state of illinois health facilities and services review … permit... · 2013-09-10 · state of...

STATE OF ILLINOIS HEALTH FACILITIES AND SERVICES REVIEW BOARD

52525 WEST JEFFERSON ST. SPRINGFIELD, ILLINOIS 62761 (217) 782-3516 FAX: (217) 785 -4111

DOCKET ITEM NUMBER:

D-02 BOARD MEETING:

September 24, 2013 PROJECT NUMBER:

#12-022

PERMIT HOLDERS(S):

Resthave Home

FACILITY NAME and LOCATION:

Resthave Home, Morrison

Project Description:

The permit holders are requesting an alteration to Permit #12-022 Resthave Home in accordance

with 77 IAC 1130.750 – Alteration of the Project. This is the first alteration request for this

project.

Board Staff notes the permit holders have exceeded the acceptable State Board standard

for its preplanning costs. This overage existing in the original State Board Staff Report

(SBSR).

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STATE AGENCY REPORT

PERMIT ALTERATION REQUEST

Project #12-022

I. Project Description and Background Information

On July 23, 2012 the State Board approved Permit #12-022. At that time the permit

holder was approved for the modernization and expansion of its existing 49-bed skilled

care facility. Upon the conclusion of the project, the facility’s bed complement will

increase to 70, through the addition of 21 beds. The approved cost of the project is

$9,510,780. The anticipated project completion date is June 1, 2014.

This project was obligated on September 7, 2012, and is being funded with cash and

securities totaling $1,000,000, and mortgages totaling $8,510,779. The permit holders

are currently compliant with all post-permit requirements.

I. The Proposed Alteration

A. The following proposed alterations require State Board approval:

1. The permit holders are proposing an increase in the total project cost by 3%

from $9,510,780 to $9,796,102 an increase of $285,322 due to increases in the

overall square footage of the facility. The clinical cost of the project is

decreasing from $4,228,315 to $3,475,593 or $752,722 or 17.8% of approved

clinical costs. The non-clinical costs are increasing from $5,282,464 to

$6,320,509 or $1,038,045 or 16.4% from the approved non-clinical costs.

2. The permit holders are proposing to increase the project square footage by

3%, from 57,580 GSF to 59,164 GSF (1,584 GSF). The permit holders note

this increased square footage is due to the addition of social and activity space

deemed necessary for the assisted living program which was missing from the

original floor plan at the time of application/permit approval. The reason for

the reduction in clinical space stems from the mislabeling of clinical space

that should have been classified as non-clinical.

3. The proposed alterations in project costs will result in an increase in the

following sources of funds:

i. $30,000 in cash and securities, from $1,000,000 to $1,030,000.

ii. $255,324 in mortgages, from $8,510,778 to $8,766,102.

B. Reason(s) for the Proposed Alteration:

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The permit holders stated that the alteration is necessary to include social and

activity space for the assisted living program. Space that was not originally

allocated in the permit application.

III. Applicable Rules

77 IAC 1130.750 specifies that a permit is valid only for the project as defined in the

application and any change to the project subsequent to permit issuance constitutes an

Alteration to the project.

Allowable alterations that require HFPB action are:

1) a change in the approved number of beds or stations provided that the

change would not independently require a permit or exemption from

HFPB;

2) abandonment of an approved category of service established under the

permit;

3) any increase in the square footage of the project up to 5% of the approved

gross square footage;

4) any decrease in square footage greater than 5% of the project;

5) any increase in the cost of the project not to exceed 5% of the total project

cost. This alteration may exceed the capital expenditure minimum in

place when the permit was issued, provided that it does not exceed 5% of

the total project cost;

6) any increase in the amount of funds to be borrowed for those permit

holders that have not documented a bond rating of "A" or better;

7) any increase in the project costs components (i.e., line item amounts) if the

increase is not in compliance with the 77 Ill. Adm. Code 1120 review

criteria; or

8) any change that substantially changes the scope or changes the functional

operation of the project, as defined in Section 1130.140.

V. Summary of State Agency Findings

All findings from the Original State Agency Report remain unchanged.

The State Agency finds the proposed Alteration appears to be in conformance with all

applicable review criteria for Part 1110.

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The State Agency finds the proposed Alteration DOES NOT appear to be in

conformance with all applicable review criteria for Part 1120.

VI. Projects Costs and Sources of Funds

Table One shows the original project costs and the altered project costs.

TABLE ONE

Project Costs and Sources of Funds

Project Costs

Original Altered

Clinical Non-Clinical Total Clinical Non-Clinical Total Difference

Preplanning $383,102 $478,612 $861,714 $314,902 $572,663 $887,565 $25,851

New Construction $3,181,380 $3,974,520 $7,155,900 $2,615,032 $4,755,545 $7,370,577 $214,863

Modernization $0 $0 $0 $0 $0 $0 $0

Contingencies $160,599 $200,637 $361,236 $132,099 $240,064 $372,073 $10,837

A & E Fees $183,809 $229,634 $413,443 $151,087 $274,758 $425,846 $12,403

Consulting Fees $25,341 $31,659 $57,000 $20,830 $37,880 $58,710 $1,710

Movable of Other Equipment $81,581 $101,919 $183,500 $67,058 $121,947 $189,005 $5,505

Net Interest Expense $92,743 $115,527 $208,000 $76,011 $138,229 $214,240 $6,240

Other Costs to be Capitalized $120,031 149,956 $269,987 $98,663 $179,423 $278,086 $8,099

Total $4,228,316 $5,282,464 $9,510,780 $3,475,593 $6,320,509 $9,796,102 $285,322

Sources of Funds

Cash and Securities $444,581 $555,419 $1,000,000 $365,437 $664,563 $1,030,000 $30,000

Mortgages $3,783,734 $4,727,044 $8,510,778 $3,110,156 $5,655,946 $8,796,102 $285,324

Total $4,228,315 $5,282,464 $9,510,780 $3,475,593 $6,320,509 $9,796,102 $285,322

VII. Projects Cost Space Requirement

The permit holders are proposing to decrease the size of the clinical portion from 25,599

GSF to 20,991 GSF or 4,608 GSF or 18%.

TABLE TWO

Altered Cost Space Chart

Department/Area Cost Proposed New Construction Modernized

Clinical

General Long Term Care $3,475,993 20,991 18,041 2,950

Subtotal Clinical $3,475,593 20,991 18,041 2,950

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TABLE TWO

Altered Cost Space Chart

Department/Area Cost Proposed New Construction Modernized

Non-Clinical

General Long Term Care $2,780,342 16,792 12,959 3,833

Assisted Living $3,540,167 21,381 3,937 17,444

Subtotal Non Clinical $6,320,509 38,173 16,896 21,277

Total $9,796,102 59,164 34,937 24,227

As seen in Table Four, the applicants are in compliance with the approved permit

amounts for the modernization of clinical service areas being proposed by this

alteration.

