2016-02-06T15:00:48-06:00 2015-09-30 208896204 Dennis G Koch CPA PO Box 1007 Quincy IL 623061007 990 2014-10-01 370724112 Good Samaritan Home of Quincy GOOD 2172238717 2130 Harrison Street Quincy IL 62301 Laura Ehrhart President 2172228471 2016-02-06 1 Dennis G Koch P01210686 2172248484 2016-02-06 X 2014 2016-08-17 19:52:53Z Michael Duffy 3831 Newcastle Dr Quincy IL 62301 16001595 0 X www.gshq.org X 1953 IL To maintain a home for the care of the aged, without regard to poverty or riches of residents. 20 20 464 180 0 0 490692 347956 15226048 15393569 1991363 30644 114716 229426 17822819 16001595 0 14545396 0 0 10115789 10452590 0 0 104665 6958004 7702129 17073793 32700115 749026 -16698520 58335801 41374697 12477309 12214725 45858492 29159972 To establish, support and maintain a home and related facilities for the care of the aged, without regard to poverty or riches of residents. 0 0 31472019 14545396 15653639 Nursing, therapy, home care and apartments for the elderly. 31472019 1 1 0 0 0 0 0 0 0 1 1 0 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 6 0 1 464 1 0 0 0 0 0 0 0 0 X 20 20 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X X The Good Samaritan Home of Quincy 2172238717 2130 Harrison Street Quincy IL 62301 X Laura Ehrhart President 10.00 X X 0 0 0 Larry Shepherd 1st Vice President 5.00 X X 0 0 0 Steve Wavering 2nd Vice President 5.00 X X 0 0 0 Jerry Jackson 3rd Vice President 5.00 X X 0 0 0 Gena Awerkamp Secretary/Treasurer 5.00 X X 0 0 0 William Winn Im Past President 5.00 X X 0 0 0 Andrew Cashman Director 5.00 X 0 0 0 Carla Derrick Director 5.00 X 0 0 0 Daron Duke Director 5.00 X 0 0 0 John Heidbreder Director 5.00 X 0 0 0 Bob Johnson Director 5.00 X 0 0 0 Paul Kemner Director 5.00 X 0 0 0 John Letts Director 5.00 X 0 0 0 Billie Menke Director 5.00 X 0 0 0 Mike Oberdahlhoff Director 5.00 X 0 0 0 Raymond Scheiter Director 5.00 X 0 0 0 Janet Schneeberger Director 5.00 X 0 0 0 Jeff Spear Director 5.00 X 0 0 0 Richard Walz Director 5.00 X 0 0 0 Robert Young Director 5.00 X 0 0 0 Michael Duffy Adminstrator 45.00 X 142430 0 14718 142430 0 14718 2 0 1 0 Kohl Wholesale 130 Jersey St Quincy IL 62301 Cafeteria Food 1034610 Peters Heating & Air Conditioning 4520 Broadway Quincy IL 62305 Heating/AC Contractor 820611 First Choice Physical Therapy 5 W State 8th Plaza Quincy IL 62305 Physical Therapy 480917 CPI Qualified Plan Consultants 1809 24th St Great Bend KS 675301167 Thrid Party Administration 366504 JRX Pharmacy Services 2404 Ave L Fort Madison IA 52627 Nursing Supplies 319953 13 347956 347956 Room Care 623000 7835795 7835795 Medicaid 623000 3437276 3437276 Cottage Rentals 623000 2349221 2349221 Medicare 623000 1771277 1771277 15393569 30644 30644 Miscellaneous 623000 131150 131150 Barber/Beauty/Gift Shop 623000 98276 98276 229426 16001595 15653639 0 0 14545396 14545396 142430 142430 8674081 7959456 629081 85544 232455 209858 19186 3411 775536 700146 66224 9166 628088 570310 51234 6544 17442 17442 169699 169699 53988 53988 678731 678731 65703 65703 253074 253074 1510438 1510438 971833 971833 Food 1003273 1003273 Supplies 816514 724828 91686 Maintenance & Repairs 534267 534267 Therapy 513657 513657 1113510 989920 123590 32700115 31472019 1123431 104665 853398 752705 2225994 814967 16455 24100 2444478 2103849 321805 285712 48331659 18923090 29213077 29408569 23260594 7984795 58335801 41374697 1311084 1606058 7618741 7318106 3547484 3290561 12477309 12214725 X 37820547 21421739 7937945 7638233 100000 100000 45858492 29159972 58335801 41374697 -16698520 0 X X 0 1 X 1 0 X 434410 985260 478865 490692 347956 2737183 14334868 14689534 14435240 15226048 15393569 74079259 14769278 15674794 14914105 15716740 15741525 76816442 0 0 0 76816442 23383 3519080 2967420 1991363 30644 8531890 23383 3519080 2967420 1991363 30644 8531890 205025 248228 144229 114716 229426 941624 14997686 19442102 18025754 17822819 16001595 86289956 0.89020 0.86230 0.09890 0.12720 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 24959360 24749 24618 16502356 84342 8422029 24380738 333701 1995544 1550884 199739 24959360 28596406 369637 2931120 7287019 229406 24380738 27990135 892976 3507128 3566544 227289 28596406 32285791 352352 7208 4397420 257796 27990135 1.00000 0 0 1135037 1135037 36684951 12913234 23771717 10511671 6009856 4501815 29408569 US Government Bonds 965942 F US Governmant Agencies 562478 F Corporate Bonds 478225 F Mutual Funds & Equities 