On June 28, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
People Of The State Of New York, By Letitia James, Attorney General Of The State Of New York,
and
Abraham Operations Associates Llc Dba Beth Abraham Center For Rehabilitation And Nursing,
Aharon Lantzitsky,
Amir Abramchik,
Aron Gittleson,
Beth Rozenberg,
Bis Funding Capital Llc,
Centers For Care Llc Dba Centers Health Care,
Cfsc Downstate Llc,
Daryl Hagler,
David Greenberg,
Delaware Operations Associates Llc Dba Buffalo Center For Rehabilitation And Nursing,
Delaware Real Property Associates Llc,
Elliot Kahan,
Hollis Operating Co Llc Dba Holliswood Center For Rehabilitation And Healthcare,
Hollis Real Estate Co Llc,
Jeffrey Sicklick,
Jonathan Hagler,
Kenneth Rozenberg,
Leo Lerner,
Light Property Holdings Ii Associates Llc,
Mordechai Moti Hellman,
Reuven Kaufman,
Schnur Operations Associates Llc Dba Martine Center For Rehabilitation And Nursing,
Skilled Staffing Llc,
Sol Blumenfeld,
for Commercial - Other - Commercial Division
in the District Court of New York County.
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023
NYSCEF BOC. NO. 60 RECEIVED NYSCEF: 06/28/2023
BUDIMIR EXHIBIT 7A
014080 HO! BORK DANA ERK 2 ORAS DM DW Eaoo}o39451549/ 2023
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8/2023
014080 HO! BORK DANA ERK 2 ORAS DM DW Eaoo}o39451549/ 2023
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8/2023
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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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The CPA Certification is to be completed on-line at the New York State
Department of Health Commerce System (HCS) web site:
https://commerce.health.state.ny.us
- Enter your HCS User ID and Password, then click Sign In
- My Applications list - click "NH Cost Report".
INDEX NO. 451549/2023
P D; [NEW YORK COUNTY CLERK 0672872023 02:27 PM
ownesdir DOC. Nd. 6Q.ames of Established Operators (1) Social Percent RECEIVED NYSCEF: 06/28/2023
Number
Information
Security Ownership
(2) Number G3)
Operations
9100 0100 g101 o101
001 | kenneth Rozenberg $5.50
002|Reuven Kaufman 10.00
003 | Jeffrey Sicklick 2.50
004 | Leo lemer 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%
INDEX NO. 451549/2023
P D; [NEW YORK COUNTY CLERK 0672872023 02:27 PM
ownesdir DOC. Nd. 6Q.ames of Established Operators (1) Social Percent RECEIVED NYSCEF: 06/28/2023
Number
Information
Security Ownership
(2) Number G3)
Operations
9100 0100 g101 o101
001 | kenneth Rozenberg $5.50
002|Reuven Kaufman 10.00
003 | Jeffrey Sicklick 2.50
004 | Leo lemer 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%
DW Eaoo}o39451549/ 2023
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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
DW Eaoo}o39451549/ 2023
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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
DW Eaoo}o39451549/ 2023
014
RepgtPerigde
oLN
OURY18 66 Ea RECEIVED a2? AAM2 8/2023
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| 1
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 NY 1 n n
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 Gy EN Aon SR 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
10
fo BD 0 We GUNREVAGLERK O62 37.g ate rhO22 2% PM) DW Eaoo}o39451549/ 2023
hip Hi 66 BU Name Code RECET VM aw Q:r9:5396M2
8/2023
Part | - 1) 0099
RHCF
Patient Services Provided
istary - Corporation
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.
11
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Rava Perigd
EDHOLN
col 8 6g2/31/18 RECET
VM aw Q:r9:5396M2 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
12
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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 75.647 75.647
1A. Managed Care Provider 032 24.014 24.014
of Which How Many Patient Days Were:
Medicare Part B eligible (only) o10 2,007 2,007
Medicare Part D eligible [only] O22 2.267 2.267
Medicare Part B and D i ble 023 56.940 56.940
Medicare Part B and D i gible O24 14,433 14,433
Medicare [Days] o12 8.227 8.227
2A. Medicare - Managed Care Provider [Days] 033 .
1,768 .