THE STATE BOARD STAFF FINDS THE PROPOSED ALTERATION

APPEARS TO BE IN CONFORMANCE WITH THE APPROVED STATE

BOARD PROJECT SIZE CRITERION (77 IAC 1110.234(a)).

VIII. 1120.140 - Economic Feasibility

C) Criterion 1120.140 (c) - Reasonableness of Project and Related Costs

The applicant shall document that the estimated project costs are reasonable

and shall document compliance with the following:

1) Preplanning costs shall not exceed the standards detailed in Appendix

A of this Part.

2) Total costs for site survey, soil investigation fees and site preparation

shall not exceed the standards detailed in Appendix A unless the

applicant documents site constraints or complexities and provides

evidence that the costs are similar to or consistent with other projects

that have experienced similar constraints or complexities.

3) Construction and modernization costs per square foot shall not exceed

the standards detailed in Appendix A unless the applicant documents

construction constraints or other design complexities and provides



HFSRB NOTE: Construction and modernization costs (i.e., all costs

contained in construction and modernization contracts) plus

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contingencies shall be evaluated for conformance with the standards

detailed in Appendix A.

4) Contingencies (stated as a percentage of construction costs for the

project's stage of architectural development) shall not exceed the

standards detailed in Appendix A unless the applicant documents

construction constraints or other design complexities and provides



HFSRB NOTE: Contingencies shall be limited in use for construction

or modernization (line item) costs only and shall be included in

construction and modernization cost per square foot calculations and

evaluated for conformance with the standards detailed in Appendix

A. If, subsequent to permit issuance, contingencies are proposed to be

used for other component (line item) costs, an alteration to the permit

(as detailed in 77 Ill. Adm. Code 1130.750) must be approved by

HFSRB prior to that use.

5) New construction or modernization fees and architectural/engineering

fees shall not exceed the fee schedule standards detailed in Appendix

A unless the applicant documents construction constraints or other

design complexities and provides evidence that the costs are similar to

or consistent with other projects that have experienced similar

constraints or complexities.

6) The costs of all capitalized equipment not included in construction

contracts shall not exceed the standards for equipment as detailed in

Appendix A unless the applicant documents the need for additional or

specialized equipment due to the scope or complexities of the services

to be provided. As documentation, the applicant must provide


of similar scope and complexity, and attest that the equipment will be

acquired at the lowest net cost available, or that the choice of higher

cost equipment is justified due to such factors as, but not limited to,

maintenance agreements, options to purchase, or greater diagnostic or

therapeutic capabilities.

7) Building acquisition, net interest expense, and other estimated costs

shall not exceed the standards detailed in Appendix A. If Appendix A

does not specify a standard for the cost component, the applicant shall

provide documentation that the costs are consistent with industry

norms based upon a comparison with previously approved projects of

similar scope and complexity.

8) Cost Complexity Index (to be applied to hospitals only)

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The mix of service areas for new construction and modernization will

be adjusted by the table of cost complexity index detailed in Appendix

A.

The State Agency notes only the clinical costs will be reviewed against the

established standards in Part 1120. The State Agency calculated the State Board

Modernization Standard using the third quartile of 2012 RS Means data adjusted

for complexity by department/function. This number was then inflated by 3.0%

per year until the Midpoint of construction.

Preplanning – These costs total $314,092 or 11.1% of

construction/modernization, contingencies and equipment costs. This appears

HIGH when compared to the approved State Board Standard of 1.8%.

New Construction and Contingencies - These costs total $2,747,041, or $130.86

per GSF ($2,747,041/20,991 = $130.86 per GSF). This appears reasonable when

compared to the approved State Board standard of $187.46 per GSF.

Contingencies: New Construction - These costs total $132,009 or 5% of new

construction costs. This appears reasonable compared to the approved State

Board standard of 10%.

Architectural and Engineering Fees - These costs total $151,087, or 5.4% of

construction and contingencies. This appears reasonable when compared to the

State Board standard of 8.64% - 12.96%

Consulting or Other Fees - These costs total $20,830. The State Board does not

have standards for this cost.

Moveable & Other Equipment - These costs total $67,058, or $957.97 per bed.

This appears to be reasonable compared to the State standard of $8,287.92.

Net Interest Expense During Construction – These costs total $76,011. The

State Board does not have standards for these costs.

Other Costs to be Capitalized – These costs total $98,663. The State Board

does not have a standard for these costs.

The permit holders appear to be in excess of the State Board Standard for it

Preplanning costs, and a negative finding has been made for this criterion.

THE BOARD STAFF FINDS THE PROPOSED ALTERATION DOES

NOT APPEAR TO BE IN CONFORMANCE WITH THE

REASONABLENESS OF PROJECT COSTS CRITERION (77 IAC

1120.140 (c)).

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Other Information

Included with this report are the alteration request and the original state agency report.

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DOCKET NO:

H-06

BOARD MEETING:

July 23-24, 2012

PROJECT NO:

12-022

PROJECT COST: Original: $9,510,780 FACILITY NAME:

Resthave Home

CITY:

Morrison

TYPE OF PROJECT: Non-substantive HSA:I PROJECT DESCRIPTION: The applicant (Resthave Home) proposes to modernize an existing long term care facility and add 21 long term care beds to existing 49-bed skilled care facility. The total cost of the project is $9,510,780. The project completion date is June 1, 2014.

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EXECUTIVE SUMMARY

PROJECT DESCRIPTION: • The applicant (Resthave Home) proposes to modernize an existing long term care

facility and add 21 long term care beds to existing 49-bed skilled care facility for a total of 70 skilled care beds. The total cost of the project is $9,510,780. The project completion date is June 1, 2014.

WHY THE PROJECT IS BEFORE THE STATE BOARD:

• The applicant is before the State Board because the applicant is proposing a substantial change in the category of service as defined by the State Board.

PURPOSE OF THE PROJECT:

• The purpose of the project is to expand existing skilled nursing services to serve the elderly residents of Morrison and the surrounding communities. The applicant identified Whiteside County as its service area, and has identified a trend involving the residents leaving Morrison/Whiteside County to seek skilled nursing care. The applicant notes the service area lacks sufficient skilled nursing and rehabilitative services.

REASON FOR THE PROJECT: • The applicant proposes to modernize a 49-bed Skilled Care Facility and add 21 long

term care beds in an effort to address issues regarding a lack of modern facilities in the service area (Whiteside County), and the residents leaving the same service area, and seeking skilled nursing care in neighboring counties/service areas/states.

BACKGROUND/COMPLIANCE ISSUES:

• The applicant, Resthave Home, attests to having no adverse background or compliance issues to report.

