2013-08-13T16:06:49-05:00 2012-12-31 810385940 ANDERSON ZURMUEHLEN & CO PC PO BOX 748 BUTTE MT 59703 990 2012-01-01 205835453 EDGERTON CARE CENTER INC EDGE 6088841332 313 STOUGHTON ROAD EDGERTON WI 53534 ANDY KERWIN 6088841332 2013-08-13 1 JAMES E WOY P00102054 4067820451 2013-08-13 2012 2016-02-24 21:20:13Z ANDY KERWIN 133 MAPLE BLUFF ROAD N STEVENS POINT WI 544829254 5197918 0 X WWW.EDGERTONCARECENTER.ORG X 2006 WI LONG-TERM CARE X 7 7 147 0 0 0 36774 222003 4047600 4974567 801 1348 28121 0 4113296 5197918 0 807024 0 0 2816418 2620988 0 0 0 1288171 2515103 4104589 5943115 8707 -745197 1117754 0 372557 0 745197 0 X TO PROVIDE CARE WITH PASSION, COMPASSION, AND DIGNITY FOR THE ELDERLY AND THEIR FAMILIES OF OUR COMMUNITY. 0 0 4965711 807024 4974567 EDGERTON CARE CENTER, INC. (THE CARE CENTER) IS LICENSED BY THE WISCONSIN DEPARTMENT OF HEALTH TO OPERATE A 61-BED SKILLED NURSING CARE FACILITY THAT COMMENCED OPERATIONS ON JANUARY 1, 2007. AS PART OF THE CARE PRIVDED, THE CARE CENTER PROVIDES PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY, SOCIAL ACTIVITIES, AND SOCIAL SERVICES.THE CARE CENTER HAS A QUALIFIED RECREATIONAL SPECIALIST THAT COORDINATES DIVERSE PROGRAMMING FOR RESIDENTS TO MEET THEIR VARIOUS NEEDS. THESE ACTIVITIES INCLUDE MUSIC, LARGE PARTIES TO INTERACT WITH PEERS, FAMILY EVENTS, AND THE OPPORTUNITY FOR CHILDREN OF VARIOUS AGES TO VISIT THE RESIDENTS. THE RESIDENTS ARE ALSO PROVIDED WITH THE OPPORTUNITY FOR MONTHLY TRIPS INTO THE COMMUNITY, ORGANIZED RELIGIOUS SERVICES ARE CONDUCTED BY RELIGIOUS LEADERS IN THE COMMUNITY ON A WEEKLY BASIS.THE CARE CENTER PROVIDES SERVICES TO RESIDENTS REGARDLESS OF PAYMENT SOURCE. THE CARE CENTER SOCIAL SERVICES AND ADMINISTRATIVE STAFF WORK PERSONALLY WITH EACH RESIDENT AND FAMILY TO DEETERMINE THEIR INDIVIDUAL FUNDING RESOURCES AVAILABLE AND TO SEARCH FOR OPTIONS IF RESOURCES SUCH AS INSURANCE OR MEDICARE ARE NOT AVAILABLE. THE CARE CENTER ALSO HAS RELATIONSHIPS WITH REGIONAL AND COUNTY SOCIAL WORKERS TO ASSIST IN THE APPLICATION PROCESS FOR MEDICAL ASSISTANCE. THIS IS AN ONGOING PROCESS FOR THOSE WITH INSURANCE, PRIVATE FUNDS, OR MEDICARE AS THOSE RESOURCES MAY BE EXHAUSTED. 4965711 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 5 0 1 147 1 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 0 0 WI X CINDY DEMOYE 3039800611 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 X CHARLES NASON 1.00 X X 0 0 0 ANDY KERWIN 1.00 X X 0 0 0 NICHOLAS LYNN 1.00 X 0 0 0 MARIAM GEHLER 1.00 X 0 0 0 JILL KRUEGER 1.00 X X 0 0 0 KEN DEVITO 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 582707 WISCONSIN ILLINOIS SENIOR HOUSING INC 13185 W GREEN MTN DRIVE LAKEWOOD CO 80228 MANAGEMENT SERVICES 263211 COMMUNITY LIVING SOLUTIONS PO BOX 241 NEENAH WI 549560241 ARCHITECTURE 187196 CARRIAGE HEALTHCARE INC 13185 W GREEN MTN DRIVE LAKEWOOD CO 80228 MANAGEMENT COMPANY 164238 SYSCO PO BOX 90 BARABOO WI 539139990 FOOD SERVICES 141192 5 148500 73503 222003 RESIDENT CARE REVENUE 623000 3689827 3689827 ANCILLIARY REVENUE 623000 1247339 1247339 MISC PATIENT BENEFIT R 623000 37401 37401 4974567 1348 1348 5197918 4974567 0 1348 807024 807024 2366211 2186764 179447 84520 76335 8185 170257 156483 13774 190830 153330 37500 15046 15046 45455 