(1) Every long-term care facility shall submit an annual report to the department on a form provided by the department by the deadline specified on the form. The annual report must be signed by the facility administrator and must include whichever of the following information is requested on the form:

(a) the facility's reporting period, and whether the facility was in operation for a full 12 months at the end of the reporting period;

(b) a discussion of the organizational aspects of the facility, including the following information:

(i) the type of organization or entity responsible for the day-to-day operation of the facility (e.g., state, county, city, federal, hospital district, church related, nonprofit corporation, individual, partnership, business corporation);

(ii) whether the controlling organization leases the physical plant from another organization. If so, the name and type of organization that owns the plant;

(iii) any changes in the ownership, board of directors or articles of incorporation of the facility during the past year;

(iv) the name of the current chairman of the board of directors of the facility;

(v) if the controlling organization has placed responsibility for the administration of the facility with another organization, the name and type of organization that manages the facility. A copy of the latest management agreement must be provided;

(vi) if the facility is operated as a part of a multi-facility system (e.g., medical center, chain of hospitals owned by a religious order, etc.) the name and address of the parent organization;

(c) utilization information, including:

(i) licensed bed capacity (skilled and intermediate);

(ii) whether the facility is certified for medicare or medicaid;

(iii) number of beds currently set up and staffed;

(iv) total patient census on first day of reporting period; total admissions, discharges, patient deaths, and patient-days of service during the reporting period;

(v) patient census on last day of reporting period, broken down by sex and age categories;

(d) financial data, including:

(i) total annual operating expenses (payroll and non- payroll);

(ii) closing date of financial statement;

(iii) sources of operating revenue, indicating percent received from medicare, medicaid, private pay, insurance, grants, contributions, and other;

(e) staff information, including number and classification of full and part-time medical personnel, as required on the survey form;

(f) patient origin data, including patients' counties of residence, and number of admissions from state institutions and from out-of-state;

(g) name of person to contact should the department have any questions regarding the information on the report.

(2) Any facility failing to timely report such information to the department may be subject to corrective action.