2025-06-04T15:19:11-05:00 2024-09-30 410746749 CLIFTONLARSONALLEN LLP 2689 COMMERCE DRIVE NW SUITE 201 ROCHESTER MN 55901 990 2023-10-01 410870856 MAPLE LAWN NURSING HOME INC MAPL 5074252571 400 7TH ST NE FULDA MN 56131 SHELBY JASS ADMINISTRATOR/CEO 5074252571 2025-05-14 1 0 KATHERINE LUTZKE CPA P01760889 5072802300 2025-05-14 2023 2025-03-06 01:10:19Z MAPLE LAWN SENIOR CARE MAPLEWOOD COURT MAPLEVIEW ESTATES SHELBY JASS 400 7TH ST NE FULDA MN 56131 6801009 0 X WWW.MAPLELAWN.ORG X 1962 MN TO PROVIDE FINE QUALITY HEALTHCARE, HOUSING AND SUPPORT SERVICES FOR AREA SENIORS. 9 9 127 15 0 0 99504 249746 5704894 6466342 16705 19722 86295 65199 5907398 6801009 3460 3104 0 0 3294743 3554916 0 0 0 2340793 2605050 5638996 6163070 268402 637939 3871660 4733756 953989 1100929 2917671 3632827 TO PROVIDE FINE QUALITY HEALTHCARE, HOUSING AND SUPPORT SERVICES FOR AREA SENIORS IN AN INDIVIDUALIZED, DIGNIFIED, AND HOMELIKE MANNER. 0 0 5575576 3104 6466342 MAPLE LAWN NURSING HOME, INC DBA MAPLE LAWN SENIOR CARE, IS A CAMPUS PROVIDING LONG TERM CARE SERVICES AT: MAPLE LAWN SENIOR CARE A 46 BED SKILLED NURSING FACILITY, MAPLEVIEW ESTATES A 24 ASSISTED LIVING APARTMENT FACILITY FOR SENIORS WHO NEED LIGHT ASSISTANCE TO MAINTAIN REASONABLY INDEPENDENT LIVES, AND MAPLEWOOD COURT ASSISTED LIVING A 15 APARTMENT FACILITY FOR SENIORS WHO NEED ASSISTANCE WITH ALL MEALS AND MEDICATIONS, BUT MAINTAIN INDEPENDENCE IN MANY OTHER CARE AREAS. AS OF JANUARY 1, 2022 THE NURSING FACILITY DELICENSED 4 BEDS ON LAYAWAY, DECREASING THE LICENSED BEDS FROM 54 TO 46. 5575576 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 34 0 127 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 MN X SHELBY JASS 5074252571 400 7TH STREET NE FULDA MN 56131 DON OLSEM BOARD PRESIDENT 0.46 X X 441 0 0 SHANNON HENNING VICE PRESIDENT 0.46 X X 343 0 0 JERRILD STEINER SECRETARY/TREASURER 0.46 X X 490 0 0 LINDA CLAUSON DIRECTOR 0.46 X 441 0 0 JIM ELSING DIRECTOR 0.46 X 490 0 0 LOUISE JOHNSON DIRECTOR 0.46 X 441 0 0 MELISSA GEHL DIRECTOR 0.46 X 245 0 0 DEAN VANOORT DIRECTOR 0.46 X 0 0 0 SUE ZINS DIRECTOR 0.46 X 343 0 0 SHELBY JASS ADMINISTRATOR/CEO 40.00 X 86792 0 2029 90026 0 2029 0 0 0 0 ONESTAFF MEDICAL LLC 10802 FARNAM DR OMAHA NE 68154 AGENCY STAFF 199009 GRAPETREE MEDICAL STAFFING 2501 BOJI BEND DR SUITE 100 MILFORD IA 51351 AGENCY STAFF 125331 PRAIRIE REHABILITATION SERVICES 1720 S CLIFF AVE SIOUX FALLS SD 57105 CONTRACTED THERAPY 115803 3 245368 4378 249746 RESIDENT SERVICES 623000 5208753 5208753 APARTMENT RENTAL 623000 1171747 1171747 ANCILLARY SERVICES 623000 85842 85842 6466342 19722 19722 OTHER REVENUES 623000 31834 31834 MISCELLANEOUS INCOME 900099 30573 30573 GARAGE REVENUE 623000 2792 2792 65199 6801009 6466342 0 84921 X 1434 1434 1670 1670 75222 75222 2850827 2827560 23267 29074 28843 231 412758 409458 3300 187035 185547 1488 2646 2646 49188 49188 896900 869512 27388 5077 5077 62842 62842 160923 155139 5784 176291 176291 2315 2315 10199 9767 432 206424 197675 8749 59996 57453 2543 MEDICAL SUPPLIES 348551 342925 5626 FOOD 245305 245305 0 OTHER EXPENSES 186342 -3104 189446 LICENSE SURCHARGE 136060 136008 52 55991 35162 20829 6163070 5575576 587494 0 704543 1514849 682606 769748 554754 597802 35378 53151 7997420 6214333 1878633 1783087 15746 15119 3871660 4733756 448032 616065 