Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023
NYSCEF BOC. NO. 54 RECEIVED NYSCEF: 06/28/2023
BUDIMIR EXHIBIT 5A
HO!
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Pre-Fatory - Certified Public
Name
Accountant
9290
Certified Public Accounting Firm 001 | Loeb & Troper LLP
Name of CPA 002|Joseph Weinberger
CPA License Number 003] 078317
Pre-fatory - RHCF Name Code
Ownership Type
3059 0099
Ownership Type oo 3 = Proprietary - Corporation
Pre-fatory - 1) Social Percent
Ownership Names of Established Operators (1) Number
Security Ownership
Information 2 Number BI
Operations
9100 0100 g101 o101
001|KENNETH ROZENBERG $5.50
002|REUVEN KAUFMAN 10.00
003 | Jeffrey Sicklick 2.50
004/Leo Lerner 2.00
005
006
oo7
008
009
oo
O11
O12
013
o14
O15
O16
O17
018
019
020
021
O22
023
024
025
099 [fal 100.00
(1) Proprietary & Not-For-Profit Corporation Identify Stockholders
or Board of Directors on next Schedule
(2) Enter 1 for each Operator
(3) Must Total 100%
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Yoluntary
Pre-fatory - 2) If Person
Corporate Number
% of
Owner.
Term Date Term Affiliated
Stockholders / Stockholders / Directors Names in Expires with Other
Board of a (2) Years MM/DD/YY] RHCF, How
Directors Many?
s102 o102 0103 o104 0105 0106
001| Kenneth Rozenberg 1 95.50
002|Reuven Kaufman 1 10.00
003 | Jeffrey Sicklick 1 2.50
004/Leo Lerner 1 2.00
005
006
oo?
oos
009
oo
O11
O12
O13
o14
O15
O16
O17
o18
019
020
021
O22
023
024
025
026
027
028
029
030
031
032
033
034
035
036
O37
038
039
o40
O41
O42
043
044
045
046
o47
o48
o4g
050
051
O99 | faba 4| 100.00
(1) Enter 1 for each person listed
(2) Must Total 100%
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Percent Ownership
Prefatory -
Social
Ownership Tangible Property Ownership(1)
Security Land | Building Moveable
Equipment
Information Owners Namefs Number
Tangible
Property
9107 oo? 0108 0109
001|HOLLIS REAL ESTATE CO 00.00% |100.00%
002|HOLLISWOOD CENTER FOR REHAB 100.00%
003
004
O05
OO6
007
008
oog
o10
ou
O12
013
O14
O15
O16
O17
O18
019
020
021
O22
023
O24
025
O99 } Eotaks: (Must = EI 100.00% |100.00% 100.00%
(1) If owner is a corporation, identify the stockholder(s) on the next schedule
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Pre-fatory - Type of
Corporate
Name of Corporation Name of Stockholder
Number | Percent
Owner
Prop.
a (2)
Stockholders
9110 3111 0110 0111 112
001
O02
003
O04
005
O06
oo?
008
009
o10
ou
o12
013
O14
O15
O16
ow
O18
019
020
021
022
023
O24
025
O99} otal
(1) Enter 1 for each stockholder
(2) Identify type of property:
=Land
uilding
= Moveable Equipment
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014
RepstPerigdc
oLN
OURYI6 54 ze RECEIVED) Wy2@ Go 28/2023
Pre-fatory - 5)
Ownership Information - Related Companies
0390
Does this RHCF have Related Companies?
IF NO enter 1, if YES enter 2 and complete the next section. o01| 2|
Principal Activity
(Enter 1]
Prefatory -
Enter Part HI Fin.
Ownership 1 for Owned) State Co.
RHCF | Realty |yonog| EDP?
acct Other
Filed
State
Information - Name of Related Company Each
a @ Specify Filed
Related Co. YorN
Companies
9391 0391 0392 9392 0393 0394 0395 0396 9394 9395 9396
001| CENTERS FOR CARE LLC 1) 100.00| NY 1 ¥ ¥
O02
003
004
005
O06
007
003
003
010
O11
o12
O13
O14
O15
09: [ei
(1) % owned by Operators of reporting RHCF
(2) State facility located in
Realty = Realty Co.
C.0./Mang. = Central Office Management
EDP/Acct. = Electronic Data Processing / Accounting
Other = Specify type
(FILED: NEW YORK COUNTY CLERK 06/28/2023 02 27 [PM INDEX NO. 451549/2023
Roe een EN ope with a NYS Nursing Home Admin License RECHIVED NYSCEF 06/28/2023
0397
Do any employees of Related Companies have a NYS Nursing Home
Administrators License?
IE NO enter 1, if YES enter 2 and complete the next section. 001
Individual with NYS NH Admin License
Pre-fatory - 6)
Related
Company
Employees with Hours
a NYS Nursing Name Related Co. Name Worked
Annual
Home Admin
Per Week
Salary
License
(continued)
9398 93599 0398 0399
001
oo2
003
O04
005
O06
oo7
oo8
oog
O10
ou
O12
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Part | - 1) RHCF
Patient Services Provided
oan
Activities Program oo
Audiology (Hearing Therapy) O02
Clinical Laboratory 003
Dental [Dentistry] oo4
Respiratory Therapy 005
Psychological 006
Occupational Therapy oo?
Outpatient Services oog
Oxygen 009
Pharmacy o10
Physical Therapy Oo
Phy an Services O12
Podiatry 013
Presi ion Drugs O14
Reside jal Personal Services O15
Special Duty Nurses O16
Social Work Services ov
Speech Therapy O18
Optometry o19 2
Diagnostic Radiology 020 2
PATIENT SERVICES PROVIDED: ENTER 10R 2 FOR EACH SERVICE
PROVIDED BY YOUR FACILITY ON LAST DAY OF COST REPORT PERIOD, LEAVE
BLANK IF NOT PROVIDED.
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Rava Perigd
EDHOLN
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RHCF
Part | - 2] Effective No. No.
Bed Capacity Date Beds Beds
Changes MM/DD/YY) From To
O40? 0408 0403
Change No. O01
Change No. nz
Change No. 003
Change No. 4 04
Change No. 5 005
Change No. 6 O06
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Part 1 - 3)
Bed Capacity - RHCF Total
Patient Days
0410 0620
B. Bed Capacity (Total Facility)
Enter Bed Capacity on Last Reporting Day
1. Beds Set Up and Staffed For Use O07 314 314
2. Certified Medicare Bed Capacity 008 314 314
C. Number of Days of Care Provided During
the Period: Include Reserve Bed Days
Medicaid Days Paid by:
1. Health O09 88.171 88.171
1A. Managed Care Provider 032 5
8.954 .