NEED FOR THE PROJECT:

• An applicant proposing the expansion of an existing long term care facility must document:

• That the expansion will provide services to the planning area; • That there is a demand for the service in the planning area; • That the facility has operated in the excess of the State Board’s target occupancy

for the past two calendar years; and, • That the applicant has the financial wherewithal and the project is economically

feasible. • The State Board Staff notes that for the expansion of an existing nursing home

the calculated bed need and the utilization of other area providers within 30 minutes is not taken into consideration.

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PUBLIC HEARING/COMMENT • No public hearing was requested and no letters of opposition or support for this project

were received by the State Agency. FINANCIAL AND ECONOMIC FEASIBILITY:

• The project will be funded through cash and securities totaling $1,000,000, and Mortgages totaling $8,510,779. The equity in the project is the land with an estimated value of $2 million and investments as documented in the audited financial statements. The applicant provided a financial feasibility assessment that indicates that the facility will be profitable by the first year after project completion. The expected payor mix of the facility is 64% private pay, 29% Medicaid, and 7% Medicare. A letter from Wells Fargo Bank and The National Bank was provided indicating these two bank willingness to provide financing for the project. However no firm commitment was provided in the application material.

CONCLUSIONS:

• The applicant is proposing to modernize a 49-bed Intermediate Care Facility into a 70-bed skilled nursing facility, through construction of new space (49,889 GSF), and modernization of existing space (6,335 GSF). The facility currently has a 5-Star Medicare rating, and a patient population in excess of the 90th percentile, the prescribed occupancy target for long term care facilities. Below is a list of criterion the applicant did not meet.

• The applicant addressed a total of 14 criteria and failed to adequately address the following:

State Board Standards Not Met

Criteria Reasons for Non-Compliance 1125.800 - Financial and Economic Feasibility From a review of the audited financial

statements it appears that the applicant is financially viable. However no evidence was provided that mortgage financing for this project has been secured. The State Board Staff is not able to make a positive recommendation for this criterion.

1125.800 - Reasonableness of Project Costs The applicant exceeds the preplanning costs. These costs total $383,102 or 11.1% of construction, contingency, and equipment costs. The State Board Standard is $61,624 or 1.8%. The applicants exceed the standard by $321,478

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STATE BOARD STAFF REPORT Resthave Home - Morrison

PROJECT #12-022

APPLICATION SUMMARY Applicant(s) Resthave Home

Facility Name Resthave Home Location Morrison

Application Received March 8, 2012 Application Deemed Complete March 13, 2012

Review Period Ended May 12, 2012 Public Hearing Held No

Can Applicant Request Deferral? Yes Review Period Extended by the State Agency? No

Applicant’ Modified the project? No I. The Proposed Project

The applicant proposes to expand/modernize its existing 49-bed long term care facility and add 21 long term care beds. The proposed project will result in a 57,580 GSF facility, and the cost of the project is $9,510,780.

II. Summary of Findings

A. The State Agency finds the proposed project appears to be in conformance with the provisions of Part 1110.

B. The State Agency finds the proposed project does not appear to be in

conformance with the provisions of Part 1120. III. General Information

The applicant is Resthave Home. The operating entity and the owner of the site is Resthave Home. The Home is a not for profit facility. The facility is located at 408 Maple Avenue, Morrison, in HSA-01, in the Whiteside County Long Term Care (“LTC”) Planning Area. The facility currently has 48 semi-private beds and 1 transitional private nursing room for a total of 49 nursing care beds. The facility also has 21 private sheltered care beds.

There are 2 hospital-based (Swing Bed) units and 11 free-standing Long Term Care (LTC) facilities in this LTC Planning area. The June 2012 Inventory Update for General Long Term Care services shows an excess of 105 LTC beds in the Whiteside County planning area.

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The project is substantive and subject to Part 1110 and Part 1120 review. Obligation will occur after permit issuance. The anticipated project completion date is June 1, 2014. Below is the projected charity care for RestHave Home. The State Board Staff Notes no charity care was reported to the State Board Staff for CY2008, 2009, 2010 for this facility.

TABLE ONE Projected Charity Care for RestHave Home

2013 2014 2015

Net Patient Revenue $4,420,683 $5,084,322 $5,263,000

Amount of Charity Care $116,334 $133,798 $138,500

Cost of Charity Care $116,334 $133,798 $138,500

Summary of Support and Opposition Comments An opportunity for a public hearing was offered on this project; however, no hearing was requested. The State Agency has received no letters in support or in opposition to the proposed project. However, the application contained 166 letters of support from various individuals and businesses in the service area. Table One displays information pertaining to other LTC providers within a 30-minute travel radius. The table includes authorized beds, distance and travel times from the applicant’s facility and respective occupancy rates of the facilities. Data on authorized beds and occupancy rates were obtained from IDPH’s 2010 Hospital and LTC profiles, distance and travel times were obtained from Map Quest, and the Medicare Star Rating was obtained from the Department of Health & Human Services’ Medicare website (www.medicare.gov). The data in the table is sorted by travel time. As Table Two shows, there are 9 other providers of LTC service in a 30-minute drive radius. Of the providers identified in Table Two, 2 (22.2%), achieved the State Board’s target utilization (90%) for 2010. The State Agency notes the applicant’s facility has a 5-star Medicare rating, and reported 98.2% occupancy on the 2010 LTC profile.

TABLE TWO Facilities within 30 Minutes Travel Time

Facility City Time (minutes)

Medicare Star

Rating Beds Occupancy%

(90% Target)

Pleasant View Rehab & Healthcare Ctr. Morrison 2 4 74 60 %

Four Seasons Living Ctr. Morrison 2 3 38 74 %

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TABLE TWO Facilities within 30 Minutes Travel Time

Facility City Time (minutes)

Medicare Star

Rating Beds Occupancy%

(90% Target)

Prophet’s Riverview Nursing Ctr. Prophetstown 15 4 70 92.6 %

Harbor Crest Home Fulton 17 4 84 63.6 % Winning Wheels Prophetstown 18 4 80 96.9 %

Coventry Living Ctr. Sterling 23 2 124 65.5 % Sterling Pavilion Sterling 24 1 121 73.3 %

Transitions Nursing & Rehab Rock Falls 25 2 55 73.6 % Rock Falls Rehab & Healthcare Ctr Rock Falls 26 2 57 47.4 % Source: Occupancy % 2010 IDPH LTC Profiles Time and Distance determined by MapQuest and adjusted per 77 IAC 1100.560 Star rating determined from www.Medicare.gov

IV. The Proposed Project – Details

The applicant proposes to modernize an existing 49-bed Intermediate Care Facility (ICF), located at 408 Maple Avenue, Morrison, to a 70-bed Skilled Nursing Facility (SNF), through 49,889 GSF of new construction, 6,335 GSF of modernized space, and the utilization of 1,356 GSF of existing space. Once completed, the expanded facility will consist of 57,580 GSF of space, and house 90 skilled nursing beds.

