2016-08-10T14:42:29-05:00 2015-09-30 411765929 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2014-10-01 410878215 ST OLAF RESIDENCE INC STOL 6125212929 2929 EMERSON AVENUE NORTH MINNEAPOLIS MN 55411 REV DALE HULME TREASURER 6125212929 2016-08-10 1 DEB NELSON CPA P01264758 6122536500 2016-08-10 2014 2016-12-15 16:53:06Z X ED ENSTROM 2929 EMERSON AVENUE NORTH MINNEAPOLIS MN 55411 7501273 0 X WWW.STOLAFCOMMUNITIES.ORG X 1962 MN LONG TERM CARE AND ASSISTED LIVING. 10 9 184 30 0 0 8123 44006 7441271 5819398 8015 9933 -29432 1609246 7427977 7482583 0 0 0 0 3848316 3470735 0 0 0 3837984 3862298 7686300 7333033 -258323 149550 4341596 4098843 5085871 4722504 -744275 -623661 X DRAWING UPON OUR CHRISTIAN HERITAGE, THE MISSION OF ST. OLAF RESIDENCE IS TO PROVIDE QUALITY HOUSING, HEALTH CARE AND SUPPORTIVE SERVICES WITH DIGNITY AND RESPECT TO THOSE WHO NEED THEM.UNDER THE LEADERSHIP OF THE BOARD OF DIRECTORS, WE WILL BE FINANCIALLY SOUND, USE OUR BUILDINGS AND LAND TO THE BENEFIT OF THOSE WE SERVE, DEVELOP PARTNERSHIPS TO STRENGTHEN THE COMMUNITY, HAVE A STRONG DEVELOPMENT PROGRAM, AND CONTINUALLY RECOGNIZE OUR STAFF AS AN ASSET. IN THIS WAY, WE WILL IMPROVE THE QUALITY OF LIFE FOR THOSE WE SERVE THROUGH MEASURABLE STANDARDS. 0 1 6481056 0 5819398 ST. OLAF RESIDENCE, INC. (ST. OLAF) PROVIDES QUALITY HOUSING, HEALTH CARE, AND SUPPORTIVE SERVICES WITH DIGNITY AND RESPECT TO THOSE WHO NEED THEM. UNDER THE LEADERSHIP OF THE VOLUNTEER BOARD OF DIRECTORS, ST. OLAF RESIDENCE, INC. OPERATES ST. OLAF RESIDENCE, A 80-BED SKILLED NURSING FACILITY AND NORTH OAKS ON EMERSON, AN ATTACHED 48-UNIT ASSISTED LIVING FACILITY. EACH FACILITY PROVIDES 24 HOUR CARE 7 DAYS A WEEK. THE SKILLED NURSING FACILITY PROVIDED 22,191 RESIDENT DAYS OF CARE FOR THIS FISCAL YEAR OF OCTOBER THROUGH SEPTEMBER 2015.NORTH OAKS ON EMERSON, OUR ASSISTED LIVING FACILITY, PROVIDED OVER $3,300.00 IN CHARITY CARE SERVICES TO THE CLIENTS RESIDING IN THE BUILDING. ST. OLAF'S DIETARY DEPARTMENT CATERS MEALS FOR THE NORTHSIDE MEALS ON WHEELS PROGRAM WHICH DISTRIBUTES, ON AVERAGE, 2,645 MEALS PER MONTH. THESE MEALS ARE DISTRIBUTED TO HOME-BOUND RESIDENTS WITHIN OUR COMMUNITY. MEALS ON WHEELS DID CLOSE ITS DOORS PERMANENTLY AS OF MAY 31, 2015. 6481056 1 0 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 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 18 0 1 184 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 1 0 0 1 1 0 1 1 0 0 0 1 1 1 1 0 1 0 0 MN X ADMINISTRATOR 6125212929 2929 EMERSON AVENUE NORTH MINNEAPOLIS MN 55411 ED ENSTROM PRESIDENT 2.00 0.00 X X 0 0 0 REV TIM SOLBERG VICE PRESIDENT (THRU JAN 2015) 2.00 0.00 X X 0 0 0 REV STEVE LOHMAN VICE PRESIDENT (FROM JAN 2015) 2.00 0.00 X X 0 0 0 WILLIAM KONRARDY SECRETARY 2.00 0.00 X X 0 0 0 REV DALE HULME TREASURER 2.00 40.00 X X 0 8680 18366 SCOTT LIEN BOARD MEMBER 1.00 0.00 X 0 0 0 JOANN ULM BOARD MEMBER 1.00 0.00 X 0 0 0 ALMOND CLEMENS BOARD MEMBER 1.00 0.00 X 0 0 0 SHIRLEY DAVIS BOARD MEMBER 1.00 0.00 X 0 0 0 PAMELAR MCCLENDON BOARD MEMBER 1.00 0.00 X 0 0 0 LORI JASPAR BOARD MEMBER (FROM MAR 2015) 1.00 0.00 X 0 0 0 ROBERT HANSON BOARD MEMBER (JAN 2015 TO JUN 2015) 1.00 0.00 X 0 0 0 MARY ANN HAMER ADMINISTRATOR (FROM MAR 2015) 40.00 0.00 X 0 0 0 DAVID USELMAN ADMINISTRATOR (THRU OCT 2014) 40.00 0.00 X 0 0 0 0 8680 18366 0 0 0 0 NEW HORIZON FOODS INC PO BOX 860246 MINNEAPOLIS MN 55486 DIETARY SERVICES 642212 HEALTH DIMENSIONS GROUP 4400 BAKER RD 100 MINNETONKA MN 55343 MANAGEMENT SERVICES 387915 2 44006 44006 RESIDENT