S954
of Which How Many Patient Days Were:
Medicare Part B eligible (only) o10 3,706 3,706
Medicare Part D eligible [only] O22 4.379 4.379
Medicare Part B and D i ble 023 64,825 64.825
Medicare Part B and D i gible O24 15,261 15.261
Medicare [Days] o12 11.842 11.842
2A. Medicare - Managed Care Provider [Days] 033 -
1,882 2
1,882
3. Blue Cross (Days) O13
4. Other Private Insurance (Days) o14 159 159
4A. rivate Pay Patient [Days] 031 1,055 1.055
5. Veterans Admin. [Days] O15
6. Other (Days) Specify O16
7. TOTAL (Sum of 009, 012-016, 031-033) o17 112.063 112.063
8_Total Number of Bed Reservations
Established During Reporting Period O18 199 199
84. Reserved Bed Days Included in
TOTAL [Line 017 Above) 019 1,307 1.307
8B. OF Line 019, Number of Medicaid
Hospital Bed Reservation Days 020 33 133
8C_ OF Line 019, Number of Medicaid
Therapeutic Leave Days 021 20 20
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Part | - 4)
Report Period and Medicare Information
0437
Report Period
Beginning Date of Report (MM/DD/YY) O01 O1/01AN6
Ending Date of Report [MM/DD/YY] oo2 12/31/16
Medicare Information
Does Facility Have a Medicare Provider Number?
(l= Yes, 2=No) O19 1
It Yes, Enter Medicare Number O20 335503
Physician Billing Code 021
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Part | - 5) RHCF Total
Census
0411 0621
Number of Patients:
1. Census Data Beginning of Report Period
A) Census Midnight of Last Day of
Previous Report Period oo 308 308
B) Of 001 Number on Bed Reservations oo2
2. Admissions During Reporting Period:
A] From Hospital oo3 381 381
B) From Private Residence oo4
C) From Another RHCF 005 13 13
D) From Adult Care Facilities (ACF) oo?
E] From OMH Psychiatric Centers aos
F) From OMR Developmental Centers 009
G) From Other Than Above (Specify) o10
H] From Other Certified Program
Service[s] At The Facility ou
I) Total Admissions and Transfers O12 401 401
3 Total Patients Under Care During
Report Period (Sum of Lines 001 + 012) O13 709 709
4 Discharges During Report Period
Al To Hospital 014 231 231
B) To Private Residence g15 124 124
C) To Another RHCF O16 23 23
D) To Adult Care Facilities (ACF) 018 15 15
E) To State Fac(Psych & Developmental Ctrs) O19
F) Deaths (In-House) 020 16 16
G) To Other Than Above Specify 071
H] To Other Certified Program
Service(s) At The Facility o22
|) Total Discharges and Transfers 023 409 409
5 Census Data End of Report Period
A) Census Midnight of Last Day of
This Report Period 024 300 300
B) Of 024 Number on Bed Reservations 025
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RHCF
Part 1 - 6] Male Female Total
Age
o412 0413 0414
Age:
0-15 001
16-20 O02
21-54 003 10 16
55-64 oo4 38 W 49
65-69 005 35 13 48
70-74 006 30 19 49
75-79 oo? 28 32 60
80-84 oos 14 22
85-89 009 23 32
50+ oo 19 24
Total O11 163 137 300
NUMBER OF PATIENTS AS OF LAST DAY OF REPORT PERIOD:
NOTE: IF AGE IS UNKNOWN APPROXIMATE. TOTALS MUST AGREE WITH
CC/LINE 0011/024 (CENSUS MIDNIGHT OF LAST DAY OF REPORT PERIOD)
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RHCF
Part | - 7) Daily Daily
Financial Arrangements Total
Rate Rate
[as of last day of report Patients
Minimum | Maximum
period)
0413 0414 0415
Payors:
Private o12 1 565.00 565.00
Medicaid 013 260 285.58 293.90
Medicare o14 39 237.03 1666.59
Blue Cross O15
Veterans Admin_ O16
Other o17
Total * o18 300
Previous Private ** og 19
|. Weighted Average
Private Pay Rate 026 565.00
NOTE: *TOTALS MUST AGREE WITH CC/LINE, 0011/024
*ME DICAID PATIENTS (INCLUDED IN LINE 013 ABOVE)
THAT WERE PREVIOUS PRIVATE PAY
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Part I - 8]
Primary Payor of New" Admissions at the time of RHCF Total
Admission
0413 0613
Medicare/Private [including Private Insurance) 020 105 105
Medicare/Medicaid 021 66 66
Private and Other O22
Medicaid 023 45 45
Veterans Admin. O24
Total 025 223 223
*TOTAL NEW ADMISSIONS IS DEFINED AS ALL ADMISSIONS (CC/LINE,
0011/012) EXCLUDING READMISSIONS (CC/LINE, 0011/027) AND, FOR
MULTILEVEL FACILITIES, ADMISSIONS FROM OTHER COLUMN OF FACILITY
(CC/LINE, 0011/011).
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RHCF
Part | - 5]
Length of Stay
for Patients To RHCF| To ACF | To Home Death
Discharged Hospital
During
Reporting
O44 415 o417 0418 0419
0-07 Days 026 54
08-14 Days O27 25
15-21 Days 028 Vv
22-30 Days 029 14 13
1-2Mo. 030 33 35
2-3Mo_ 031 20 13
3-4 Mo. 032 12
4-5 Mo. 033 10
5-6 Mo_ 034
6-3 Mo. 035 12 10
9-12 Mo. 036
12-15 Mo. O37
15-18 Mo. 038
18-21 Mo. 039
21-24 Mo. o40
24-27 Mo. 041
27-30 Mo. O42
30-33 Mo. O43
33-36 Mo. O44
36-35 Mo. 045
39-42 Mo. O46
42-45 Mo. oa?
45-48 Mo. 048
48+ Mo. 049
Total O50 231 23 15 124 16
17
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A. PATIENT ORIGIN BY COUNTY, RESIDENTIAL HEALTH CARE PATIENTS ONLY.
ENTER THE NUMBER OF PATIENTS UNDER CARE AS OF THE LAST DAY OF
THE REPORT PERIOD BY COUNTY OF RESIDENCE AT THE TIME OF MOST
RECENT ADMISSION AND BY SOURCE OF PAYMENT. DESIGNATE THE
COUNTY OF ORIGIN BY ENTERING THE FOLLOWING APPROPRIATE CODE
NUMBERS IN COLUMN A.