V. Project Costs and Sources of Funds

The applicant’ provided the project costs for both clinical and non-clinical aspects of the proposed project. Table Three shows the project costs and funding sources using these considerations.

TABLE THREE Project Costs and Source of Funds

Project 12-022 Resthave Home Use of Funds Clinical Non -Clinical Total

Preplanning Costs $383,102 $478,612 $861,714

New Construction Contracts $3,181,380 $3,974,520 $7,155,900 Modernization Contracts $0 $0 $0

Contingencies $160,599 $200,637 $361,236

Architectural & Engineering Fees $183,809 $229,634 $413,443 Consulting & Other Fees $25,341 $31,659 $57,000

Moveable & Other Equipment $81,581 $101,919 $183,500 Net Interest Expense During Construction

$92,473 $115,527 $208,000

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http://www.medicare.gov/�

TABLE THREE Project Costs and Source of Funds

Project 12-022 Resthave Home Other Costs to be Capitalized $120,031 $149,956 $269,987 Totals $4,228,316 $5,282,464 $9,510,780

Source of Funds Cash & Securities $444,581 $555,419 $1,000,000

Mortgages $3,783,734 $4,727,044 $8,510,778 Total $4,228,315 $5,282,464 $9,510,780

VI. Cost/Space Requirements

Table Four displays the project’s space requirements for the clinical and non-clinical portions of the project. The definition of non-clinical as defined in the Planning Act [20 ILCS 3960/3] states, “non-clinical service area means an area for the benefit of the patients, visitors, staff or employees of a health care facility and not directly related to the diagnosis, treatment, or rehabilitation of persons receiving treatment at the health care facility.” The State Agency notes the project involves the construction of new patient rooms contiguous to the existing facility, and the addition of 21 skilled care beds. The applicant note the proposed project will add 49,889 GSF of space to an existing building containing 7,591 GSF of space.

TABLE FOUR Space Chart

Department/Area Proposed GSF

New Construction Modernized

Patient Rooms 14,151 14,151 0

Patient Bathrooms 3,590 3,590 0

Nurses Station/Med Prep 641 366 275

LR/DR/Activity 4,271 2,431 1,840

Exam Room 75 75 0

Kitchen/Food Service 821 211 610

PT/OT 684 0 684

Laundry 234 234 0

Janitor Closet 30 30 0

Clean/Soiled Linen 830 792 38

Beauty/Barber 272 272 0

Total Clinical 25,599 22,152 3,447

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TABLE FOUR Space Chart

Department/Area Proposed GSF

New Construction Modernized

Office/Admin 1,523 0 0

EE Lounge 434 0 434

Mechanical 676 0 0

Lobby 631 0 631

Storage/Maintenance 1,200 0 570

Corridor/Public Toilet 6,518 5,463 1,055

Structure/Misc. 1,298 1,100 198

Stairs/Elevator 50 0 0

Total Non-Clinical 12,330 6,563 2,888

TOTAL 37,929 28,735 6,335

VII. Purpose of Project and Alternatives to the Project

A. Criterion 1125.320 – Purpose of the Project The criterion states: “The applicant shall document that the project will provide health services that improve the health care or well-being of the market area population to be served. The applicant shall define the planning area or market area, or other, per the applicant's definition.

1) The applicant shall address the purpose of the project, i.e.,

identify the issues or problems that the project is proposing to address or solve. Information to be provided shall include, but is not limited to, identification of existing problems or issues that need to be addressed, as applicable and appropriate for the project. Examples of such information include: A) The area's demographics or characteristics (e.g., rapid area

growth rate, increased aging population, higher or lower fertility rates) that May affect the need for services in the future;

B) The population's morbidity or mortality rates;

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C) The incidence of various diseases in the area; D) The population's financial ability to access health care

(e.g., financial hardship, increased number of charity care patients, changes in the area population's insurance or managed care status);

E) The physical accessibility to necessary health care (e.g.,

new highways, other changes in roadways, changes in bus/train routes or changes in housing developments).

2) The applicant shall cite the source of the information (e.g., local

health department Illinois Project for Local Assessment of Need (IPLAN) documents, Public Health Futures, local mental health plans, or other health assessment studies from governmental or academic and/or other independent sources).

3) The applicant shall detail how the project will address or improve

the previously referenced issues, as well as the population's health status and well-being. Further, the applicant shall provide goals with quantified and measurable objectives with specific time frames that relate to achieving the stated goals.

4) For projects involving modernization, the applicant shall describe

the conditions being upgraded. For facility projects, the applicant shall include statements of age and condition and any regulatory citations. For equipment being replaced, the applicant shall also include repair and maintenance records.”

According to the applicant, the purpose of the project is to address a need for a modernized health care facility in Morrison and HSA-01. The applicant also notes being aware of a recent trend where residents of HSA-01 and the Whiteside County LTC Planning Area are leaving the service area to seek skilled nursing care. This exodus has sent residents to the nearby Quad Cities, and the state of Iowa as well.

B. Criterion 1125.330 - Alternatives to the Proposed Project

The criterion states: “The applicant shall document that the proposed project is the most effective or least costly alternative for meeting the health care needs of the population to be served by the project.

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1) Alternative options shall be addressed. Examples of alternative

options include:

A) Proposing a project of greater or lesser scope and cost;

B) Pursuing a joint venture or similar arrangement with one or more providers or entities to meet all or a portion of the project's intended purposes; developing alternative settings to meet all or a portion of the project's intended purposes;

C) Utilizing other health care resources that are available to

serve all or a portion of the population proposed to be served by the project; and

D) Other considerations.

2) Documentation shall consist of a comparison of the project to

alternative options. The comparison shall address issues of cost, patient access, quality and financial benefits in both the short term (within one to three years after project completion) and long term. This May vary by project or situation.

3) The applicant shall provide empirical evidence, including

quantified outcome data; that verifies improved quality of care, as available.”

The applicant considered the following four alternatives: 1. A Project of Greater of Lesser Scope

The applicant reviewed both options, and notes a project of smaller size would have similar staffing requirements, with operational costs and salaries spread over a smaller number of beds, and a facility of larger size would exceed the need of the service area. The applicant also acknowledges the replacement of the existing physical plant would cost approximately $20 million dollars, which greatly exceed the cost of a combined modernization and expansion. Based on this cost estimate, this alternative was rejected. The applicant identified an estimated cost of $20,000,000 with this alternative.

2. Pursue a Joint Venture or Similar Arrangement

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The applicant rejected this alternative because a suitable partner could not be identified in Morrison. The applicant notes the local hospital prefers the use of its own facility, and Pleasant View Rehab & Healthcare is part of a for-profit chain of health care organizations, and a partnership with Pleasant View would require extensive renovation of its physical plant, resulting in project costs of approximately $11-$12 million dollars.