1.768
3. Blue Cross (Days) O13
4. Other Private Insurance (Days) o14 637 637
4A. rivate Pay Patient [Days] 031 1.317 1317
5. Veterans Admin. [Days] O15
6. Other (Days) Specify O16
7. TOTAL (Sum of 009, 012-016, 031-033) o17 111,610 111.610
8_Total Number of Bed Reservations
Established During Reporting Period O18 mW mW
84. Reserved Bed Days Included in
TOTAL [Line 017 Above) 019 856 856
8B. OF Line 019, Number of Medicaid
Hospital Bed Reservation Days 020 555 555
8C_ OF Line 019, Number of Medicaid
Therapeutic Leave Days 021 3
13
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Part | - 4)
Report Period and Medicare Information
0437
Report Period
Beginning Date of Report (MM/DD/YY) O01 O1/01N8
Ending Date of Report [MM/DD/YY] oo2 12/31/18
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
14
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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 306 306
B) Of 001 Number on Bed Reservations oo2
2. Admissions During Reporting Period:
A] From Hospital oo3 335 335
B) From Private Residence oo4 18 18
C) From Another RHCF 005
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 360 360
3 Total Patients Under Care During
Report Period (Sum of Lines 001 + 012) O13 666 666
4 Discharges During Report Period
Al To Hospital 014 153 153
B) To Private Residence g15 113 113
C) To Another RHCF O16 12 12
D) To Adult Care Facilities (ACF) 018 Vv Vv
E) To State Fac(Psych & Developmental Ctrs) O19
F) Deaths (In-House) 020 64 64
G) To Other Than Above Specify 071
H] To Other Certified Program
Service(s) At The Facility o22
|) Total Discharges and Transfers 023 359 359
5 Census Data End of Report Period
A) Census Midnight of Last Day of
This Report Period 024 307 307
B) Of 024 Number on Bed Reservations 025
15
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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 18 22
55-64 oo4 24 16 45
65-69 005 33 19 52
70-74 006 32 20 52
75-79 oo? 18 30 48
80-84 oos 23 19 42
85-89 009 10 18 28
50+ oo 15 18
Total O11 166 141 307
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)
16
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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 550.00 615.00
Medicaid 013 281 277.19 279.89
Medicare o14 19 327.46 764.81
Blue Cross O15
Veterans Admin_ O16
Other o17 281.47 475.00
Total * o18 307
Previous Private ** og 19
|. Weighted Average
Private Pay Rate 026 590.00
NOTE: *TOTALS MUST AGREE WITH CC/LINE, 0011/024
*ME DICAID PATIENTS (INCLUDED IN LINE 013 ABOVE)
THAT WERE PREVIOUS PRIVATE PAY
17
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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 44 44
Private and Other O22 u u
Medicaid 023 79 79
Veterans Admin. O24
Total 025 239 239
*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).
18
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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 32
08-14 Days O27 19
15-21 Days 028 15 16
22-30 Days 029 18 7
1-2Mo. 030 13 27
2-3Mo_ 031 14 Vv
3-4 Mo. 032
4-5 Mo. 033
5-6 Mo_ 034
6-3 Mo. 035 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 W
Total O50 153 12 WF 113 64
19
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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
20
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RHCF
Part I - 10) Private
County of so
Medicaid | Medicare Pay or
Origin Other
0422 0423 0424 0425
001 73 276 18 7
oo2 72 3
003 7o 2 1
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
Outside US. 048
Total O49 ag: 281 19 7
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.
21
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RHCF
Part 1-11]
Nursing /
Resident Unit
Cert Bed
Capacities
O4: o4: o4:
NUL 1-8 O01
O12 20 60 60 58 58 58
NLU. 9-16 002
O13
NUL 17-24 003 2
ow
NUL 25-31 O04 ‘Total
O15 314
22
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marae PerigdtOURyl8 Ea
EDHOLN DM
66: 20 RECET
VM aw Q:r9:5396M2 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:
23
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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 WwW? 09/30/21
02 MAINTENANCE 003 09/30/21
03 TECHNICAL O04
o4 PHARMACY 005
05 CLERICAL 006 18 09/30/21
06 LPN O07 09/30/21
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] 257| 53 173| 483
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.