01 ALBANY 19 GREENE 39 PUTNAM 59 WESTCHESTER
02 ALLEGANY 20 HAMILTON 41 RENSSELAER 60 WYOMING
03 BROOME 21 HERKIMER 43 ROCKLAND 61 YATES
04 CATTARAUGUS 22 JEFFERSON 44 ST. LAWRENCE 70 BRONX
05 CAYUGA 24 LEWIS 45 SARATOGA 71 KINGS
06 CHAUTAUGUA 25 LIVINGSTON 46 SCHENECTADY 72 MANHATTAN
07 CHEMUNG 26 MADISON 47 SCHOHARIE 73 QUEENS
08 CHENANGO 27 MONROE 48 SCHUYLER 74 RICHMOND
09 CLINTON 28 MONTGOMERY 49 SENECA
10 COLUMBIA 29 NASSAU 50 STEUBEN
11 CORTLAND 31 NIAGARA 51 SUFFOLK
12 DELAWARE 32 ONEIDA 52 SULLIVAN
13 DUTCHESS 33 ONONDAGA 53 TIOGA
14 ERIE 34 ONTARIO 54 TOMPKINS
15 ESSEX 35 ORANGE 55 ULSTER
16 FRANKLIN 36 ORLEANS 56 WARREN
17 FULTON 37 OSWEGO 57 WASHINGTON
18 GENESEE 38 OTSEGO 58 WAYNE
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RHCF
Part I - 10) Private
County of so
Medicaid | Medicare Pay or
Origin Other
0422 0423 0424 0425
001 73 251 2 1
oo2 72 6
003
oo4
O05
O06
oo?
O08
oog
o10
o1
O12
O13
O14
O15
O16
oF
O18
019
020
021
022
023
O24
025
026
O27
028
029
030
031
032
033
O34
035
036
O37
038
039
040
O41
CT O42
MA 043
NJ O44 oe
PA O45
¥I O46
Other U.S. O47 9
Outside US. 048
Total O49 ag: 260 39 1
NOTE: COLUMN TOTALS MUST AGREE WITH CORRESPONDING TOTALS ON CC/LINE
0413/018. PLEASE USE ONLY ONE LINE FOR EACH COUNTY OF ORIGIN,
STARTING WITH LINE 1.
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RHCF
Part 1-11]
Nursing /
Resident Unit
Cert Bed
Capacities
O4: o4: o4:
NUL 1-8 O01
O12 20 58 58 58 60 60
NLU. 9-16 002
O13
NUL 17-24 003 2
ow
NUL 25-31 O04 ‘Total
O15 314
20
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A. LABOR ORGANIZATION:
1. ARE ANY RESIDENTIAL HEALTH CARE FACILITY EMPLOYEES
REPRESENTED BY A LABOR ORGANIZATION ENTER ?
IF ANSWER TO Al IS YES, SUPPLY APPROPRIATE INFORMATION BELOW
USING THE CODE NUMBER IN COLUMN B TO INDICATE UNION AFFILIATION
FOR EACH UNIT AS DEFINED IN THE RECOGNITION CLAUSE OF THE LABOR
AGREEMENT. IF THE RECOGNITION CLAUSE COVERS MORE THAN ONE UNIT,
DATA FOR EACH UNIT MUST BE PROVIDED.
EX: RECOGNITION CLAUSE COVERS NON-PROFESSIONAL EMPLOYEES INCLUDING
HOUSEKEEPING, DIETARY, AIDES, ORDERLIES, MAINTENANCE AND CLERICAL.
THE HOUSEKEEPING, DIETARY AND ORDERLIES WOULD BE REPORTED ON THE
‘SERVICE' LINE 01, THE MAINTENANCE EMPLOYEES ON LINE 02, AND THE
CLERICAL EMPLOYEES ON LINE 05.
COLUMN B - UNION CODE
01 DISTRICT 1199, NATIONAL UNION OF HOSPITAL AND HEALTH CARE
EMPLOYEES
02 LOCAL 144, HOTEL, HOSP., NURSING HOME AND ALLIED SERVICES-SEIU
03 LOCAL 200, HOTEL, HOSP., NURSING HOME AND ALLIED SERVICES-SEIU
04 LOCAL 721, LICENSED PRACTICAL NURSES OF NYC, AFFIL. WITH
HOTEL, HOSP., ETC. - SEIU
05 LOCAL 1115, JOINT BOARD OF NURSING AND HOSPITAL EMPLOYEES
06 LOCAL 4, MEDICAL AND HEALTH EMPLOYEES UNION
07 LOCAL 810, INTERNATIONAL BROTHERHOOD OF TEAMSTERS
08 LOCAL 30, INTERNATIONAL UNION OF OPERATING ENGINEERS
09 LOCAL 907, INTERNATIONAL UNION OF OPERATING ENGINEERS
10 BUFFALO & WESTERN NEW YORK HOSPITAL AND NURSING HOME COUNCIL
11 SNA - NEW YORK STATE NURSES ASSOCIATION
12 CSEA - CIVIL SERVICE EMPLOYEES ASSOCIATION
13 COUNCIL 66, AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL
EMPLOYEES
14 DISTRICT COUNCIL 37, AMERICAN FEDERATION OF STATE, COUNTY &
MUNICIPAL EMPLOYEES
15 OTHER UNION - PLEASE SPECIFY ON NOTEPAD:
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CONTRACT
Part | - 12) coL EMPLOYEES | EXPIRATION OTHER UNION
Labor Organization IN UNIT DATE SPECIFY
MM/DD/YY
0603 o604 0605 9605
Are any RHCF employees represented
by a labor organization O01
(Enter 1 if YES, o1 2 if NO)
COL BARGAINING/NEGOTIATING
UNITS
oH SERVICE oo2 156 O9/30/18
02 MAINTENANCE 003 09/30/18
03 TECHNICAL O04
o4 PHARMACY 005
05 CLERICAL 006 09/30/18
06 LPN O07 40 09/30/18
oF RN os
08 SUPY. NURSES: 003
03 SOCIAL WORKERS o10
10 OTHER - SPECIFY o11
NOTE: LEAVE ANY ‘BARGAINING UNIT' LINE BLANK FOR ANY GROUP OF
WORKERS WHO ARE EITHER: 1) NOT REPRESENTED BYA UNION OR 2) NOT
ON THE FACILITY PAYROLL.