3. Develop Alternative Settings to Meet All or a Portion of the Project’s Intended Purposes

The applicant notes Resthave currently provides assisted living services, and notes the alternative of developing alternative settings is being developed to meet a portion of the project’s intended purposes. The applicant did not identify an estimated cost with this alternative.

4. Utilize Other LTC Resources that are Available to Serve All or a Portion of the Population Proposed to be Served by the Project

The applicant cites the alternative of utilizing other skilled nursing facilities was discussed in option 2, and that home health care would be the only other viable health care alternative. The applicant notes home health care lacks the level of acuity needed for treating skilled care patients, and that Resthave’s alternative to develop a skilled nursing unit would best meet the area’s need for high-quality skilled nursing care. The applicant identified no associated costs with this alternative.

The applicant has supplied the information requested in accordance with this criterion.

VIII. Expansion of Existing Services

A. Criterion 1125.520 - Background of Applicant The criterion:

“An applicant must demonstrate that it is fit, willing and able, and has the qualifications, background and character, to adequately provide a proper standard of health care service for the community. [20 ILCS

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3960/6] In evaluating the qualifications, background and character of the applicant, HFPB shall consider whether adverse action has been taken against the applicant, or against any health care facility owned or operated by the applicant, directly or indirectly, within three years preceding the filing of the application. A health care facility is considered "owned or operated" by every person or entity that owns, directly or indirectly, an ownership interest. If any person or entity owns any option to acquire stock, the stock shall be considered to be owned by such person or entity (refer to 77 Ill. Adm. Code 1100 and 1130 for definitions of terms such as "adverse action", "ownership interest" and "principal shareholder").”

The applicant provided licensure and certification information for Resthave Home as required, provided representations attesting that no adverse actions have been taken against this facility, and the State Agency can access any and all information to determine whether adverse actions have been taken against the applicant. The applicant provided all the necessary information required to address this criterion.

B) Criterion 1125.530(b) - Planning Area Need

The applicant shall document that the number of beds to be established or added is necessary to serve the planning area's population, based on the following: b) Service to Planning Area Residents 1) Applicant proposing to establish or add beds shall document that the primary purpose of the project will be to provide necessary LTC to the residents of the area in which the proposed project will be physically located (i.e., the planning or geographical service area, as applicable), for each category of service included in the project. 2) Applicant proposing to add beds to an existing general LTC service shall provide resident/patient origin information for all admissions for the last 12-month period, verifying that at least 50% of admissions were residents of the area. For all other projects, applicant shall document that at least 50% of the projected resident volume will be from residents of the area. 3) Applicant proposing to expand an existing general LTC service shall submit resident/patient origin information by zip code, based

20

upon the resident's/patient's legal residence (other than an LTC facility).

The applicant proposes to modernize 49 existing long care beds and through new construction and modernization, add 21 new beds, resulting in a 70-bed skilled nursing facility in Morrison. The 21-bed addition will be in the form of a newly constructed wing, and is necessary to provide health care to residents of the Whiteside County LTC Planning area. The applicant notes the proposed service will improve access for a patient requiring Medicare-certified skilled nursing care upon discharge from a hospital stay. Although skilled nursing service is offered in the area, current and prospective residents have expressed a preference for receiving said service from Resthave, due to their non-profit status, reputation, and track record of quality care and service. The applicant provided a list (application, p. 160), identifying 12 admissions in the last 12 months. Of the 12 admissions, 8 (75%), originated from the zip code for Morrison. The applicant continued by supplying three other zip codes from the service area, meeting the requirement that over 50% of the admissions must originate from the service area. The applicant is projecting that 70% of the residents will come from within the planning area-Whiteside County. The applicant has met the requirements of this criterion. THE STATE AGENCY FINDS THE PROPOSED PROJECT TO BE IN CONFORMANCE WITH THE GENERAL LONG TERM CARE REVIEW CRITERION (77 IAC 1125.530).

C) Criterion 1125.550 - Service Demand

The number of beds to be added at an existing facility is necessary to reduce the facility's experienced high occupancy and to meet a projected demand for service. The applicant shall document subsection (a) and either subsection (b) or (c).

a) Historical Service Demand

1) An average annual occupancy rate that has equaled or exceeded

occupancy standards for general LTC, as specified in Section 1125.210(c), for each of the latest two years.

2) If prospective residents have been referred to other facilities in

order to receive the subject services, the applicant shall provide documentation of the referrals, including completed applications

21

that could not be accepted due to lack of the subject service and documentation from referral sources, with identification of those patients by initials and date.

b) Projected Referrals The applicant shall provide documentation as described in Section 1125.540(d).

The applicant’s long term care occupancy for 2010 was 98.2% and 98.4% for 2009. The applicant has provided referral letters from area physicians and from CGH Medical Center proposing to refer a total of 33 patients annually to the facility. The applicants have met the requirements of this criterion. State Board Staff Notes only those referral letters that were notarized were used in the calculation of the number of annual referrals. THE STATE AGENCY FINDS THE PROPOSED PROJECT TO BE IN CONFORMANCE WITH THE GENERAL LONG TERM CARE REVIEW CRITERION (77 IAC 1125.550).

D) Criterion 1125.590 - Staffing Availability

The applicant notes the current 49-bed long term care facility (ICF) is sufficiently staffed, according to licensing standards, and notes additional staff (RNs, LPNs, and CNAs) can be recruited from area nursing schools, when needed. The applicant also notes having applications on file for the following positions: Registered Nurse (RN): 10 Applications Licensed Practical Nurse (LPN): 9 Applications Certified Nursing Assistant (CNA): 42 Applications

The applicant attests that any remaining staffing needs for the proposed facility can be recruited from the local labor pool in the Morrison and Sterling/Rock Falls area. THE STATE AGENCY FINDS THE PROPOSED PROJECT TO BE IN CONFORMANCE WITH THE WITH THE STAFFING AVAILABILITY REVIEW CRITERION (77 IAC 1125.590).

E) Criterion 1125.600 - Performance Requirements – Bed Capacity/Facility

Size The maximum size of a general long term care facility is 250 beds, unless the applicant documents that a larger facility would provide personalization of patient care and documents provision of quality care based on the experience of the applicant and compliance with IDPH's

22

licensure standards (77 Ill. Adm. Code: Chapter I, Subchapter c − Long-Term Care Facilities) over a two-year period of time.

The applicant notes the facility will consist of 70 skilled nursing beds after project completion. It appears the applicant is in conformance with the Bed Capacity criterion. The applicant also notes the proposed spatial configuration for the project is not excessive, and meets the State standard of 435 GSF to 735 GSF per bed.

THE STATE AGENCY FINDS THE PROPOSED PROJECT TO BE IN CONFORMANCE WITH THE BED CAPACITY/FACILITY SIZE CRITERION (77 IAC 1125.600, and 1125.620).