24
boro: v7 7
Jleport DR ohiOo3d!51549/
2023
Repatiherigde
OURY18 6 92/31/18 ~22- RECE LVM 3209: 5398"'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|{
25
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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 22,823,672 22,823,672
B. Managed Care Provider 025
C__ Other Services O12
TOTAL MEDICAID NET REVENUE 001 22,823,672 22,823.672
Medicare Net Revenue
A. Part A - All Income oo2 5,275,203 5,275,203
B Part B - Income 003 809,753 809,753
C. Part B - Final Settlement 004
D._ Managed Care Provider 026
TOTAL MEDICARE NET REVENUE O13 6,084,956 6,084,956
Private Patient Revenue 005 9,425,000 3,425,000
Other Net Patient Revenue O06
TOTAL NET PATIENT REYENUE o10 38,333,628 38,333,620
All Other Operating Revenue” O15 3. 7 47
TOTAL OPERATING REVENUE O20 38.673.175 38.673.175
*Line 0015 Column 00160 would be used for reporting revenue
for all other operating revenue centers.
26
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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 021 618,846
For Prior Year O22 112,900
All Other Years 023
TOTAL 030 731,746
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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 7.634 0041 005
Litigation Against the State oo4
Christmas Parties and Gifts (Not For All Emp] 005
Advertising O06 179,597 0041 /005
Contributions oo? 3.604 0041 005
Private Duty Nursing Fees oo8
Ancillary Cost Not Included in Medicaid Rate:
AMBULANCE 009 73,739 0039/043
LAB o10 18,708 0037/031
x RAY O11 18,120 0038/034
EXG 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 88.540 0037/041
(2) Speech Pathologist - Fringe Benefits 021 14,856 0036/041
(3) Speech Pathology - Other Direct Expense 022
Director of Volunteers 023
Work. Capital Int. Exp. On Obligation{1) > 1 YR O24
‘Work. Capital Int. Exp. On Obligation{1) <= 1 YR 025 102,200 0041 005
Ambulance Fees 027
Insurance
(1)_ Malpractice 028 1,792,123 0041 005
(2]_ General Liability 029 352,787 0041005
(3) Umbrella (Blanket) 030
031
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.
28
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Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 60 RECEIVED NYSCEF: 06/28/2023 BUDIMIR EXHIBIT 7A 014080 HO! BORK DANA ERK 2 ORAS DM DW Eaoo}o39451549/ 2023 RapotPerigdt mes 6a2/31/18 RECET VM aw Q:r9:526M2 8/2023 014080 HO! BORK DANA ERK 2 ORAS DM DW Eaoo}o39451549/ 2023 RapotPerigdt mes 6a2/31/18 RECET VM aw Q:r9:526M2 8/2023 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue RECET VM aw Q:r9:526M2 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% 014080 HO! N Dik DW Eaoo}o39451549/ 2023 RapotPerigdt OUAGIE gA2/5118 RECET VM aw Q:r9:526M2 8/2023 The CPA Certification is to be completed on-line at the New York State Department of Health Commerce System (HCS) web site: https://commerce.health.state.ny.us - Enter your HCS User ID and Password, then click Sign In - My Applications list - click "NH Cost Report". INDEX NO. 451549/2023 P D; [NEW YORK COUNTY CLERK 0672872023 02:27 PM ownesdir DOC. Nd. 6Q.ames of Established Operators (1) Social Percent RECEIVED NYSCEF: 06/28/2023 Number Information Security Ownership (2) Number G3) Operations 9100 0100 g101 o101 001 | kenneth Rozenberg $5.50 002|Reuven Kaufman 10.00 003 | Jeffrey Sicklick 2.50 004 | Leo lemer 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% INDEX NO. 451549/2023 P D; [NEW YORK COUNTY CLERK 0672872023 02:27 PM ownesdir DOC. Nd. 6Q.ames of Established Operators (1) Social Percent RECEIVED NYSCEF: 06/28/2023 Number Information Security Ownership (2) Number G3) Operations 9100 0100 g101 o101 001 | kenneth Rozenberg $5.50 002|Reuven Kaufman 10.00 003 | Jeffrey Sicklick 2.50 004 | Leo lemer 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% DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue RECET VM aw Q:r9:526M2 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 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue RECET VM aw Q:r9:526M2 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 DW Eaoo}o39451549/ 2023 014 RepgtPerigde oLN OURY18 66 Ea RECEIVED a2? AAM2 8/2023 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| 1 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 NY 1 n n 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 Gy EN Aon SR 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 10 fo BD 0 We GUNREVAGLERK O62 37.g ate rhO22 2% PM) DW Eaoo}o39451549/ 2023 hip Hi 66 BU Name Code RECET VM aw Q:r9:5396M2 8/2023 Part | - 1) 0099 RHCF Patient Services Provided istary - Corporation 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. 