Part | - 13] Full Time Part Time Casual Total
Number of Employees
0606 O60? 0608 609
Number of Employees 12] 255] 81| 259| 595
COUNT EACH PERSON EMPLOYED AND EACH CATEGORY. (I.E. ONE PERSON
COULD BE COUNTED TWICE IF THEY WERE EMPLOYED BOTH FULL AND PART
TIME) CASUAL SHALL BE DEFINED AS: ANY PERSON EMPLOYED BY THE
NURSING HOME ONA PER DIEM BASIS OR THROUGH A CONTRACT WITH A NON-
RELATED AGENCY, SERVING IN A CAPACITY NORMALLY FILLED BY A FULL
TIME OR PART TIME STAFF INDIVIDUAL. ALL EMPLOYEES HIRED THROUGH
A RELATED COMPANY SHALL BE CLASSIFIED AS IF THEY ARE STAFF OF THE
NURSING HOME.
22
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2023
Repatiherigde
OURY TE 5 42/31/16 ~22- RECELVED) Wy 32 09:4998"'2. 81/2023
Enter CCALN where cost
Part 1-14) Non- is report ed on
Nursing Home Expenses funded with Health Recruitment and Total Compenstion at
Retention funds Compensation Expenditures Exhi it H.
If more than one CC/LN
enter detail in notepad
0626 0627 0628
Salary 001}
Employee Uniform Allowance 002] |
Group Health Insurance 003] ]
Pension & Retirement - Union 004] |
Pensi ‘& Retirement Non Union 0054
Disability 006] |
Union Health and Welfare oor]
Employee Meal Allowance: 008] |
Other Specify Below
009)
010)
O11
012,
013
014
015
ng
017
a8
013)
020)
Total o35|{
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Schedule 7 -
Analysis of Net Patient Revenue RHCF Revenue - Other Total
& Total Operating Revenue
0463 o160 o161
Analysis of Total Operating Revenue
Medicaid Net Revenue
A. Social Services onl 27,810,285 27,810,285
B. Managed Care Provider 025 2,466,315 2.466.315
C__ Other Services O12
TOTAL MEDICAID NET REVENUE 001 30,276,600 30,276,600
Medicare Net Revenue
A. Part A - All Income oo2 6,935,706 6,935,706
B Part B - Income 003 779,785 779,785
C. Part B - Final Settlement 004
D._ Managed Care Provider 026 668.955 668,955
TOTAL MEDICARE NET REVENUE O13 8.384.446 8,384,446
Private Patient Revenue 005 772,866 772,866
Other Net Patient Revenue O06 224,366 224,366
TOTAL NET PATIENT REYENUE o10 39,658,278 39,658,278
All Other Operating Revenue” O15 a 1 61
TOTAL OPERATING REVENUE O20 40,141,639 40,141,639
*Line 0015 Column 00160 would be used for reporting revenue
for all other operating revenue centers.
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Schedule 7 -
Analysis of Net Patient Revenue Blue Cross Travelers Other
& Total Operating Revenue (continued)
0243 0244 0245
Part B Cash Receipts By Intermediary
For Report Year 021 452,682
For Prior Year O22
All Other Years 023
TOTAL 030 452.682
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Location on
Schedule 8 - Amount Part I¥*
Medicaid Rate Calculation Supplement Column/Line
Number
0250 0251
Imputed Value Service Rendered by Operator 001
Life Insurance Premium on Life of Operator O02
Interest Not Related To Patient Care 003
Litigation Against the State oo4
Christmas Parties and Gifts (Not For All Emp] 005
Advertising O06 150,480 0041 /005
Contributions oo? 6,530 0041 005
Private Duty Nursing Fees oo8
Ancillary Cost Not Included in Medicaid Rate:
Laboratory 009 32,555 0033/031
Radiology o10 47,272 0039/034
O11
O12
Maintenance Furnished To Institutional Employee O13
Maintenance Furnished To Other Employees O14
Clothing and Incidentals O15
Non-Institutional Costs O16
Medicare Part B - Final Settlement:
(1) Physicians oF
(2) Physical Therapy og
o19
Speech Therapy:
(1) Speech Pathologist - Salaries & Fees O20 73,575 034/041
(2) Speech Pathologist - Fringe Benefits 021 24,103 0035/041
(3) Speech Pathology - Other Direct Expense 022
Director of Volunteers 023
Work. Capital Int. Exp. On Obligation{1) > 1 YR O24 81,800 0041 /005
‘Work. Capital Int. Exp. On Obligation{1) <= 1 YR 025
Ambulance Fees 027
Insurance
(1)_ Malpractice 028 16,000 0041 005
(2]_ General Liability 029 1,270,649 0041005
(3) Umbrella (Blanket) 030
Crime Insurance $5,200 & Bond Insurance $3199 031 8,399 0041 /005
Interest On Letters Of Credit To Acquire
Minimum Equity 032
Intergovernmental Transfer (1.G.1.] 033
*Location on Part IV refers to the column line where an item is actually reported or the column and
line affected if the item would not be properly included on the part IV, ie. prepared in accordance
with generally accepted accounting principles.
(1) Do not include: (1) Interest paid to NYSDSS on recovery determinations.
(2) Interest paid on funds borrowed to repay NYSDSS recovery determinations.
(3) Interest paid to related parties.
26
BORE ¥od¥9524151549/ 2023
RewatiFereseQURGTS 5 42/3. Me 26 RECEIVED) WYSir09:4QAM2 8/2023
Location On
Schedule 8A - Amount
Part I¥
Medicaid Rate Calculation Supplement (continued) Column/Line
Number
0260 0261
Marketing Salaries 034 32.660 0034/005
Marketing Salaries Benefits 035 13,417 0036/005
Marketing Consultant 036 33,165 0037/005
Marketing Food O37 13,813 0035/005
Marketing Lease 038 645 0040/005
Penalties 039 294 0041 005
Marketing Travel o40 12,056 0041005
Assoc dues - lobby portion O41 4.936 041/005
Business Development O42 2.741 0041 005
043
O44
045
046
oa?
048
049
O50
051
052
053
O54
055
O56
os?