204880 374774 210626 16956 16100 15065 74351 78069 953989 1100929 X 2907671 3623827 10000 9000 2917671 3632827 3871660 4733756 637939 77217 0 X 0 1 X 1 0 X 1795 857735 415158 99504 249746 1623938 5553617 5296560 5534501 5704894 6466342 28555914 31464 48825 42818 58104 34626 215837 5586876 6203120 5992477 5862502 6750714 30395689 0 771358 485522 1025567 1213178 1230904 4726529 771358 485522 1025567 1213178 1230904 4726529 25669160 11462 5562 1279 16705 19722 54730 11462 5562 1279 16705 19722 54730 26689 36073 13235 30573 106570 5625027 6244755 6006991 5879207 6801009 30556989 0.84000 0.85570 0.00180 0.00190 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS REVENUES RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 5923367 4440105 1483262 366450 179546 186904 1707603 1594682 112921 1783087 ASSET RETIREMENT OBLIGATION 78069 78069 X 6878226 77217 77217 6801009 0 6801009 6163070 0 6163070 0 6163070 PART IV, LINE 2B: RESIDENTS MAKE A SECURITY DEPOSIT WHEN THEY MOVE INTO THE FACILITIES. EACH RESIDENT RECEIVES THEIR SECURITY DEPOSIT, WITH INTEREST, WHEN THEY LEAVE THE FACILITIES. RESIDENT TRUSTS ARE SMALL AMOUNTS THAT RESIDENTS HOLD WITH MAPLE LAWN FOR MINOR EXPENSES AND FOR USE IN RESIDENT OUTINGS. PART X, LINE 2: THE CORPORATION HAS BEEN GRANTED EXEMPT STATUS RELATIVE TO FEDERAL AND MINNESOTA CORPORATE INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND APPLICABLE STATE STATUTES. THE CORPORATION BELIEVES IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING THEIR ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE CORPORATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. THE CORPORATION'S ANNUAL TAX FILINGS ARE SUBJECT TO REVIEW BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE CORPORATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE CORPORATION IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OTHER TAXES. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERSHIP OF THE ORGANIZATION CONSISTS OF ANY PERSON (AGE 21 OR OLDER) OR ORGANIZATION DONATING $100 OR MORE FOR THE PURPOSE OF MEMBERSHIP TO THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION'S MEMBERS ELECT THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION'S MEMBERS HAVE THE POWER TO AMEND THE ARTICLES AND BYLAWS AND TO TERMINATE MEMBERSHIPS. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WAS PROVIDED TO THE BOARD OF DIRECTORS AT A BOARD MEETING AND APPROVED PRIOR TO BEING FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY IS ANNUALLY REVIEWED AND SIGNED BY THE BOARD MEMBERS AND KEY STAFF MEMBERS. BOARD MEMBERS ARE REQUIRED TO SELF-DISCLOSE POTENTIAL OR REAL CONFLICTS OF INTEREST TO THE BOARD. IF A CONFLICT EXISTS THE INDIVIDUAL WILL NOT BE ALLOWED TO VOTE ON THE RELATED ISSUE. CONFLICTS ARE HANDLED ON A CASE BY CASE BASIS. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD USES COMPARATIVE DATA FROM THE LONG TERM CARE IMPERATIVE COMPENSATION REPORT AND COMPARATIVE INFORMATION FROM A MAJOR ACCOUNTING FIRM WHEN DETERMINING THE ADMINISTRATOR'S SALARY. INFORMATION IS REVIEWED BY THE FULL BOARD AND DOCUMENTED IN THE MINUTES. THIS WAS LAST COMPLETED IN 2018. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 869,512. MANAGEMENT AND GENERAL EXPENSES 27,388. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 896,900.