Hillview Health Care Center 2018 0045302 - Illinois
FOR BHF USELL12018STATE OF ILLINOISDEPARTMENT OF HEALTHCARE AND FAMILY SERVICESFINANCIAL AND STATISTICAL REPORT (COST REPORT)FOR LONG-TERM CARE FACILITIES(FISCAL YEAR 2018)I.IDPH License ID Number:Facility Name:0045302II.512 NORTH 11TH STREETNumberCounty:JOHNSONTelephone Number:618-658-2951VIENNACity62995Zip CodeFax # 618-658-6404Date of Initial License for Current Owners:Type of Ownership:VOLUNTARY,NON-PROFITX Charitable Corp.TrustIRS Exemption CodeI have examined the contents of the accompanying report to the01/01/2018to12/31/2018State of Illinois, for the period fromand certify to the best of my knowledge and belief that the said contentsare true, accurate and complete statements in accordance withapplicable instructions. Declaration of preparer (other than provider)is based on all information of which preparer has any knowledge.Intentional misrepresentation or falsification of any informationin this cost report may be punishable by fine and/or imprisonment.HFS ID tePartnershipCorporation"Sub-S" Corp.Limited Liability Co.TrustOtherIn the event there are further questions about this report, please contact:Name:PATRICK BARGER, CPATelephone Number:Email Address:HFS 3745 (N-4-99)CERTIFICATION BY AUTHORIZED FACILITY OFFICERHILLVIEW HEALTHCARE CENTERAddress:XIMPORTANT NOTICETHIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATIONTHAT IS NECESSARY TO ACCOMPLISH THE STATUTORYPURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSUREOF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDEANY INFORMATION ON OR BEFORE THE DUE DATE WILLRESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORMHAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.618-997-5700(Signed)Officer orAdministrator (Type or Print Name) PATRICK BARGERof Provider(Title) er(Print Nameand Title)PATRICK BARGERCPA(Firm Name& Address)PATRICK BARGER, CPA1104 N. COURT STREET, MARION, IL 62959618-997-5700Fax #618-993-5079(Telephone)MAIL TO: BUREAU OF HEALTH FINANCEILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICES201 S. Grand Avenue EastPhone # (217) 782-1630Springfield, IL 62763-0001IL478-2471
STATE OF ILLINOISFacility Name & ID NumberHILLVIEW HEALTHCARE CENTERIII.STATISTICAL DATAA. Licensure/certification level(s) of care; enter number of beds/bed days,(must agree with license). Date of change in licensed beds12Beds atBeginning ofReport PeriodLicensureLevel of Care123456587588910111213E. List all services provided by your facility for non-patients.(E.g., day care, "meals on wheels", outpatient therapy)NONE34Beds at End ofReport PeriodLicensedBed Days DuringReport PeriodSkilled (SNF)Skilled Pediatric (SNF/PED)Intermediate (ICF)Intermediate/DDSheltered Care (SC)ICF/DD 16 or Less58TOTALS5821,17021,170B. Census-For the entire report period.12345Level of CarePatient Days by Level of Care and Primary Source of PaymentMedicaidRecipientPrivate /DDSCDD 16 OR LESS14 TOTALS8,1085,427C. Percent Occupancy. (Column 5, line 14 divided by total licensedbed days on line 7, column 4.)71.20%HFS 3745 (N-4-99)1,537Page 2#0045302Report Period Beginning:01/01/2018Ending: 12/31/2018D. How many bed reserve days during this year were paid by the Department?0(Do not include bed reserve days in Section B.)15,072F. Does the facility maintain a daily midnight census?1234567YESG. Do pages 3 & 4 include expenses for services orinvestments not directly related to patient care?YESNOXH. Does the BALANCE SHEET (page 17) reflect any non-care assets?YESNOXI. On what date did you start providing long term care at this location?Date started01/01/2008J. Was the facility purchased or leased after January 1, 1978?YESX Date 01/01/2008NOK. Was the facility certified for Medicare during the reporting year?YESXNOIf YES, enter numberof beds certified58and days of care provided891011121314Medicare Intermediary1,399WISCONSIN PHYSICIANS SERVICEIV. ACCOUNTING BASISACCRUALXMODIFIEDCASH*Is your fiscal year identical to your tax year?CASH*YESXNOTax Year:12/31Fiscal Year:12/31* All facilities other than governmental must report on the accrual basis.IL478-2471