058
O59
O60
27
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Rava Perigd
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 54 RECEIVED NYSCEF: 06/28/2023 BUDIMIR EXHIBIT 5A HO! ERK OG DM BORE ¥od¥9524151549/ 2023 are igdc0: AIS 5, ee RECEIVED) WYSir09:4QAM2 8/2023 HO! ERK OG DM BORE ¥od¥9524151549/ 2023 are igdc0: AIS 5, ee RECEIVED) WYSir09:4QAM2 8/2023 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me RECEIVED) WYSir09:4QAM2 8/2023 Pre-Fatory - Certified Public Name Accountant 9290 Certified Public Accounting Firm 001 | Loeb & Troper LLP Name of CPA 002|Joseph Weinberger CPA License Number 003] 078317 Pre-fatory - RHCF Name Code Ownership Type 3059 0099 Ownership Type oo 3 = Proprietary - Corporation Pre-fatory - 1) Social Percent Ownership Names of Established Operators (1) Number Security Ownership Information 2 Number BI Operations 9100 0100 g101 o101 001|KENNETH ROZENBERG $5.50 002|REUVEN KAUFMAN 10.00 003 | Jeffrey Sicklick 2.50 004/Leo Lerner 2.00 005 006 oo7 008 009 oo O11 O12 013 o14 O15 O16 O17 018 019 020 021 O22 023 024 025 099 [fal 100.00 (1) Proprietary & Not-For-Profit Corporation Identify Stockholders or Board of Directors on next Schedule (2) Enter 1 for each Operator (3) Must Total 100% BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me RECEIVED) WYSir09:4QAM2 8/2023 Yoluntary Pre-fatory - 2) If Person Corporate Number % of Owner. Term Date Term Affiliated Stockholders / Stockholders / Directors Names in Expires with Other Board of a (2) Years MM/DD/YY] RHCF, How Directors Many? s102 o102 0103 o104 0105 0106 001| Kenneth Rozenberg 1 95.50 002|Reuven Kaufman 1 10.00 003 | Jeffrey Sicklick 1 2.50 004/Leo Lerner 1 2.00 005 006 oo? oos 009 oo O11 O12 O13 o14 O15 O16 O17 o18 019 020 021 O22 023 024 025 026 027 028 029 030 031 032 033 034 035 036 O37 038 039 o40 O41 O42 043 044 045 046 o47 o48 o4g 050 051 O99 | faba 4| 100.00 (1) Enter 1 for each person listed (2) Must Total 100% BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me RECEIVED) WYSir09:4QAM2 8/2023 Percent Ownership Prefatory - Social Ownership Tangible Property Ownership(1) Security Land | Building Moveable Equipment Information Owners Namefs Number Tangible Property 9107 oo? 0108 0109 001|HOLLIS REAL ESTATE CO 00.00% |100.00% 002|HOLLISWOOD CENTER FOR REHAB 100.00% 003 004 O05 OO6 007 008 oog o10 ou O12 013 O14 O15 O16 O17 O18 019 020 021 O22 023 O24 025 O99 } Eotaks: (Must = EI 100.00% |100.00% 100.00% (1) If owner is a corporation, identify the stockholder(s) on the next schedule BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me RECEIVED) WYSir09:4QAM2 8/2023 Pre-fatory - Type of Corporate Name of Corporation Name of Stockholder Number | Percent Owner Prop. a (2) Stockholders 9110 3111 0110 0111 112 001 O02 003 O04 005 O06 oo? 008 009 o10 ou o12 013 O14 O15 O16 ow O18 019 020 021 022 023 O24 025 O99} otal (1) Enter 1 for each stockholder (2) Identify type of property: =Land uilding = Moveable Equipment BORE ¥od¥9524151549/ 2023 014 RepstPerigdc oLN OURYI6 54 ze RECEIVED) Wy2@ Go 28/2023 Pre-fatory - 5) Ownership Information - Related Companies 0390 Does this RHCF have Related Companies? IF NO enter 1, if YES enter 2 and complete the next section. o01| 2| Principal Activity (Enter 1] Prefatory - Enter Part HI Fin. Ownership 1 for Owned) State Co. RHCF | Realty |yonog| EDP? acct Other Filed State Information - Name of Related Company Each a @ Specify Filed Related Co. YorN Companies 9391 0391 0392 9392 0393 0394 0395 0396 9394 9395 9396 001| CENTERS FOR CARE LLC 1) 100.00| NY 1 ¥ ¥ O02 003 004 005 O06 007 003 003 010 O11 o12 O13 O14 O15 09: [ei (1) % owned by Operators of reporting RHCF (2) State facility located in Realty = Realty Co. C.0./Mang. = Central Office Management EDP/Acct. = Electronic Data Processing / Accounting Other = Specify type (FILED: NEW YORK COUNTY CLERK 06/28/2023 02 27 [PM INDEX NO. 451549/2023 Roe een EN ope with a NYS Nursing Home Admin License RECHIVED NYSCEF 06/28/2023 0397 Do any employees of Related Companies have a NYS Nursing Home Administrators License? IE NO enter 1, if YES enter 2 and complete the next section. 001 Individual with NYS NH Admin License Pre-fatory - 6) Related Company Employees with Hours a NYS Nursing Name Related Co. Name Worked Annual Home Admin Per Week Salary License (continued) 9398 93599 0398 0399 001 oo2 003 O04 005 O06 oo7 oo8 oog O10 ou O12 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me RECEIVED) WYSir09:4QAM2 8/2023 Part | - 1) RHCF Patient Services Provided oan Activities Program oo Audiology (Hearing Therapy) O02 Clinical Laboratory 003 Dental [Dentistry] oo4 Respiratory Therapy 005 Psychological 006 Occupational Therapy oo? Outpatient Services oog Oxygen 009 Pharmacy o10 Physical Therapy Oo Phy an Services O12 Podiatry 013 Presi ion Drugs O14 Reside jal Personal Services O15 Special Duty Nurses O16 Social Work Services ov Speech Therapy O18 Optometry o19 2 Diagnostic Radiology 020 2 PATIENT SERVICES PROVIDED: ENTER 10R 2 FOR EACH SERVICE PROVIDED BY YOUR FACILITY ON LAST DAY OF COST REPORT PERIOD, LEAVE BLANK IF NOT PROVIDED. BORE ¥od¥9524151549/ 2023 Rava Perigd EDHOLN col 6 5 42/31/16 RECEIVED) WYSir09:4QAM2 8/2023 RHCF Part | - 2] Effective No. No. Bed Capacity Date Beds Beds Changes MM/DD/YY) From To O40? 