2011192 35934260 44420361 3214250 4300194 190125 230445 25734998 34395002 2251355 53988 51902 31444716 38977543 X 4489544 5442818 4489544 5442818 35934260 44420361 X 788867 164407 X X 0 1 1 X 0 X 8661 9563 7633 19999 39569 85425 18087765 20196628 24701607 28822103 30421464 122229567 18096426 20206191 24709240 28842102 30461033 122314992 0 0 0 122314992 229829 199562 200161 83860 190842 904254 229829 199562 200161 83860 190842 904254 18326255 20405753 24909401 28925962 30651875 123219246 0.99270 0.99210 0.00730 0.00780 X 3110843 3110843 29927558 8059356 21868202 24979045 RESTRICTED BOND RESERVES 7878594 F 7878594 RESIDENT TRUST ACCOUNTS 51869 INTERCOMPANY PAYABLES 33 51902 30688607 29899740 788867 167804 -3397 164407 953274 30873600 167804 17189 184993 30688607 0 30688607 29919800 20756 20756 29899044 696 696 29899740 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 X: RESIDENT TRUST ACCOUNTS BALANCE $54,425 CARRIAGE QUALITY INC MANAGEMENT AGENT PAYABLE $107,043 DUE TO THIRD PARTY PAYORS $31,166 PART XII LINE 2D ROUNDED FINANCIAL STATEMENT ADJUSTMENT -175 RENTAL EXPENSES -PG 9 LINE 6B 7,529 NET ADJUSTMENT - LINE 2D 7,354 PART XIII LINE 2D ROUNDEND FINANCIAL STATEMENT ADJUSTMENT -587 RENTAL EXPENSES - PG 9 LINE 6B 7,529 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 2006 0 0 0 0 2006 0 0 0 0 2006 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 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 2007 0 0 0 0 2007 0 0 0 0 2007 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 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 33178 2010 0 0 0 0 42226 2010 0 0 0 0 226210 2010 0 0 0 0 0 0 0 0 1 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, 2011. 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 GAINS ON INVESTMENTS: 167,804. DEPRECIATION ADJUSTMENT -3,567. ROUNDING 170. TOTAL TO FORM 990, PART XI, LINE 5: 164,407. 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 4990300 13785600 N/A