STATE OF ILLINOISFacility Name & ID NumberHILLVIEW HEALTHCARE CENTER#0045302V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)Costs Per General LedgerReclassOperating ExpensesSalary/WageSuppliesOtherTotalificationA. General Services12345Dietary116,96816,6845,185138,837Food Laundry48,6474,22752,874Heat and Other Other (specify):* TRASH REMOVAL2,7062,7061234567891010a1112131415TOTAL General ServicesB. Health Care and ProgramsMedical DirectorNursing and Medical RecordsTherapyActivitiesSocial ServicesCNA TrainingProgram TransportationOther (specify):*16 TOTAL Health Care and Programs1718192021222324252627C. General AdministrationAdministrativeDirectors FeesProfessional ServicesDues, Fees, Subscriptions & PromotionsClerical & General Office ExpensesEmployee Benefits & Payroll TaxesInservice Training & EducationTravel and SeminarOther Admin. Staff TransportationInsurance-Prop.Liab.MalpracticeOther (specify):*28 TOTAL General AdministrationTOTAL Operating 7669,16731,684149,7716,8106,810HFS 3745 (N-4-99)Ending:Page l8138,29696,08899,30852,87481,76893,2112,706FOR BHF USE tach a schedule if more than one type of cost is included on this line, or if the total exceeds 1000.NOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification.29 (sum of lines 8, 16 & 28)01/01/2018112,91059,73090,041Report Period 0829IL478-2471
Facility Name & ID NumberHILLVIEW HEALTHCARE CENTERSTATE OF ILLINOIS#0045302#Report Period Beginning:01/01/2018Ending:Page 412/31/2018V. COST CENTER EXPENSES (continued)30313233343536Capital ExpenseD. OwnershipDepreciationAmortization of Pre-Op. & Org.InterestReal Estate TaxesRent-Facility & GroundsRent-Equipment & VehiclesOther (specify):*Salary/Wage1Cost Per General 537 TOTAL Ownership383940414243Ancillary ExpenseE. Special Cost CentersMedically Necessary TransportationAncillary Service CentersBarber and Beauty ShopsCoffee and Gift ShopsProvider Participation FeeOther (specify):*46,98744 TOTAL Special Cost CentersGRAND TOTAL COST45 (sum of lines 29, 37 & 876Adjustments7(4,335)AdjustedTotal814,876FOR BHF USE ttach a schedule if more than one type of cost is included on this line, or if the total exceeds 1000.HFS 3745 (N-4-99)IL478-2471
STATE OF ILLINOISPage 5Facility Name & ID Number HILLVIEW HEALTHCARE CENTER# 0045302Report Period Beginning:01/01/2018Ending:12/31/2018VI. ADJUSTMENT DETAILA. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7.In column 2 below, reference the line on which the particular cost was included. (See instructions.)123ReferBHF USEB. If there are expenses experienced by the facility which do not appear in theNON-ALLOWABLE EXPENSESAmountenceONLYgeneral ledger, they should be entered below.(See instructions.)1 Day Care 1122 Other Care for Outpatients2AmountReference3 Governmental Sponsored Special Programs331 Non-Paid Workers-Attach Schedule* 4 Non-Patient Meals432 Donated Goods-Attach Schedule*5 Telephone, TV & Radio in Resident Rooms(4,335) 395Amortization of Organization &6 Rented Facility Space633 Pre-Operating Expense7 Sale of Supplies to Non-Patients7Adjustments for Related Organization8 Laundry for Non-Patients834 Costs (Schedule VII)9 Non-Straightline Depreciation935 Other- Attach Schedule10 Interest and Other Investment Income1036 SUBTOTAL (B): (sum of lines 31-35) 11 Discounts, Allowances, Rebates & Refunds11(sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary1237 TOTAL ADJUSTMENTS (A) and (B) ) (5,806)13 Sales Tax(541) 11314 Non-Care Related Interest14*These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions15licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation)16on these lines.17 Non-Care Related Fees1718 Fines and Penalties18C. Are the following expenses included in Sections A to D of pages 319 Entertainment19and 4? If so, they should be reclassified into Section E. Please20 Contributions(850) 2120reference the line on which they appear before reclassification.21 Owner or Key-Man Insurance21(See instructions.)123422 Special Legal Fees & Legal Retainers22Yes NoAmountReference23 Malpractice Insurance for Individuals2338 Medically Necessary Transport. 24 Bad Debt243925 Fund Raising, Advertising and Promotional(80) 202540 Gift and Coffee ShopsIncome Taxes and Illinois Personal41 Barber and Beauty Shops26 Property Replacement Tax2642 Laboratory and Radiology27 CNA Training for Non-Employees2743 Prescription Drugs28 Yellow Page Advertising284429 Other-Attach Schedule2945 Other-Attach Schedule30 SUBTOTAL (A): (Sum of lines 1-29) (5,806) 3046 Other-Attach Schedule47 TOTAL (C): (sum of lines 38-46) BHF USE ONLY4849505152HFS 3745 71