0408 0403 Change No. O01 Change No. nz Change No. 003 Change No. 4 04 Change No. 5 005 Change No. 6 O06 10 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 10 RECEIVED) WYSir09:4QAM2 8/2023 Part 1 - 3) Bed Capacity - RHCF Total Patient Days 0410 0620 B. Bed Capacity (Total Facility) Enter Bed Capacity on Last Reporting Day 1. Beds Set Up and Staffed For Use O07 314 314 2. Certified Medicare Bed Capacity 008 314 314 C. Number of Days of Care Provided During the Period: Include Reserve Bed Days Medicaid Days Paid by: 1. Health O09 88.171 88.171 1A. Managed Care Provider 032 5 8.954 . S954 of Which How Many Patient Days Were: Medicare Part B eligible (only) o10 3,706 3,706 Medicare Part D eligible [only] O22 4.379 4.379 Medicare Part B and D i ble 023 64,825 64.825 Medicare Part B and D i gible O24 15,261 15.261 Medicare [Days] o12 11.842 11.842 2A. Medicare - Managed Care Provider [Days] 033 - 1,882 2 1,882 3. Blue Cross (Days) O13 4. Other Private Insurance (Days) o14 159 159 4A. rivate Pay Patient [Days] 031 1,055 1.055 5. Veterans Admin. [Days] O15 6. Other (Days) Specify O16 7. TOTAL (Sum of 009, 012-016, 031-033) o17 112.063 112.063 8_Total Number of Bed Reservations Established During Reporting Period O18 199 199 84. Reserved Bed Days Included in TOTAL [Line 017 Above) 019 1,307 1.307 8B. OF Line 019, Number of Medicaid Hospital Bed Reservation Days 020 33 133 8C_ OF Line 019, Number of Medicaid Therapeutic Leave Days 021 20 20 11 BORE ¥od¥9524151549/ 2023 AewatiFeradeOURETE 5 42/3. Ie Ir RECEIVED) WYSir09:4QAM2 8/2023 Part | - 4) Report Period and Medicare Information 0437 Report Period Beginning Date of Report (MM/DD/YY) O01 O1/01AN6 Ending Date of Report [MM/DD/YY] oo2 12/31/16 Medicare Information Does Facility Have a Medicare Provider Number? (l= Yes, 2=No) O19 1 It Yes, Enter Medicare Number O20 335503 Physician Billing Code 021 12 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 12 RECEIVED) WYSir09:4QAM2 8/2023 Part | - 5) RHCF Total Census 0411 0621 Number of Patients: 1. Census Data Beginning of Report Period A) Census Midnight of Last Day of Previous Report Period oo 308 308 B) Of 001 Number on Bed Reservations oo2 2. Admissions During Reporting Period: A] From Hospital oo3 381 381 B) From Private Residence oo4 C) From Another RHCF 005 13 13 D) From Adult Care Facilities (ACF) oo? E] From OMH Psychiatric Centers aos F) From OMR Developmental Centers 009 G) From Other Than Above (Specify) o10 H] From Other Certified Program Service[s] At The Facility ou I) Total Admissions and Transfers O12 401 401 3 Total Patients Under Care During Report Period (Sum of Lines 001 + 012) O13 709 709 4 Discharges During Report Period Al To Hospital 014 231 231 B) To Private Residence g15 124 124 C) To Another RHCF O16 23 23 D) To Adult Care Facilities (ACF) 018 15 15 E) To State Fac(Psych & Developmental Ctrs) O19 F) Deaths (In-House) 020 16 16 G) To Other Than Above Specify 071 H] To Other Certified Program Service(s) At The Facility o22 |) Total Discharges and Transfers 023 409 409 5 Census Data End of Report Period A) Census Midnight of Last Day of This Report Period 024 300 300 B) Of 024 Number on Bed Reservations 025 13 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 13 RECEIVED) WYSir09:4QAM2 8/2023 RHCF Part 1 - 6] Male Female Total Age o412 0413 0414 Age: 0-15 001 16-20 O02 21-54 003 10 16 55-64 oo4 38 W 49 65-69 005 35 13 48 70-74 006 30 19 49 75-79 oo? 28 32 60 80-84 oos 14 22 85-89 009 23 32 50+ oo 19 24 Total O11 163 137 300 NUMBER OF PATIENTS AS OF LAST DAY OF REPORT PERIOD: NOTE: IF AGE IS UNKNOWN APPROXIMATE. TOTALS MUST AGREE WITH CC/LINE 0011/024 (CENSUS MIDNIGHT OF LAST DAY OF REPORT PERIOD) 14 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 14 RECEIVED) WYSir09:4QAM2 8/2023 RHCF Part | - 7) Daily Daily Financial Arrangements Total Rate Rate [as of last day of report Patients Minimum | Maximum period) 0413 0414 0415 Payors: Private o12 1 565.00 565.00 Medicaid 013 260 285.58 293.90 Medicare o14 39 237.03 1666.59 Blue Cross O15 Veterans Admin_ O16 Other o17 Total * o18 300 Previous Private ** og 19 |. Weighted Average Private Pay Rate 026 565.00 NOTE: *TOTALS MUST AGREE WITH CC/LINE, 0011/024 *ME DICAID PATIENTS (INCLUDED IN LINE 013 ABOVE) THAT WERE PREVIOUS PRIVATE PAY 15 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 15 RECEIVED) WYSir09:4QAM2 8/2023 Part I - 8] Primary Payor of New" Admissions at the time of RHCF Total Admission 0413 0613 Medicare/Private [including Private Insurance) 020 105 105 Medicare/Medicaid 021 66 66 Private and Other O22 Medicaid 023 45 45 Veterans Admin. O24 Total 025 223 223 *TOTAL NEW ADMISSIONS IS DEFINED AS ALL ADMISSIONS (CC/LINE, 0011/012) EXCLUDING READMISSIONS (CC/LINE, 0011/027) AND, FOR MULTILEVEL FACILITIES, ADMISSIONS FROM OTHER COLUMN OF FACILITY (CC/LINE, 0011/011). 