45455 79 79 7601 7601 13519 13519 656331 221854 434477 11372 652 10720 4382 4382 59297 59297 PURCHASED SERVICES AND 783998 774536 9462 SUPPLIES 457533 453414 4119 BUSINESS TAXES 124440 124440 BAD DEBT EXPENSE 15396 15396 129824 71640 58184 5943115 4965711 977404 0 X 630426 0 477134 0 10194 0 1117754 0 361487 0 11070 0 372557 0 X 728387 0 16810 0 745197 0 1117754 0 -745197 0 X X 0 1 X 1 0 X 55825 17994 5490 44175 222003 345487 4478788 4539851 3912583 4068320 4921770 21921312 4534613 4557845 3918073 4112495 5143773 22266799 0 0 0 22266799 1348 1348 1348 1348 4534613 4557845 3918073 4112495 5145121 22268147 0.99990 1.00000 0.00010 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 X 5182400 -15518 -15518 5197918 0 5197918 5120600 0 5120600 822515 822515 5943115 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, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR ALLOWANCE FOR BAD DEBTS -15,396. ROUNDING -122. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR ALLOWANCE FOR BAD DEBTS 15,396. ROUNDING 95. CONTRIBUTION EXPENSE TO WISCONSIN ILLINOIS SENIOR HOUSING, INC. 807,024. 1 WISCONSIN ILLINOIS SENIOR HOUSING INC 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 364016275 501(C)(3) 807024 EDGERTON CARE CENTER, INC. CONTRIBUTED ITS NET ASSETS AS OF DECEMBER 31, 2012 TO WISCONSIN ILLINOIS SENIOR HOUSING (WISH). 1 THE NET ASSETS OF EDGERTON CARE CENTER, INC (ECC) WERE CONTRIBUTED TO WISCONSIN ILLINOIS SENIOR HOUSING, INC (WISH), AS ECC WOULD BE OPERATING UNDER WISH EFFECTIVE 1/1/13. 2012-12-31 807024 THE DISTRIBUTION WAS BASED ON THE EDGERTON CARE CENER, INC. ENDING NET ASSET VALUE AS OF 12/31/12. 364016275 WISCONSIN ILLINOIS SENIOR HOUSING INC 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 501(C)(3) 1 0 0 0 PART II, LINE 2E: CHARLES NASON, ANDY KERWIN, NICHOLAS LYNN, MARIAM GEHLER, JILL KRUEGER, KEN DEVITO, RAJEEV KUMAR PART II, LINE 2E: THESE TRUSTEES OF EDERATON CARE CENTER, INC. ARE BOARD MEMBERS OF WISCONSIN ILLINOIS SENIOR HOUSING, INC., THE SUCCESSOR ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION HAS ENGAGED CARRIAGE HEALTHCARE, INC. (CHC) TO PROVIDE MANAGEMENT SERVICES. 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 BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS ARE REVIEWED ON AN ANNUAL BASIS. EACH OFFICER, DIRECTOR, AND KEY EMPLOYEE MUST SIGN A DISCLOSURE ANNUALLY. BOARD MEMBERS ARE EXPECTED TO DISCLOSE CONFLICTS AS THEY BECOME RELEVANT AT BOARD MEETINGS AND REFRAIN FROM VOTING ON MATTERS IN WHICH THEY HAVE A CONFLICT. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION AND MANGEMENT COMPANY AGREEMENTS ARE REVIEWED 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 GOVERNING DOCUMENTS, POLICIES AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. 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 REFLECTS THIS TRANSFER OF BALANCES ACCORDINGLY. 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. WISCONSIN ILLINOIS SENIOR HOUSING INC 13185 W GREEN MOUNTAIN DRIVE LAKEWOOD CO 80228 364016275 LONG-TERM CARE FACILITIES IL 501(C)(3) LINE 9 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 WISCONSIN ILLINOIS SENIOR HOUSING INC B 807024 FAIR MARKET VALUE WISCONSIN ILLINOIS SENIOR HOUSING INC K 402000 LEASE AGREEMENT