F) Criterion 1125.620 – Project Size The criterion states: “The applicant shall document that the amount of physical space proposed for the project is necessary and not excessive. The proposed gross square footage (GSF) cannot exceed the GSF standards of Appendix B, unless the additional GSF can be justified by documenting one of the following:

1) Additional space is needed due to the scope of services provided,

justified by clinical or operational needs, as supported by published data or studies;

2) The existing facility's physical configuration has constraints or

impediments and requires an architectural design that results in a size exceeding the standards of Appendix B;

3) The project involves the conversion of existing bed space that

results in excess square footage.” The applicant is proposing 366 GSF per room which is below the State Board standard. The applicant has met the requirement of this criterion. A positive finding can be made for this criterion.

TABLE FIVE Project #11-02

Departments Unit of Measure

State Standard/Unit of Measure

State Standard GSF

Proposed GSF Difference

Meets Standards

Nursing Care Beds 70 beds/ 435-713 BGSF/Bed 49,910 25,599 GSF 24,311

23

TABLE FIVE Project #11-02

Departments Unit of Measure

State Standard/Unit of Measure

State Standard GSF

Proposed GSF Difference

Meets Standards

365.7 GSF per bed GSF Yes THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE SIZE OF PROJECT – REVIEW CRITERION (77 IAC 1125.620).

G) Criterion 1125.640 – Assurances

1) The applicant representative who signs the CON application shall submit a signed and dated statement attesting to the applicant's understanding that, by the second year of operation after the project completion, the applicant will achieve and maintain the occupancy standards specified in 77 Ill. Adm. Code 1100 for each category of service involved in the proposal.

2) For beds that have been approved based upon representations for

continuum of care (subsection (c)) or defined population (subsection (d)), the facility shall provide assurance that it will maintain admissions limitations as specified in those subsections for the life of the facility. To eliminate or modify the admissions limitations, prior approval of HFPB will be required.

The applicant provided the required signed documents to satisfy the Assurances Review criterion 1125.640 (application, p. 182). THE STATE AGENCY FINDS THE PROPOSED PROJECT TO BE IN CONFORMANCE WITH THE WITH THE ASSURANCES REVIEW FUNCTIONS CRITERION (77 IAC 1125.640).

IX. 1120.120 - Availability of Funds

The applicant shall document that financial resources shall be available and be equal to or exceed the estimated total project cost plus any related project costs by providing evidence of sufficient financial resources from the following sources, as applicable:

a) Cash and Securities − statements (e.g., audited financial statements, letters from financial institutions, board resolutions) as to:

24

1) the amount of cash and securities available for the project, including the identification of any security, its value and availability of such funds; and

2) interest to be earned on depreciation account funds or to be

earned on any asset from the date of applicant's submission through project completion;

b) Pledges − for anticipated pledges, a summary of the anticipated pledges showing anticipated receipts and discounted value, estimated time table of gross receipts and related fundraising expenses, and a discussion of past fundraising experience. Provide a list of confirmed pledges from major donors (over $100,000);

c) Gifts and Bequests − verification of the dollar amount, identification of any conditions of use, and the estimated time table of receipts;

d) Debt − a statement of the estimated terms and conditions (including the debt time period, variable or permanent interest rates over the debt time period, and the anticipated repayment schedule) for any interim and for the permanent financing proposed to fund the project, including:

1) For general obligation bonds, proof of passage of the required referendum or evidence that the governmental unit has the authority to issue the bonds and evidence of the dollar amount of the issue, including any discounting anticipated;

2) For revenue bonds, proof of the feasibility of securing the specified amount and interest rate;

3) For mortgages, a letter from the prospective lender attesting to the expectation of making the loan in the amount and time indicated, including the anticipated interest rate and any conditions associated with the mortgage, such as, but not limited to, adjustable interest rates, balloon payments, etc.;

4) For any lease, a copy of the lease, including all the terms and conditions, including any purchase options, any capital improvements to the property and provision of capital equipment;

25

e) Governmental Appropriations − a copy of the appropriation Act or ordinance accompanied by a statement of funding availability from an official of the governmental unit. If funds are to be made available from subsequent fiscal years, a copy of a resolution or other action of the governmental unit attesting to this intent;

f) Grants − a letter from the granting agency as to the availability of funds in terms of the amount and time of receipt;

g) All Other Funds and Sources − verification of the amount and type of any other funds that will be used for the project.

The total estimated project cost is $9,510,780 and the applicant will fund the project with cash and securities totaling $1,000,000, and Mortgages totaling $8,510,779. It is unclear from the documentation provided whether the mortgage financing will be secured for this project. The State Board Staff is unable to make a positive finding regarding this criterion. THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO MEET THE REQUIREMENTS OF THE AVAILABILITY OF FUNDS CRITERION (77 IAC 1125.800)

X. 1125.800 - Financial Viability

The applicant shall demonstrate the financial feasibility of the project based upon the projection of reasonable Medicare, Medicaid and private pay charges, expenses of operation, and staffing patterns relative to other facilities in the market area in which the proposed project will be located. The applicant provided the necessary documentation and provided a financial feasibility study that indicates the proposed project is financial feasible. State Board Staff notes that for long term care facilities financial viability ratios are required for new facilities only and not for existing facilities. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO MEET THE REQUIREMENTS OF THE FINANCIAL FEASBILITY CRITERION (77 IAC 1125.800)

XI. Review Criteria - Economic Feasibility

A. Criterion 1120.140(a) - Reasonableness of Financing Arrangements

26

The criterion states:

“This criterion is not applicable if the applicant has documented a bond rating of "A" or better pursuant to Section 1120.210. An applicant that has not documented a bond rating of "A" or better must document that the project and related costs will be: 1) funded in total with cash and equivalents including investment securities, unrestricted funds, and funded depreciation as currently defined by the Medicare regulations (42 USC 1395); or 2) funded in total or in part by borrowing because:

A) a portion or all of the cash and equivalents must be retained in the balance sheet asset accounts in order that the current ratio does not fall below 2.0 times;

B) or borrowing is less costly than the liquidation of existing investments and the existing investments being retained may be converted to cash or used to retire debt within a 60 day period. The applicant must submit a notarized statement signed by two authorized representatives of the applicant entity (in the case of a corporation, one must be a member of the board of directors) that attests to compliance with this requirement.

C) The project is classified as a Class B project. The co-applicant do not have a bond rating of “A”. No capital costs, except fair market value of leased space and used equipment, are being incurred by the co-applicant.”

The total estimated project cost is $9,510,780 and the applicant attests to funding the project with cash and securities ($1,000,000), and a mortgage ($8,510,779). The applicant has attested that all cash and securities are being used prior to borrowing. However the financing has not been secured at the time of this report, a positive finding cannot be made.

THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO MEET THE REQUIREMENTS OF THE REASONABLENESS OF FINANCING CRITERION (77 IAC 1120.140 (a))

B. Criterion 1120.140(b) - Conditions of Debt Financing

This criterion states:

27

“The applicant must certify that the selected form of debt financing the project will be at the lowest net cost available or if a more costly form of financing is selected, that form is more advantageous due to such terms as prepayment privileges, no required mortgage, access to additional indebtedness, term (years), financing costs, and other factors. In addition, if all or part of the project involves the leasing of equipment or facilities, the applicant must certify that the expenses incurred with leasing a facility and/or equipment are less costly than constructing a new facility or purchasing new equipment. Certification of compliance with the requirements of this criterion must be in the form of a notarized statement signed by two authorized representative (in the case of a corporation, one must be a member of the board of directors) of the applicant entity.”

The total estimated project cost is $9,510,780 and the applicant attests to funding the project with cash and securities ($1,000,000), and a mortgage ($8,510,779). The applicant has provided the necessary attestation as provided in rule. However the financing has not been secured at the time of this report, a positive finding cannot be made.

THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO MEET THE REQUIREMENTS OF THE TERMS OF DEBT FINANCING CRITERION (77 IAC 1120.140 (b))

C. Criterion 1120.140(c) - Reasonableness of Project Cost

The criteria states: “1) Construction and Modernization Costs

Construction and modernization costs per square foot for non-hospital based ambulatory surgical treatment centers and for facilities for the developmentally disabled, and for chronic renal dialysis treatment centers projects shall not exceed the standards detailed in Appendix A of this Part unless the applicant documents construction constraints or other design complexities and provides evidence that the costs are similar or consistent with other projects that have similar constraints or complexities. For all other projects, construction and modernization costs per square foot shall not exceed the adjusted (for inflation, location, economies of scale and mix of service) third quartile as provided for in the Means Building Construction Cost Data publication unless the applicant documents construction constraints or other design complexities and provides evidence that the costs are

28

similar or consistent with other projects that have similar constraints or complexities.

2) Contingencies Contingencies (stated as a percentage of construction costs for the stage of architectural development) shall not exceed the standards detailed in Appendix A of this Part unless the applicant documents construction constraints or other design complexities and provides evidence that the costs are similar or consistent with other projects that have similar constraints or complexities. Contingencies shall be for construction or modernization only and shall be included in the cost per square foot calculation. BOARD NOTE: If, subsequent to permit issuance, contingencies are proposed to be used for other line item costs, an alteration to the permit (as detailed in 77 Ill. Adm. Code 1130.750) must be approved by the State Board prior to such use.

3) Architectural Fees Architectural fees shall not exceed the fee schedule standards detailed in Appendix A of this Part unless the applicant documents construction constraints or other design complexities and provides evidence that the costs are similar or consistent with other projects that have similar constraints or complexities.

4) Major Medical and Movable Equipment A) For each piece of major medical equipment, the applicant

must certify that the lowest net cost available has been selected, or if not selected, that the choice of higher cost equipment is justified due to such factors as, but not limited to, maintenance agreements, options to purchase, or greater diagnostic or therapeutic capabilities.

B) Total movable equipment costs shall not exceed the standards for equipment as detailed in Appendix A of this Part unless the applicant documents construction constraints or other design complexities and provides evidence that the costs are similar or consistent with other projects that have similar constraints or complexities.

5) Other Project and Related Costs The applicant must document that any preplanning, acquisition, site survey and preparation costs, net interest expense and other estimated costs do not exceed industry norms based upon a comparison with similar projects that have been reviewed.”

The State Agency notes the cost identified below are for clinical expenses only.

29

Preplanning Costs – These costs total $383,102 or 11.1% of construction, contingency, and equipment costs. This appears high compared to the State standard of 1.8%.

New Construction and Contingencies – This cost is $3,341,979 or $130.55 per GSF. This appears reasonable when compared to the adjusted State Board standard of $181.28 per GSF.

Contingencies – This cost is $160,599 or 5% of new construction costs. This appears reasonable when compared to the State Board standards of 10% for new construction.

Architectural and Engineering Fees – This cost is $183,809 or 5.5% of construction and contingency costs. This appears reasonable when compared to the State Board standard of 6.42 – 9.64%.

Consulting and Other Fees – These costs total $25,341. The State Board does not have a standard for this cost. Moveable Equipment - These costs total $81,581, or $1,165.44 per bed. This is reasonable compared to the State Standard of $6,491.00 per LTC bed. Net Interest Expense During Construction – These costs total $92,473. The State Board does not have a standard for this cost.

Other Costs to be Capitalized – These costs total $120,031. The State Board does not have a standard for this cost.

It appears that the applicant has Preplanning Costs in excess of the allowable standard and a positive finding cannot be made for this criterion.

THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO MEET THE REQUIREMENTS OF REASONABLENESS OF PROJECT COST CRITERION (77 IAC 1120.140 (c))

D. Criterion 1120.140(d) - Projected Operating Costs

The criterion states:

30

“The applicant must provide the projected direct annual operating costs (in current dollars per equivalent patient day or unit of service) for the first full fiscal year after project completion or the first full fiscal year when the project achieves or exceeds target utilization pursuant to 77 Ill. Adm. Code 1100, whichever is later. Direct cost means the fully allocated costs of salaries, benefits, and supplies for the service.” The applicant state this cost will be $190.93 per patient day. The State Board does not have a standard for this cost. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE PROJECTED OPERATING COSTS REVIEW CRITERION (77 IAC 1120.140 (d)).

E. Criterion 1120.140(e) - Total Effect of the Project on Capital Costs

The criterion states: “The applicant must provide the total projected annual capital costs (in current dollars per equivalent patient day) for the first full year after project completion or the first full fiscal year when the project achieves or exceeds target utilization pursuant to 77 Ill. Adm. Code 1100, whichever is later.” The applicant state this cost will be $26.93 per patient day. The State Board does not have a standard for this cost. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE TOTAL EFFECT OF THE PROJECT ON CAPITAL COSTS REVIEW CRITERION (77 IAC 1120.140 (e)).

31

Copyright © and (P) 1988–2006 Microsoft Corporation and/or its suppliers. All rights reserved. http://www.microsoft.com/mappoint/Portions © 1990–2005 InstallShield Software Corporation. All rights reserved. Certain mapping and direction data © 2005 NAVTEQ. All rights reserved. The Data for areas of Canada includes information taken with permission from Canadian authorities, including: © Her Majesty the Queen in Right of Canada, © Queen's Printer for Ontario. NAVTEQ and NAVTEQ ON BOARD are trademarks of NAVTEQ. © 2005 Tele Atlas North America, Inc. All rights reserved. Tele Atlas and Tele Atlas North America are trademarks of Tele Atlas, Inc.