16 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 16 RECEIVED) WYSir09:4QAM2 8/2023 RHCF Part | - 5] Length of Stay for Patients To RHCF| To ACF | To Home Death Discharged Hospital During Reporting O44 415 o417 0418 0419 0-07 Days 026 54 08-14 Days O27 25 15-21 Days 028 Vv 22-30 Days 029 14 13 1-2Mo. 030 33 35 2-3Mo_ 031 20 13 3-4 Mo. 032 12 4-5 Mo. 033 10 5-6 Mo_ 034 6-3 Mo. 035 12 10 9-12 Mo. 036 12-15 Mo. O37 15-18 Mo. 038 18-21 Mo. 039 21-24 Mo. o40 24-27 Mo. 041 27-30 Mo. O42 30-33 Mo. O43 33-36 Mo. O44 36-35 Mo. 045 39-42 Mo. O46 42-45 Mo. oa? 45-48 Mo. 048 48+ Mo. 049 Total O50 231 23 15 124 16 17 50140%D HO! N Dik BORE ¥od¥9524151549/ 2023 RapotPerigdt OURGTC 5 PBUIS RECEIVED) WYSir09:4QAM2 8/2023 A. PATIENT ORIGIN BY COUNTY, RESIDENTIAL HEALTH CARE PATIENTS ONLY. ENTER THE NUMBER OF PATIENTS UNDER CARE AS OF THE LAST DAY OF THE REPORT PERIOD BY COUNTY OF RESIDENCE AT THE TIME OF MOST RECENT ADMISSION AND BY SOURCE OF PAYMENT. DESIGNATE THE COUNTY OF ORIGIN BY ENTERING THE FOLLOWING APPROPRIATE CODE NUMBERS IN COLUMN A. 01 ALBANY 19 GREENE 39 PUTNAM 59 WESTCHESTER 02 ALLEGANY 20 HAMILTON 41 RENSSELAER 60 WYOMING 03 BROOME 21 HERKIMER 43 ROCKLAND 61 YATES 04 CATTARAUGUS 22 JEFFERSON 44 ST. LAWRENCE 70 BRONX 05 CAYUGA 24 LEWIS 45 SARATOGA 71 KINGS 06 CHAUTAUGUA 25 LIVINGSTON 46 SCHENECTADY 72 MANHATTAN 07 CHEMUNG 26 MADISON 47 SCHOHARIE 73 QUEENS 08 CHENANGO 27 MONROE 48 SCHUYLER 74 RICHMOND 09 CLINTON 28 MONTGOMERY 49 SENECA 10 COLUMBIA 29 NASSAU 50 STEUBEN 11 CORTLAND 31 NIAGARA 51 SUFFOLK 12 DELAWARE 32 ONEIDA 52 SULLIVAN 13 DUTCHESS 33 ONONDAGA 53 TIOGA 14 ERIE 34 ONTARIO 54 TOMPKINS 15 ESSEX 35 ORANGE 55 ULSTER 16 FRANKLIN 36 ORLEANS 56 WARREN 17 FULTON 37 OSWEGO 57 WASHINGTON 18 GENESEE 38 OTSEGO 58 WAYNE 18 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 18 RECEIVED) WYSir09:4QAM2 8/2023 RHCF Part I - 10) Private County of so Medicaid | Medicare Pay or Origin Other 0422 0423 0424 0425 001 73 251 2 1 oo2 72 6 003 oo4 O05 O06 oo? O08 oog o10 o1 O12 O13 O14 O15 O16 oF O18 019 020 021 022 023 O24 025 026 O27 028 029 030 031 032 033 O34 035 036 O37 038 039 040 O41 CT O42 MA 043 NJ O44 oe PA O45 ¥I O46 Other U.S. O47 9 Outside US. 048 Total O49 ag: 260 39 1 NOTE: COLUMN TOTALS MUST AGREE WITH CORRESPONDING TOTALS ON CC/LINE 0413/018. PLEASE USE ONLY ONE LINE FOR EACH COUNTY OF ORIGIN, STARTING WITH LINE 1. 19 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 19 RECEIVED) WYSir09:4QAM2 8/2023 RHCF Part 1-11] Nursing / Resident Unit Cert Bed Capacities O4: o4: o4: NUL 1-8 O01 O12 20 58 58 58 60 60 NLU. 9-16 002 O13 NUL 17-24 003 2 ow NUL 25-31 O04 ‘Total O15 314 20 BORE ¥od¥9524151549/ 2023 marae PerigdtOURG6 ze EDHOLN DM 54: 20 RECEIVED) WYSir09:4QAM2 8/2023 A. LABOR ORGANIZATION: 1. ARE ANY RESIDENTIAL HEALTH CARE FACILITY EMPLOYEES REPRESENTED BY A LABOR ORGANIZATION ENTER ? IF ANSWER TO Al IS YES, SUPPLY APPROPRIATE INFORMATION BELOW USING THE CODE NUMBER IN COLUMN B TO INDICATE UNION AFFILIATION FOR EACH UNIT AS DEFINED IN THE RECOGNITION CLAUSE OF THE LABOR AGREEMENT. IF THE RECOGNITION CLAUSE COVERS MORE THAN ONE UNIT, DATA FOR EACH UNIT MUST BE PROVIDED. EX: RECOGNITION CLAUSE COVERS NON-PROFESSIONAL EMPLOYEES INCLUDING HOUSEKEEPING, DIETARY, AIDES, ORDERLIES, MAINTENANCE AND CLERICAL. THE HOUSEKEEPING, DIETARY AND ORDERLIES WOULD BE REPORTED ON THE ‘SERVICE' LINE 01, THE MAINTENANCE EMPLOYEES ON LINE 02, AND THE CLERICAL EMPLOYEES ON LINE 05. COLUMN B - UNION CODE 01 DISTRICT 1199, NATIONAL UNION OF HOSPITAL AND HEALTH CARE EMPLOYEES 02 LOCAL 144, HOTEL, HOSP., NURSING HOME AND ALLIED SERVICES-SEIU 03 LOCAL 200, HOTEL, HOSP., NURSING HOME AND ALLIED SERVICES-SEIU 04 LOCAL 721, LICENSED PRACTICAL NURSES OF NYC, AFFIL. WITH HOTEL, HOSP., ETC. - SEIU 05 LOCAL 1115, JOINT BOARD OF NURSING AND HOSPITAL EMPLOYEES 06 LOCAL 4, MEDICAL AND HEALTH EMPLOYEES UNION 07 LOCAL 810, INTERNATIONAL BROTHERHOOD OF TEAMSTERS 08 LOCAL 30, INTERNATIONAL UNION OF OPERATING ENGINEERS 09 LOCAL 907, INTERNATIONAL UNION OF OPERATING ENGINEERS 10 BUFFALO & WESTERN NEW YORK HOSPITAL AND NURSING HOME COUNCIL 11 SNA - NEW YORK STATE NURSES ASSOCIATION 12 CSEA - CIVIL SERVICE EMPLOYEES ASSOCIATION 13 COUNCIL 66, AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL EMPLOYEES 14 DISTRICT COUNCIL 37, AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL EMPLOYEES 15 OTHER UNION - PLEASE SPECIFY ON NOTEPAD: 21 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 21 RECEIVED) WYSir09:4QAM2 8/2023 CONTRACT Part | - 12) coL EMPLOYEES | EXPIRATION OTHER UNION Labor Organization IN UNIT DATE SPECIFY MM/DD/YY 0603 o604 0605 9605 Are any RHCF employees represented by a labor organization O01 (Enter 1 if YES, o1 2 if NO) COL BARGAINING/NEGOTIATING UNITS oH SERVICE oo2 156 O9/30/18 02 MAINTENANCE 003 09/30/18 03 TECHNICAL O04 o4 PHARMACY 005 05 CLERICAL 006 09/30/18 06 LPN O07 40 09/30/18 oF RN os 08 SUPY. NURSES: 003 03 SOCIAL WORKERS o10 10 OTHER - SPECIFY o11 NOTE: LEAVE ANY ‘BARGAINING UNIT' LINE BLANK FOR ANY GROUP OF WORKERS WHO ARE EITHER: 1) NOT REPRESENTED BYA UNION OR 2) NOT ON THE FACILITY PAYROLL. Part | - 13] Full Time Part Time Casual Total Number of Employees 0606 O60? 