STATE OF ILLINOISHILLVIEW HEALTHCARE CENTERID#0045302Report Period Beginning:01/01/2018Ending:12/31/2018Page 5ANON-ALLOWABLE EXPENSES123456789Sch. V LineReferenceAmount 344454647474849 Total4849HFS 3745 (N-4-99)0IL478-2471
STATE OF ILLINOIS# 0045302Facility Name & ID Number HILLVIEW HEALTHCARE CENTERSUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I1234567891010a1112131415Operating ExpensesA. General ServicesDietaryFood PurchaseHousekeepingLaundryHeat and Other UtilitiesMaintenanceOther (specify):*TOTAL General ServicesB. Health Care and ProgramsMedical DirectorNursing and Medical RecordsTherapyActivitiesSocial ServicesCNA TrainingProgram TransportationOther (specify):*16 TOTAL Health Care and Programs1718192021222324252627C. General AdministrationAdministrativeDirectors FeesProfessional ServicesFees, Subscriptions & PromotionsClerical & General Office ExpensesEmployee Benefits & Payroll TaxesInservice Training & EducationTravel and SeminarOther Admin. Staff TransportationInsurance-Prop.Liab.MalpracticeOther (specify):*28 TOTAL General AdministrationTOTAL Operating Expense29 (sum of lines 8,16 & 28)HFS 3745 (N-4-99)PAGES5 & 5A(541)000000(541)PAGE6PAGE6APAGE6BPAGE6CReport Period Summary A12/31/2018Ending:PAGE6ISUMMARYTOTALS(to Sch V, col.7)(541) 10 20 30 40 50 60 7(541) 000(930)0000000000(930) 28(1,471)0000000000(1,471) 291718192021222324252627IL478-2471
Facility Name & ID NumberSTATE OF ILLINOISHILLVIEW HEALTHCARE CENTER#0045302Report Period Beginning:Summary B12/31/201801/01/2018 Ending:SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I30313233343536Capital ExpenseD. OwnershipDepreciationAmortization of Pre-Op. & Org.InterestReal Estate TaxesRent-Facility & GroundsRent-Equipment & VehiclesOther (specify):*37 TOTAL Ownership383940414243Ancillary ExpenseE. Special Cost CentersMedically Necessary TransportationAncillary Service CentersBarber and Beauty ShopsCoffee and Gift ShopsProvider Participation FeeOther (specify):*44 TOTAL Special Cost CentersPAGES5 & AGE6HPAGE6ISUMMARYTOTALS(to Sch V, col.7)0 300 310 320 330 340 350 0000000000000(4,335)0000(4,335)0000000000(4,335) 44(5,806)0000000000(5,806) 45037383940414243GRAND TOTAL COST45 (sum of lines 29, 37 & 44)HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberHILLVIEW HEALTHCARE CENTERSTATE OF ILLINOIS#0045302Report Period Beginning:01/01/2018Ending:Page 612/31/2018VII. RELATED PARTIESA. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.123OWNERSRELATED NURSING HOMESOTHER RELATED BUSINESS ENTITIESNameOwnership %NameCityNameCityType of BusinessN/AB. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,management fees, purchase of supplies, and so forth.YESX NOIf yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance withthe instructions for determining costs as specified for this form.45 Cost to Related Organization123 Cost Per General LedgerSchedule VLineVVVVVVVVVVVVV14 Total12345678910111213ItemAmountName of Related Organization6PercentofOwnership7Operating Costof RelatedOrganization8 Difference:Adjustments forRelated OrganizationCosts (7 minus 4) 12345678910111213 *14* Total must agree with the amount recorded on line 34 of Schedule VI.HFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberHILLVIEW HEALTHCARE CENTERSTATE OF ILLINOIS#0045302Report Period Beginning:Page 6-Supplemental01/01/2018 Ending:12/31/2018VII. RELATED PARTIESA. (Continued)Enter below the names of ALL owners and related organizations (parties) as defined in the instructions123OWNERSRELATED NURSING HOMESOTHER RELATED BUSINESS ENTITIESNameOwnership %NameCityNameCityType of Business1 930HFS 3745 627282930IL478-2471
