2024-08-15T16:09:38-05:00 2023-09-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-10-01 410944721 PINE HAVEN INC PINE 5073568304 210 3RD STREET NW PINE ISLAND MN 55963 SARA BLAIR INTERIM ADMINISTRATOR 5073568304 2024-08-15 1 1 MICHAEL J PETERSON CPA P01833529 2187224705 2024-08-15 2022 2024-08-08 14:25:15Z PINE HAVEN CARE CENTER SARA BLAIR 210 3RD STREET NW PINE ISLAND MN 55963 7835656 0 X WWW.PINEHAVENCOMMUNITY.ORG X 1964 MN PROVIDE QUALITY, AFFORDABLE SERVICES FOR OLDER ADULTS AND FAMILIES IN OUR COMMUNITY. 7 7 182 50 0 0 498556 603126 7113291 7217637 452 13 142899 14880 7755198 7835656 0 0 0 0 3239623 5380189 0 0 0 3074706 3522055 6314329 8902244 1440869 -1066588 8819164 7098089 6697983 9072041 2121181 -1973952 PINE HAVEN COMMUNITY PROVIDES A CONTINUUM OF CARE THROUGH THE BELIEF THAT EVERY PERSON IS UNIQUE. 0 0 6859257 7217637 PINE HAVEN, INC. (PINE HAVEN COMMUNITY) IS RESPONSIBLE FOR PROVIDING NURSING CARE AND HOUSING FOR THE ELDERLY AND DISABLED, OPERATING A 70 BED LICENSED NURSING FACILITY LOCATED IN PINE ISLAND, MINNESOTA. PROVIDE MANAGEMENT SERVICES TO EVERGREEN PLACE, AN ASSISTED LIVING HOUSING FACILITY OWNED BY THE CITY OF PINE ISLAND, MINNESOTA. DURING THE YEAR, APPROXIMATELY 17,000 INPATIENT DAYS WERE PROVIDED. 6859257 1 1 0 0 0 0 0 0 1 0 1 0 0 0 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 1 1 0 0 0 1 8 0 182 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 0 1 1 1 0 0 0 0 1 1 1 1 1 1 0 0 X JESSICA RIVERA 5073568304 210 3RD STREET NW PINE ISLAND MN 55963 RANDY HOFFARTH CHAIR 1.00 1.00 X X 0 0 0 JOANNE JUDGE-DIETZ VICE CHAIR 1.00 X X 0 0 0 GLEN HEMANN TREASURER 1.00 1.00 X X 0 0 0 TERESA BUCK SECRETARY 1.00 X X 0 0 0 RON FLEMKE DIRECTOR 1.00 X 0 0 0 JERRY VETTEL DIRECTOR 1.00 1.00 X 0 0 0 WAYNE WELLIK DIRECTOR 1.00 1.00 X 0 0 0 ERIC EVERSON CEO/ADMINISTRATOR 40.00 1.00 X 0 0 0 JESSICA RIVERA FINANCE DIRECTOR 40.00 X 68003 0 45 68003 0 45 0 0 0 0 PATHWAY HEALTH SERVICES 11240 STILLWATER BLVD LAKE ELMO MN 55042 MANAGEMENT SERVICES 671665 KOMASSO SUMO 1201 HIGHWAY DR ALBANY MN 56307 POOL AGENCY STAFF 103176 2 603078 48 603126 RESIDENT SERVICES 623000 6744941 6744941 APARTMENT REVENUE 623000 410578 410578 MANAGEMENT SERVICES 623000 62118 62118 7217637 13 13 14880 14880 14880 7835656 7217637 0 14893 X 360092 360092 4124106 3923811 200295 581807 541968 39839 314184 292648 21536 2055097 1058267 996830 88497 88497 43410 43410 58842 58842 214383 206344 8039 76 76 NURSING SUPPLIES 459815 459815 FOOD EXPENSE 308766 308766 LICENSES AND FEES 40827 40827 BAD DEBT 36889 36889 215453 30749 184704 8902244 6859257 2042987 0 -2694 -2693 1959416 1029913 1346935 416911 108645 247096 11202888 5799542 5403346 5403346 3516 3516 8819164 7098089 946604 3414276 18468 22556 5625415 5625415 97702 0 9794 9794 6697983 9072041 X 2121181 -1973952 2121181 -1973952 8819164 7098089 X -1066588 -3028545 X 0 0 0 X 6495 751511 699725 498556 603126 2559413 6981446 7607692 8160383 7113291 7217637 37080449 5553 32163 217054 874502 14880 1144152 6993494 8391366 9077162 8486349 7835643 40784014 0 0 0 