0608 609 Number of Employees 12] 255] 81| 259| 595 COUNT EACH PERSON EMPLOYED AND EACH CATEGORY. (I.E. ONE PERSON COULD BE COUNTED TWICE IF THEY WERE EMPLOYED BOTH FULL AND PART TIME) CASUAL SHALL BE DEFINED AS: ANY PERSON EMPLOYED BY THE NURSING HOME ONA PER DIEM BASIS OR THROUGH A CONTRACT WITH A NON- RELATED AGENCY, SERVING IN A CAPACITY NORMALLY FILLED BY A FULL TIME OR PART TIME STAFF INDIVIDUAL. ALL EMPLOYEES HIRED THROUGH A RELATED COMPANY SHALL BE CLASSIFIED AS IF THEY ARE STAFF OF THE NURSING HOME. 22 boro: v7 7 Jleport DARE %odbA52451549/ 2023 Repatiherigde OURY TE 5 42/31/16 ~22- RECELVED) Wy 32 09:4998"'2. 81/2023 Enter CCALN where cost Part 1-14) Non- is report ed on Nursing Home Expenses funded with Health Recruitment and Total Compenstion at Retention funds Compensation Expenditures Exhi it H. If more than one CC/LN enter detail in notepad 0626 0627 0628 Salary 001} Employee Uniform Allowance 002] | Group Health Insurance 003] ] Pension & Retirement - Union 004] | Pensi ‘& Retirement Non Union 0054 Disability 006] | Union Health and Welfare oor] Employee Meal Allowance: 008] | Other Specify Below 009) 010) O11 012, 013 014 015 ng 017 a8 013) 020) Total o35|{ 23 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 23 RECEIVED) WYSir09:4QAM2 8/2023 Schedule 7 - Analysis of Net Patient Revenue RHCF Revenue - Other Total & Total Operating Revenue 0463 o160 o161 Analysis of Total Operating Revenue Medicaid Net Revenue A. Social Services onl 27,810,285 27,810,285 B. Managed Care Provider 025 2,466,315 2.466.315 C__ Other Services O12 TOTAL MEDICAID NET REVENUE 001 30,276,600 30,276,600 Medicare Net Revenue A. Part A - All Income oo2 6,935,706 6,935,706 B Part B - Income 003 779,785 779,785 C. Part B - Final Settlement 004 D._ Managed Care Provider 026 668.955 668,955 TOTAL MEDICARE NET REVENUE O13 8.384.446 8,384,446 Private Patient Revenue 005 772,866 772,866 Other Net Patient Revenue O06 224,366 224,366 TOTAL NET PATIENT REYENUE o10 39,658,278 39,658,278 All Other Operating Revenue” O15 a 1 61 TOTAL OPERATING REVENUE O20 40,141,639 40,141,639 *Line 0015 Column 00160 would be used for reporting revenue for all other operating revenue centers. 24 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 24 RECEIVED) WYSir09:4QAM2 8/2023 Schedule 7 - Analysis of Net Patient Revenue Blue Cross Travelers Other & Total Operating Revenue (continued) 0243 0244 0245 Part B Cash Receipts By Intermediary For Report Year 021 452,682 For Prior Year O22 All Other Years 023 TOTAL 030 452.682 25 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 25 RECEIVED) WYSir09:4QAM2 8/2023 Location on Schedule 8 - Amount Part I¥* Medicaid Rate Calculation Supplement Column/Line Number 0250 0251 Imputed Value Service Rendered by Operator 001 Life Insurance Premium on Life of Operator O02 Interest Not Related To Patient Care 003 Litigation Against the State oo4 Christmas Parties and Gifts (Not For All Emp] 005 Advertising O06 150,480 0041 /005 Contributions oo? 6,530 0041 005 Private Duty Nursing Fees oo8 Ancillary Cost Not Included in Medicaid Rate: Laboratory 009 32,555 0033/031 Radiology o10 47,272 0039/034 O11 O12 Maintenance Furnished To Institutional Employee O13 Maintenance Furnished To Other Employees O14 Clothing and Incidentals O15 Non-Institutional Costs O16 Medicare Part B - Final Settlement: (1) Physicians oF (2) Physical Therapy og o19 Speech Therapy: (1) Speech Pathologist - Salaries & Fees O20 73,575 034/041 (2) Speech Pathologist - Fringe Benefits 021 24,103 0035/041 (3) Speech Pathology - Other Direct Expense 022 Director of Volunteers 023 Work. Capital Int. Exp. On Obligation{1) > 1 YR O24 81,800 0041 /005 ‘Work. Capital Int. Exp. On Obligation{1) <= 1 YR 025 Ambulance Fees 027 Insurance (1)_ Malpractice 028 16,000 0041 005 (2]_ General Liability 029 1,270,649 0041005 (3) Umbrella (Blanket) 030 Crime Insurance $5,200 & Bond Insurance $3199 031 8,399 0041 /005 Interest On Letters Of Credit To Acquire Minimum Equity 032 Intergovernmental Transfer (1.G.1.] 033 *Location on Part IV refers to the column line where an item is actually reported or the column and line affected if the item would not be properly included on the part IV, ie. prepared in accordance with generally accepted accounting principles. (1) Do not include: (1) Interest paid to NYSDSS on recovery determinations. (2) Interest paid on funds borrowed to repay NYSDSS recovery determinations. (3) Interest paid to related parties. 26 BORE ¥od¥9524151549/ 2023 RewatiFereseQURGTS 5 42/3. Me 26 RECEIVED) WYSir09:4QAM2 8/2023 Location On Schedule 8A - Amount Part I¥ Medicaid Rate Calculation Supplement (continued) Column/Line Number 0260 0261 Marketing Salaries 034 32.660 0034/005 Marketing Salaries Benefits 035 13,417 0036/005 Marketing Consultant 036 33,165 0037/005 Marketing Food O37 13,813 0035/005 Marketing Lease 038 645 0040/005 Penalties 039 294 0041 005 Marketing Travel o40 12,056 0041005 Assoc dues - lobby portion O41 4.936 041/005 Business Development O42 2.741 0041 005 043 O44 045 046 oa? 048 049 O50 051 052 053 O54 055 O56 os? 058 O59 O60 27 BORE ¥od¥9524151549/ 2023 Rava Perigd