Facility Name & ID NumberHILLVIEW HEALTHCARE CENTERSTATE OF ILLINOIS#0045302Report Period Beginning:01/01/2018Ending:Page 712/31/2018VII. RELATED PARTIES (continued)C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors.NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this homemust be listed on this schedule.1Name1 estCompensationReceivedFrom OtherNursing Homes*6Average Hours Per WorkWeek Devoted to thisFacility and % of TotalWork WeekHoursPercent78Compensation Includedin Costs for thisReporting Period**DescriptionAmount TOTALSchedule V.Line &ColumnReference123456789101112 13* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s)of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS.** This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees).FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME,ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATIONHFS 3745 (N-4-99)IL478-2471
Facility Name & ID NumberSTATE OF ILLINOIS# 0045302 Report Period Beginning:HILLVIEW HEALTHCARE CENTERPage 801/01/2018Ending:2/31/2018VIII. ALLOCATION OF INDIRECT COSTSName of Related OrganizationStreet AddressCity / State / Zip CodePhone NumberFax NumberA. Are there any costs included in this report which were derived from allocations of central officeor parent organization costs? (See instructions.)YESNOXB. Show the allocation of costs below. If necessary, please attach worksheets.1Schedule 32425 TOTALSHFS 3745 (N-4-99)2Item3Unit of Allocation(i.e.,Days, Direct Cost,Square Feet)4Total Units5Number ofSubunits BeingAllocated Among6Total IndirectCost BeingAllocated((7Amount of SalaryCost Containedin Column 6))89FacilityUnitsAllocation(col.8/col.4)x col.6 1
Facility Name & ID NumberSTATE OF ILLINOIS# 0045302Report Period Beginning:HILLVIEW HEALTHCARE CENTERIX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSEA. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)12345Name of LenderRelated**YES NOPurpose of LoanMonthlyPaymentRequiredDate ofNote67Amount of InterestRate(4 Digits)Page 912/31/201810ReportingPeriodInterestExpenseA. Directly Facility RelatedLong-Term12345 Working CapitalBANTERRA BANK6789XWORKING CAPITAL N/ATOTAL Facility RelatedB. Non-Facility Related* 145,000 12345678145,000 1011121391011121314 TOTAL Non-Facility Related 1415 145,000 15TOTALS (line 9 line14)16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. N/ALine #* Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7.(See instructions.)** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.(See instructions.)HFS 3745 (N-4-99)IL478-2471
Page 1012/31/2018STATE OF ILLINOISFacility Name & ID Number HILLVIEW HEALTHCARE CENTERIX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued)B. Real Estate Taxes#0045302Report Period Beginning:01/01/2018 Ending:Important, please see the next worksheet, "RE Tax". The real estate taxstatement and bill must accompany the cost report.1. Real Estate Tax accrual used on 2017 report. 12. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) 28,42323. Under or (over) accrual (line 2 minus line 1). 28,42334. Real Estate Tax accrual used for 2018 report. (Detail and explain your calculation of this accrual on the lines below.) 4(Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) 56. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costsclassified as a real estate tax cost plus one-half of any remaining refund.TOTAL REFUND ForTax Year.(Attach a copy of the real estate tax appeal board's decision.) 67. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. 5. Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C.28,4237Real Estate Tax History:Real Estate Tax Bill for Calendar 8,43728,42389101112FOR BHF USE ONLY13FROM R. E. TAX STATEMENT FOR 2017 1314PLUS APPEAL COST FROM LINE 5 1415LESS REFUND FROM LINE 6 151
12 Social Services 55,246 1,777 57,023 57,023 57,023 12 13 CNA Training 13 14 Program Transportation 250 250 250 250 14 15 Other (specify):* 15 16 TOTAL Health Care and Programs 669,167 31,684 169,043 869,894 869,894 869,894 16 C. General Administration 17 Administrative 59,730 59,730
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