11 DW Eaoo}o39451549/ 2023 Rava Perigd EDHOLN col 8 6g2/31/18 RECET VM aw Q:r9:5396M2 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 12 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 10 RECET VM aw Q:r9:5396M2 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 75.647 75.647 1A. Managed Care Provider 032 24.014 24.014 of Which How Many Patient Days Were: Medicare Part B eligible (only) o10 2,007 2,007 Medicare Part D eligible [only] O22 2.267 2.267 Medicare Part B and D i ble 023 56.940 56.940 Medicare Part B and D i gible O24 14,433 14,433 Medicare [Days] o12 8.227 8.227 2A. Medicare - Managed Care Provider [Days] 033 . 1,768 . 1.768 3. Blue Cross (Days) O13 4. Other Private Insurance (Days) o14 637 637 4A. rivate Pay Patient [Days] 031 1.317 1317 5. Veterans Admin. [Days] O15 6. Other (Days) Specify O16 7. TOTAL (Sum of 009, 012-016, 031-033) o17 111,610 111.610 8_Total Number of Bed Reservations Established During Reporting Period O18 mW mW 84. Reserved Bed Days Included in TOTAL [Line 017 Above) 019 856 856 8B. OF Line 019, Number of Medicaid Hospital Bed Reservation Days 020 555 555 8C_ OF Line 019, Number of Medicaid Therapeutic Leave Days 021 3 13 DW Eaoo}o39451549/ 2023 AewatiFeradeOURETE 6602/3 Me Ir RECET VM aw Q:r9:5396M2 8/2023 Part | - 4) Report Period and Medicare Information 0437 Report Period Beginning Date of Report (MM/DD/YY) O01 O1/01N8 Ending Date of Report [MM/DD/YY] oo2 12/31/18 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 14 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 12 RECET VM aw Q:r9:5396M2 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 306 306 B) Of 001 Number on Bed Reservations oo2 2. Admissions During Reporting Period: A] From Hospital oo3 335 335 B) From Private Residence oo4 18 18 C) From Another RHCF 005 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 360 360 3 Total Patients Under Care During Report Period (Sum of Lines 001 + 012) O13 666 666 4 Discharges During Report Period Al To Hospital 014 153 153 B) To Private Residence g15 113 113 C) To Another RHCF O16 12 12 D) To Adult Care Facilities (ACF) 018 Vv Vv E) To State Fac(Psych & Developmental Ctrs) O19 F) Deaths (In-House) 020 64 64 G) To Other Than Above Specify 071 H] To Other Certified Program Service(s) At The Facility o22 |) Total Discharges and Transfers 023 359 359 5 Census Data End of Report Period A) Census Midnight of Last Day of This Report Period 024 307 307 B) Of 024 Number on Bed Reservations 025 15 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 13 RECET VM aw Q:r9:5396M2 8/2023 RHCF Part 1 - 6] Male Female Total Age o412 0413 0414 Age: 0-15 001 16-20 O02 21-54 003 18 22 55-64 oo4 24 16 45 65-69 005 33 19 52 70-74 006 32 20 52 75-79 oo? 18 30 48 80-84 oos 23 19 42 85-89 009 10 18 28 50+ oo 15 18 Total O11 166 141 307 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) 16 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 14 RECET VM aw Q:r9:5396M2 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 550.00 615.00 Medicaid 013 281 277.19 279.89 Medicare o14 19 327.46 764.81 Blue Cross O15 Veterans Admin_ O16 Other o17 281.47 475.00 Total * o18 307 Previous Private ** og 19 |. Weighted Average Private Pay Rate 026 590.00 NOTE: *TOTALS MUST AGREE WITH CC/LINE, 0011/024 *ME DICAID PATIENTS (INCLUDED IN LINE 013 ABOVE) THAT WERE PREVIOUS PRIVATE PAY 17 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 15 RECET VM aw Q:r9:5396M2 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 44 44 Private and Other O22 u u Medicaid 023 79 79 Veterans Admin. O24 Total 025 239 239 *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). 