12-022 Resthave Home - Morrison

0 mi 5 10 15 20

32

ILLINOIS LONG-TERM CARE PROFILE-CALENDAR YEAR 2011 RESTHAVE HOME - WHITESIDE CO MORRISON

001 1956007884

RESTHAVE HOME - WHITESIDE CO408 MAPLE AVENUEMORRISON, IL. 61270

AdministratorTami Tegeler

Contact Person and TelephoneMary Burgess815-772-4021

Registered Agent InformationTami Tegeler408 Maple AvenueMorrison, IL 61270

Date Completed

3/7/2012

FACILITY OWNERSHIPNON-PROF CORPORATION

Reference Numbers

Aggressive/Anti-Social 1Chronic Alcoholism 1Developmentally Disabled 1Drug Addiction 0Medicaid Recipient 0Medicare Recipient 1Mental Illness 0Non-Ambulatory 0Non-Mobile 0Public Aid Recipient 0Under 65 Years Old 0Unable to Self-Medicate 0

Other Restrictions 0No Restrictions 0

ADMISSION RESTRICTIONS

Note: Reported restictions denoted by '1'

Neoplasms 0Endocrine/Metabolic 0Blood Disorders 0

Alzheimer Disease 20Mental Illness 0Developmental Disability 0

*Nervous System Non Alzheimer 3

Circulatory System 39Respiratory System 5Digestive System 0Genitourinary System Disorders 0Skin Disorders 0Musculo-skeletal Disorders 1Injuries and Poisonings 0Other Medical Conditions 0Non-Medical Conditions 0

RESIDENTS BY PRIMARY DIAGNOSISDIAGNOSIS

TOTALS 68

LEVEL OF CARE BEDSLICENSED

TOTAL BEDS 74

47

PEAKBEDS

SET-UP

00

22

69

PEAKBEDSUSED

69

BEDSIN USE

68

0

MEDICARECERTIFIED

49

MEDICAIDCERTIFIED

49

00

LICENSED BEDS, BEDS IN USE, MEDICARE/MEDICAID CERTIFIED BEDS

BEDSSET-UP

68

3

AVAILABLEBEDS

003

6

Nursing Care 49Skilled Under 22 0Intermediate DD 0Sheltered Care 25

4700

22

4600

22

4600

22

0

ADMISSIONS AND DISCHARGES - 2011

FACILITY UTILIZATION - 2011BY LEVEL OF CARE PROVIDED AND PATIENT PAYMENT SOURCE

LEVEL OF CAREMedicare

Intermediate DDSheltered Care

Medicaid

3900

Other Public

0

16391

TOTAL

00

24270

7879

91.6%

Occ. Pct.

0.0%0.0%

89.9%

86.3%

Beds

95.5%

Occ. Pct.

0.0%0.0%

96.4%

98.1%

Set UpPat. days Occ. Pct.

0.0% 21.8%0.0%0.0%

21.8%

Nursing CareSkilled Under 22

0

TOTALS 0.0%0

Pat. days Occ. Pct.

390000

Pat. days Pat. days

Residents on 1/1/2011 66Total Admissions 2011 29Total Discharges 2011 27Residents on 12/31/2011 68

AGE GROUPS Male

TOTALS 10

Female

36

NURSING CAREMale

0

Female

0

SKL UNDER 22Male

0

Female

0

INTERMED. DDMale

4

Female

18

SHELTERED

00000

Male

113

14

00000

Female

846

54

TOTAL

00000

TOTAL

959

68

GRANDRESIDENTS BY AGE GROUP, SEX AND LEVEL OF CARE - DECEMBER 31, 2011

Under 18 018 to 44 045 to 59 060 to 64 065 to 74 075 to 84 185+ 9

000006

30

0000000

0000000

0000000

0000000

0000004

000002

16

Ventilator Dependent 1Infectious Disease w/ Isolation 0

Facility IDHealth Service Area Planning Service Area

0000

InsurancePat. days

Peak BedsLicensedPrivatePay

Pat. days

Private

1249100

7879

0000

0000

CarePat. days

Charity

0 20370 0

CONTINUING CARE COMMUNITYLIFE CARE FACILITY

NoNo

Total Residents Diagnosed as Mentally Ill 0

Identified Offenders 0

Page 1657 of 21908/29/2012Source:Long-Term Care Facility Questionnaire for 2011, Illinois Department of Public Health, Health Systems Development

33

ILLINOIS LONG-TERM CARE PROFILE-CALENDAR YEAR 2011 RESTHAVE HOME - WHITESIDE CO MORRISON

RESIDENTS BY PAYMENT SOURCE AND LEVEL OF CARELEVELOF CARE Medicare

ICF/DDSheltered Care

TOTALS 0

Medicaid

11

Public

0

OtherInsurance

0

Pay

57

PrivateCare

0

CharityTOTALS

4600

68

22

Nursing Care 0Skilled Under 22 0

1100

0000

0000

3500

22

0000

Nursing Care 218

AVERAGE DAILY PAYMENT RATES

Skilled Under 22 0

LEVEL OF CARE

Intermediate DD 0Shelter 86

SINGLE161

000

DOUBLE

RACE Nursing

Total 46

ETHNICITY

Total 46

SklUnd22

0

0

ICF/DD

0

0

Shelter

22

22

68

0

Totals

00

0

0

68

0680

68

RESIDENTS BY RACIAL/ETHNICITY GROUPING

Nursing SklUnd22 ICF/DD Shelter Totals

White 46

Black 0Amer. Indian 0Asian 0

Hispanic 0

Hawaiian/Pac. Isl. 0

Race Unknown 0

Non-Hispanic 46Ethnicity Unknown 0

0

000

0

0

0

00

0

000

0

0

0

00

22

000

0

0

0

220

Administrators 1.00Physicians 0.00Director of Nursing 1.00Registered Nurses 4.00LPN's 7.60Certified Aides 24.20Other Health Staff 18.20Non-Health Staff 11.70

Totals 67.70

STAFFINGEMPLOYMENT

CATEGORYFULL-TIME

EQUIVALENT

001 1956007884

RESTHAVE HOME - WHITESIDE CO408 MAPLE AVENUEMORRISON, IL. 61270Reference Numbers Facility IDHealth Service Area Planning Service Area

NET REVENUE BY PAYOR SOURCE (Fiscal Year Data)

Medicare Medicaid Other Public Private Insurance Private Pay Expense*TOTALS

0 289,192 0 0 2,733,103 3,022,295 00.0% 9.6% 0.0% 0.0% 90.4% 0.0%

Charity Care

Total Net Revenue

Charity Care Expense as % of

100.0%

*Charity Expense does not include expenses which may be considered a community benefit.

Page 1658 of 21908/29/2012Source:Long-Term Care Facility Questionnaire for 2011, Illinois Department of Public Health, Health Systems Development

34

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