5978150 F 7984795 Refundable Deposits 3290561 3290561 X 16001595 0 16001595 0 16001595 32700115 0 32700115 0 32700115 Part V, Line 4: The Home's endowment fund is used to 1) provide income to offset operating costs in order to provide affordable skilled nursing care to residents and 2) provide a source of income to pay for capital improvements to the Home's physical plant. Part X, Line 2: The evaluation of a tax position in accordance with this Interpretation 48 is a two-step process. The first step is recognition: The organization determines whether it is more likely than not that a tax position will be sustained upon examination, including resolution of any related appeals or litigation processes, based on the technical merits of the position. In evaluating whether a tax position has met the more-likely-than-not recognition threshold, the enterprise should presume that the position will be examined by the appropriate taxing authority that has full knowledge of all relevant information. The second step is measurement: A tax position that meets the more-likely-than-not recognition threshold is measured to determine the amount of benefit to recognize in the financial statements. The tax position is measured at the largest amount of benefit that is greater than 50 percent likely of being realized upon ultimate settlement. Implementation of ASC Section 740 began with Good Samaritan's year ended September 30, 2009. The implementation of ASC Section 740 has not had any material effect on the financial statements of the Good Samaritan Home of Quincy. 0 Good Samaritan Home Foundation 2130 Harrison St Quincy IL 62301 461945910 501(c)(3) 14545396 FMV-Actively Traded Markets Investment securities Grant was made to establish an endowment in the Good Samritan Home Foundation, dedicated to supporting the Good Samaritan Home of Quincy 1 X X X 0 0 0 0 0 0 0 0 0 Michael Duffy Adminstrator 142430 0 0 0 0 0 5583 0 9135 0 157148 0 0 0 Part I, Line 3 The Board's Executive Committee serves as the compensation committee and reviews the compensation of the Administrator annually. Salary comparisons are made to other comparable nursing homes in the area when determining the salary. A City of Quincy Adams County Illinois 376000378 2009-12-01 100 To finance a portion of the Home's construction project 0 0 0 A 300635 2011 0 0 1 1 A 0 0 0 0 0 0 0 A 1 0 0 0 0 0 A 0 During the year ended September 30, 2015, Good Samaritan Home transferred a portion of its endowment to fund the Good Samaritan Home Foundation, an emtity dedicated to the support of the Good Samaritan Home of Quincy. Assets transferred included cash and investment securities. 2015-02-02 14545396 Fair value of the assets transferred as quoted on active markets 461945910 Good Samaritan Home Foundatiion 2130 Harrison St Quincy IL 62301 501(c)(3) 0 0 0 0 Form 990, Part VI, Section A, line 2 One board member is a partner in the law firm that represents the Organization, a second board member is a principal in a painting firm that was hired by the general contractor overseeing the construction and renovation project undertaken by the Organization. Form 990, Part VI, Section B, line 11 Federal Form 990 and the audited financial statements are presented to the Board of Directors for their review. The auditor is available to members of the finance committee for questions before the 990 is filed. Form 990, Part VI, Section B, line 12c Officers and directors are required to disclose any potential conflicts of interest to the CEO and to abstain from voting on any such item. Form 990, Part VI, Section B, line 15 The Executive Committee of the Organization annually reviews the performance of the Administrator and Assistant Administrator. Compensation is determined by reviewing the performance assessment and comparable salaries of like individuals in area and regional nursing homes of similar size. The salary package is approved by the Executive Committee and documented in the records of the Organization. Form 990, Part VI, Section C, line 18 Federal Form 990 is available online at www.guidestar.org Form 990, Part VI, Section C, line 19 Information regarding the tax-exempt status of the Organization is available upon request. Federal Form 990 is available upon request or online at www.guidestar.org Form 990, Part XI, Line 2C The Finance Commitee of the Board of Directors is responsible for oversight of the audit