40784014 803 1599 2297 452 13 5164 803 1599 2297 452 13 5164 6994297 8392965 9079459 8486801 7835656 40789178 0.99990 0.99980 0.00010 0.00020 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 116790 116790 9472044 4452257 5019787 1566029 1299260 266769 48025 48025 0 5403346 DUE TO PINE HAVEN FOUNDATION 9794 9794 PART IV, LINE 2B: THE ORGANIZATION IS THE TRUSTEE OF VARIOUS RESIDENT FUNDS AND HAS FIDUCIARY RESPONSIBILITY FOR THE ADMINISTRATION AND DISTRIBUTION OF THESE FUNDS FOR THE RESIDENTS. THESE FUNDS ARE ON DEPOSIT IN A SEPARATE BANK ACCOUNT. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION IS UNDER RECEIVERSHIP - FROM THE MN DEPARTMENT OF HEALTH. AS A PART OF THE PROCESS THEY HAVE ENGAGED PATHWAY HEALTH TO ASSIST WITH ADMINSTRATOR, MANAGEMENT AND FISCAL SERVICES. THIS INCLUDES ERIC EVERSON, DENNIS ANDERSON AND SARA BLAIR. THE TOTAL PAID IS REPORTED ON PART VII, SECTION B. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION IS CURRENTLY IN A RECEIVERSHIP AND THE BOARD OF DIRECTORS ARE NO LONGER INVOLVED WITH DECISION MAKING. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION DOES NOT HAVE COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION B, LINE 11B MANAGEMENT OF THE ORGANIZATION REVIEWS FORM 990 PRIOR TO SUBMISSION TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S CONFLICT OF INTEREST POLICY APPLIES TO ANY DIRECTOR, PRINCIPAL OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST. IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICT OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE GOVERNING BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF THE CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT EXISTS. UPON DETERMINATION OF THE CONFLICT OF INTEREST, THE INTERESTED PERSON MUST LEAVE THE MEETING DURING THE DISCUSSION AND VOTE UPON THE TRANSACTION AT HAND. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS REVIEWS AND DETERMINES COMPENSATION FOR THE ADMINISTRATOR DURING THE ADMINISTRATOR'S ANNUAL PERFORMANCE APPRAISAL. THE BENCHMARK WHICH THE BOARD COMPARES THE SALARY FOR THE ADMINISTRATOR IS PROVIDED BY THE SALARY SURVEY COMPLETED BY LEADINGAGE MINNESOTA. THIS IS THE AGING SERVICES TRADE ORGANIZATION WHICH THE ORGANIZATION BELONGS TO. DURING THIS RECEIVERSHIP, THE BOARD OF DIRECTORS ARE NOT INVOLVED IN THE COMPENSATION DECISION FOR THE ADMINISTRATOR AS THE STATE OF MN HAS APPOINTED A MANAGING AGENT THAT HAS EMPLOYED THEIR OWN ADMINISTRATOR. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER HEALTH CARE PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 1,047,767. MANAGEMENT AND GENERAL EXPENSES 996,830. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,044,597. NURSING SERVICES: PROGRAM SERVICE EXPENSES 10,500. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,500. FORM 990, PART XI, LINE 9: PRIOR PERIOD ADJUSTMENT -3,028,545. PINE HAVEN FOUNDATION INC 210 3RD STREET NW PINE ISLAND MN 55963 411580669 SUPPORT PINE HAVEN, INC MN 501(C)(3) LINE 12A, I PINE HAVEN INC 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0