2014-02-01T09:20:29-06:00 2013-09-30 208896204 Dennis G Koch CPA PO Box 1007 Quincy IL 623061007 990 2012-10-01 370724112 Good Samaritan Home of Quincy GOOD 2172238717 2130 Harrison Street Quincy IL 62301 Michael Duffy 2172228471 2013-12-19 1 Dennis G Koch P01210686 2172248484 2014-02-01 X 2012 2015-11-30 17:44:51Z Michael Duffy 3831 Newcastle Dr Quincy IL 62301 18025754 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. 21 21 454 0 0 0 985260 478865 14689533 14435240 3519081 2967420 248228 144229 19442102 18025754 0 0 0 0 10724222 9841505 0 0 79181 6951875 6587632 17676097 16429137 1766005 1596617 59920276 57992498 16407327 12882932 43512949 45109566 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 15002765 17546889 Nursing, therapy, home care and apartments for the elderly. 15002765 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 5 0 1 454 1 0 0 0 0 0 0 0 0 X 21 21 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 Robert Johnson 10.00 X X 0 0 0 Gena Awerkamp 5.00 X X 0 0 0 William Winn 5.00 X X 0 0 0 Laura Ehrhart 5.00 X X 0 0 0 Carla Derrick 5.00 X X 0 0 0 Daron Duke 5.00 X X 0 0 0 Mike Bickhaus 5.00 X 0 0 0 John Letts 5.00 X 0 0 0 Paula Reinhardt 5.00 X 0 0 0 Billie Menke 5.00 X 0 0 0 Ray Scheiter 5.00 X 0 0 0 Dean Hunziker 5.00 X 0 0 0 Charles Scholz 5.00 X 0 0 0 Jerry Jackson 5.00 X 0 0 0 Larry Shepherd 5.00 X 0 0 0 Richard Walz 5.00 X 0 0 0 Michael Oberdahlhoff 5.00 X 0 0 0 Janet Schneeberger 5.00 X 0 0 0 John Heidbreder 5.00 X 0 0 0 Robert Young 5.00 X 0 0 0 Steve Wavering 5.00 X 0 0 0 Michael Duffy 45.00 X 137744 0 15608 137744 0 15608 2 0 1 0 Maas Construction 3615 At Anthony Rd Quincy IL 62305 Construction Services 4421347 Kohl Wholesale 130 Jersey St Quincy IL 62301 Quincy IL 62301 Cafeteria Food 865720 First Choice Physical Therapy 5 W State 8th Plaza Quincy IL 62305 Physical Therapy 601529 CPI Qualified Plan Consultants PO Box 167 Great Bend KS 67530 Quincy IL 62305 Thrid Party Administration 398370 Wells Fargo Advisors 510 Maine St 9th Fl Quincy IL 62301 Investment Services 257796 14 478865 478865 Room Care 623000 7961895 7961895 Medicaid 623000 2713185 2713185 Cottage Rentals 623000 2114543 2114543 Medicare 623000 1645617 1645617 14435240 707193 707193 2260227 0 2260227 2260227 2260227 Barber/Beauty/Gift Shop 623000 95232 95232 Miscellaneous 623000 48997 48997 144229 18025754 17546889 0 0 8221830 7404589 754566 62675 267251 240687 24059 2505 759828 684302 66320 9206 592596 532548 55253 4795 42421 42421 27679 27679 212006 212006 2985 2985 531697 531697 311148 311148 1393606 1393606 510742 510742 Food 892025 892025 Supplies 795778 719282 76496 Therapy 486219 486219 Licensing 455898 455898 925428 840022 85406 16429137 15002765 1347191 79181 908335 917403 2271476 1279024 268756 123881 2630874 2101815 389428 441248 46682781 16777940 27237550 29904841 26213857 23224286 59920276 57992498 2459037 1769196 11471834 7915374 2476456 3198362 16407327 12882932 X 42959597 44691969 453352 317597 100000 100000 43512949 45109566 59920276 57992498 1596617 0 X X 0 1 X 1 0 X 844034 1119527 434410 985260 478865 3862096 12965698 13164178 14334868 14689534 14435240 69589518 13809732 14283705 14769278 15674794 14914105 73451614 0 0 0 73451614 1394822 2615852 23383 3519080 2967420 10520557 1394822 2615852 23383 3519080 2967420 10520557 188892 206184 205025 248228 144229 992558 15393446 17105741 14997686 19442102 18025754 84964729 0.86450 0.94100 0.12380 0.04630 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 28596406 369637 2931120 7287019 229406 24380738 27990135 892976 3507128 3566544 227289 28596406 32285791 352352 7208 4397420 257796 27990135 26692748 3286598 2535488 229043 32285791 27366419 806953 1222110 2465598 237136 26692748 0 0 1135037 1135037 35446994 11327967 24119027 10100750 5449973 4650777 29904841 Refundable Deposits 3198362 3198362 X 18025754 0 18025754 0 18025754 16429137 0 16429137 0 16429137 Description of Intended Use of Endowment Funds: 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. Description of Uncertain Tax Positions Under FIN 48: 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. X X X 0 0 0 0 0 0 0 0 0 Michael Duffy 137744 0 0 0 0 0 5490 0 10118 0 153352 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 2011 0 0 1 1 A 0 0 0 0 0 0 0 A 1 0 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