18 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 16 RECET VM aw Q:r9:5396M2 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 32 08-14 Days O27 19 15-21 Days 028 15 16 22-30 Days 029 18 7 1-2Mo. 030 13 27 2-3Mo_ 031 14 Vv 3-4 Mo. 032 4-5 Mo. 033 5-6 Mo_ 034 6-3 Mo. 035 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 W Total O50 153 12 WF 113 64 19 50140%D HO! N Dik DW Eaoo}o39451549/ 2023 RapotPerigdt OUAGIE gA2/5118 RECET VM aw Q:r9:5396M2 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 20 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 18 RECET VM aw Q:r9:5396M2 8/2023 RHCF Part I - 10) Private County of so Medicaid | Medicare Pay or Origin Other 0422 0423 0424 0425 001 73 276 18 7 oo2 72 3 003 7o 2 1 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 Outside US. 048 Total O49 ag: 281 19 7 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. 21 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 19 RECET VM aw Q:r9:5396M2 8/2023 RHCF Part 1-11] Nursing / Resident Unit Cert Bed Capacities O4: o4: o4: NUL 1-8 O01 O12 20 60 60 58 58 58 NLU. 9-16 002 O13 NUL 17-24 003 2 ow NUL 25-31 O04 ‘Total O15 314 22 DW Eaoo}o39451549/ 2023 marae PerigdtOURyl8 Ea EDHOLN DM 66: 20 RECET VM aw Q:r9:5396M2 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: 23 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 21 RECET VM aw Q:r9:5396M2 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 WwW? 09/30/21 02 MAINTENANCE 003 09/30/21 03 TECHNICAL O04 o4 PHARMACY 005 05 CLERICAL 006 18 09/30/21 06 LPN O07 09/30/21 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] 257| 53 173| 483 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. 24 boro: v7 7 Jleport DR ohiOo3d!51549/ 2023 Repatiherigde OURY18 6 92/31/18 ~22- RECE LVM 3209: 5398"'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|{ 25 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 23 RECET VM aw Q:r9:5396M2 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 22,823,672 22,823,672 B. Managed Care Provider 025 C__ Other Services O12 TOTAL MEDICAID NET REVENUE 001 22,823,672 22,823.672 Medicare Net Revenue A. Part A - All Income oo2 5,275,203 5,275,203 B Part B - Income 003 809,753 809,753 C. Part B - Final Settlement 004 D._ Managed Care Provider 026 TOTAL MEDICARE NET REVENUE O13 6,084,956 6,084,956 Private Patient Revenue 005 9,425,000 3,425,000 Other Net Patient Revenue O06 TOTAL NET PATIENT REYENUE o10 38,333,628 38,333,620 All Other Operating Revenue” O15 3. 7 47 TOTAL OPERATING REVENUE O20 38.673.175 38.673.175 *Line 0015 Column 00160 would be used for reporting revenue for all other operating revenue centers. 26 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 24 RECET VM aw Q:r9:5396M2 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 021 618,846 For Prior Year O22 112,900 All Other Years 023 TOTAL 030 731,746 27 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 25 RECET VM aw Q:r9:5396M2 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 7.634 0041 005 Litigation Against the State oo4 Christmas Parties and Gifts (Not For All Emp] 005 Advertising O06 179,597 0041 /005 Contributions oo? 3.604 0041 005 Private Duty Nursing Fees oo8 Ancillary Cost Not Included in Medicaid Rate: AMBULANCE 009 73,739 0039/043 LAB o10 18,708 0037/031 x RAY O11 18,120 0038/034 EXG 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 88.540 0037/041 (2) Speech Pathologist - Fringe Benefits 021 14,856 0036/041 (3) Speech Pathology - Other Direct Expense 022 Director of Volunteers 023 Work. Capital Int. Exp. On Obligation{1) > 1 YR O24 ‘Work. Capital Int. Exp. On Obligation{1) <= 1 YR 025 102,200 0041 005 Ambulance Fees 027 Insurance (1)_ Malpractice 028 1,792,123 0041 005 (2]_ General Liability 029 352,787 0041005 (3) Umbrella (Blanket) 030 031 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. 28 DW Eaoo}o39451549/ 2023 AawatiFereseOURGTE 6602/3 ue 26 RECET VM aw Q:r9:5396M2 8/2023