SERVICE REVENUE 623000 5702559 5702559 MEALS AT HOME REVENUE 624200 105775 105775 11064 11064 5819398 9933 9933 53584 18690 34894 34894 34894 GAIN ON SALE OF BED LICENSES 900099 1202500 1202500 GAIN ON DEBT FORGIVENESS 900099 248609 248609 GAIN ON INSURANCE RECOVER 900099 123243 123243 1574352 7482583 5819398 0 1619179 2978303 2698997 279306 17304 15681 1623 240650 218082 22568 234478 212489 21989 370000 370000 10998 10998 17481 17481 670415 626728 43687 11108 11108 251808 227595 24213 29388 29388 322879 322879 5233 5233 46945 381 46564 215922 215922 279988 279988 41590 41590 FOOD 834797 834797 BAD DEBTS EXPENSE 476780 476780 SURCHARGE 233026 233026 43940 30392 13548 7333033 6481056 851977 0 127764 1441990 1380574 41837 16299 8594094 6564698 2270977 2029396 355244 381908 74593 18411 156955 144491 4341596 4098843 1238044 1119223 37929 3590000 3495000 35767 28807 58986 38846 125145 40628 5085871 4722504 X -771521 -623661 27246 0 -744275 -623661 4341596 4098843 149550 -28936 0 X 0 1 X 1 0 X 1741 1687 1286 8123 44006 56843 6743560 6986120 7255882 7441271 5819398 34246231 6745301 6987807 7257168 7449394 5863404 34303074 0 259010 87900 616872 191688 64137 1219607 259010 87900 616872 191688 64137 1219607 33083467 38680 15798 37640 43932 63517 199567 38680 15798 37640 43932 63517 199567 1574352 1574352 6783981 7003605 7294808 7493326 7501273 36076993 0.91700 0.95660 0.00550 0.00570 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: GAIN ON SALE OF BED LICENSES - 2014 AMOUNT: $ 1,202,500. GAIN ON DEBT FORGIVENESS - 2014 AMOUNT: $ 248,609. GAIN ON INSURANCE RECOVER - 2014 AMOUNT: $ 123,243. 0 1 X 361971 361971 5658892 4561843 1097049 2506738 1942366 564372 66493 60489 6004 2029396 CAPITALIZED LEASE OBLIGATIONS 40628 40628 X 7489984 0 7489984 -7401 -7401 7482583 7340434 7401 7401 7333033 0 7333033 PART IV, LINE 2B: THE ORGANIZATION HOLDS FUNDS IN TRUST ON BEHALF OF THE RESIDENTS. PART X, LINE 2: THE RESIDENCE IS ORGANIZED AS A MINNESOTA NOT-FOR-PROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE RESIDENCE IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE RESIDENCE IS SUBJECT TO INCOME TAX ON ANY NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE RESIDENCE BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND, AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE RESIDENCE 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. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN REVENUE FOR TAX PURPOSES. -7,401. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSE INCLUDED IN REVENUE FOR TAX PURPOSES. 7,401. A CITY OF MINNEAPOLIS 416005375 603908NJ9 2005-07-06 4150000 REFINANCE BONDS ISSUED 10/6/1993 AND CAPITAL UPDATES. 0 0 0 A 655000 4140129 305347 80925 400000 3356910 2007 1 0 1 1 A 0 0 0 0 0.01400 0.01400 0 0 0 A 0 0 0 1 0 0 0 0 0 A 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF MINNEAPOLIS DATE THE REBATE COMPUTATION WAS PERFORMED: 07/01/2015 SCHEDULE K, PART II, LINE 3 THE AMOUNT REPORTED HERE IS THE ISSUE PRICE OF $4,150,000 LESS THE ORIGINAL ISSUE DISCOUNT OF $9,871. FORM 990, PART III, LINE 3 THE MINNEAPOLIS MEALS ON WHEELS (3RD PARTY) OFFICE WAS CLOSED IN FISCAL 2015. ST OLAF CONTINUED TO PROVIDE MEALS AT COST FOR THAT PROGRAM UNTIL IT CLOSED ON MAY 31, 2015. ALSO, IN SEPTEMBER 2015 THE RESIDENCE MADE THE DECISION TO CLOSE THE NURSING FACILITY AND SOLD 80 BED LICENSES. IN ADDITION, THE RESIDENCE IS IN THE PROCESS OF SELLING THE ASSISTED LIVING FACILITY. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION ENGAGED ECUMEN AND HEALTH DIMENSIONS GROUP, EACH UNRELATED MANAGEMENT COMPANIES, FOR ADMINSTRATOR SERVICES. THE ADMINISTRATOR WAS DAVID USELMAN (ECUMEN) THROUGH OCTOBER 2014 AND THEN JAMES E LAINE (HEALTH DIMENSIONS GROUP) FROM DECEMBER 2014 THROUGH FEBRUARY 2015. THE ADMINISTRATOR POSITION WAS VACANT UNTIL MARY ANN HAMER (HEALTH DIMENSIONS GROUP) BEGAN IN MARCH 2015. THE ADMINISTRATOR SUPERVISES THE CLINICAL AND ADMINISTRATIVE AFFAIRS FOR THE CAMPUS. THE ADMINISTRATOR DEVELOPS AND IMPLEMENTS POLICIES AND PROCEDURES TO COMPLY WITH FEDERAL, STATE AND LOCAL REQUIREMENTS AND TO FULFILL LICENSURE CERTIFICATION STANDARDS. THE ADMINISTRATOR HIRES, MONITORS AND DIRECTS THE ACTIVITIES OF SEVERAL DEPARTMENT HEADS REPORTING TO THIS POSITION. THIS POSITION CONTINUOUSLY ANALYZES DEPARTMENTAL OPERATIONS, EVALUATES THE ENVIRONMENT AND EQUIPMENT NECESSARY FOR EFFECTIVE FUNCTIONING AND IMPLEMENTS ANY NECESSARY PROCEDURAL CHANGE. THE ADMINISTRATOR DEVELOPS AND ENSURES CONFORMANCE WITH THE ANNUAL BUDGET. THE ADMINISTRATOR CONFERS WITH MEDICAL DIRECTOR AND OTHER CONSULTANTS AS NECESSARY AND REPORTS TO THE BOARD AND MANAGEMENT PARTNER. COMPENSATION CHARGED TO ST. OLAF FOR CALENDAR YEAR 2014 WAS: DAVID USELMAN (EMPLOYEE OF ECUMEN) - $98,905 JAMES E LAINE (CONTRACTOR OF HEALTH DIMENSIONS GROUP) - $27,750 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION SHALL HAVE ONE CLASS OF MEMBERS CONSISTING OF THE VOTING MEMBERS OF ST. OLAF LUTHERAN CHURCH OF MINNEAPOLIS. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF ST. OLAF COMMUNITY CAMPUS, INC. MAY CONSIDER A RESOLUTION TO PERMIT THE DIRECTORS OF ST. OLAF COMMUNITY CAMPUS, INC. TO ELECT THE DIRECTORS OF THE CORPORATION. IF THE RESOLUTION IS APPROVED, THE DIRECTORS OF ST. OLAF COMMUNITY CAMPUS, INC. WILL ELECT THE DIRECTORS OF THE CORPORATION. IF THE RESOLUTION IS NOT APPROVED, THE DIRECTORS OF THE CORPORATION SHALL BE NOMINATED BY THE BOARD OF DIRECTORS AND ELECTED BY A MAJORITY OF MEMBERS PRESENT AT A DULY HELD MEETING OF THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11 THE FINANCIAL SERVICES DIRECTOR OF HEALTH DIMENSIONS GROUP, THE MANAGEMENT COMPANY, AND THE BOARD PRESIDENT WILL REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C ALL OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE COVERED BY THE POLICY. ALL POTENTIAL CONFLICTS ARE TO BE REVEALED TO THE DIRECTORS AND COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS WILL CONSIDER THE POTENTIAL CONFLICT. AFTER ALL FACTS RELATED TO THE POTENTIAL CONFLICT HAVE BEEN DISCLOSED, THE PERSON WITH THE POTENTIAL CONFLICT MUST LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. FORM 990, PART VI, SECTION B, LINE 15A THE ORGANIZATION ENGAGED WITH HEALTH DIMENSIONS GROUP, A MANAGEMENT COMPANY, BEGINNING DECEMBER OF 2014 FOR THE SERVICES PROVIDED BY THE ADMINISTRATOR. THE ORGANIZATION RELIES ON THE MANAGEMENT COMPANY TO DETERMINE THE ADMINISTRATOR'S COMPENSATION. THE CONTRACT WITH THE MANAGEMENT COMPANY IS APPROVED BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. ST OLAF COMMUNITY CAMPUS INC 2901 EMERSON AVENUE NORTH MINNEAPOLIS MN 55411 411648596 SUPPORT OF EXEMPT ORGANIZATIONS MN 501(C)(3) 7 N/A 0 ST OLAF CAMPUS FOUNDATION INC 2901 EMERSON AVENUE NORTH MINNEAPOLIS MN 55411 410984619 SUPPORT AFFILIATED ORGANIZATIONS MN 501(C)(3) 11, TYPE II N/A 0 ST OLAF LUTHERAN CHURCH 2901 EMERSON AVENUE NORTH MINNEAPOLIS MN 55411 410760822 CHURCH MN 501(C)(3) 1 N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0