2020-07-15T18:42:22-05:00 2019-06-30 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-07-01 270705237 KODA LIVING COMMUNITY KODA 7633472200 6499 UNIVERSITY AVENUE NE NO 300 MINNEAPOLIS MN 55432 KEVIN RYMANOWSKI CFO 7633472200 2020-07-13 1 CHRISTOPHER STEINHOFF P01587351 6123764500 2020-07-12 67.137.57.251 2020-07-13 08:45:56 CD P 0F8E070079B3822AD2CB83B8DB3E34CBC54CDB6E 8DF0D5A1DBF8E44DE93554FEEDBEEE801640FE4C 2018 2021-01-29 14:40:06Z X DAVID VANDERGON 6499 UNIVERSITY AVENUE NE NO 300 MINNEAPOLIS MN 55432 11831584 0 X WWW.KODALIVINGCOMMUNITY.ORG X 2009 MN BY WORKING TOGETHER, OUR MISSION IS TO INTEGRATE A CONTINUUM OF SERVICES WITH GENUINE COMPASSIONATE CARE FOR OUR COMMUNITIES. 9 7 268 35 0 0 3218729 0 10969942 11823775 -3210910 -20635 4720380 6538 15698141 11809678 33757 54716 0 0 6874033 7121522 0 0 0 5255902 4265584 12163692 11441822 3534449 367856 16070717 15701742 15935892 15130971 134825 570771 BY WORKING TOGETHER, OUR MISSION IS TO INTEGRATE A CONTINUUM OF SERVICES WITH GENUINE COMPASSIONATE CARE FOR OUR COMMUNITIES. 0 0 8377228 54716 10109044 KODA LIVING COMMUNITY OPERATES A 79 BED SKILLED NURSING FACILITY IN OWATONNA, MN CALLED KODA LIVING COMMUNITY.THE FACILITIES COMBINED HAD 97% OCCUPANCY AT THE END OF THE FISCAL YEAR 6/30/2019 AND SERVED 321 INDIVIDUALS. 1420975 0 1714731 OPERATION OF PARK PLACE, IS A 50 UNIT CONGREGATE CARE AND ASSISTED LIVING FACILITY IN OWATONNA, MINNESOTA.THE FACILITY HAD AN AVERAGE OCCUPANCY OF 93% AND SERVED 67 INDIVIDUALS DURING THE FISCAL YEAR ENDING 6/30/2019. 9798203 1 0 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 47 0 1 268 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 7 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X KEVIN RYMANOWSKI CFO 7636896107 6499 UNIVERSITY AVENUE NE SUITE 300 MINNEAPOLIS MN 55432 JERRY CARLEY CEO OF BHS 1.00 39.00 X 0 493059 136483 KEVIN RYMANOWSKI SECRETARY/TREASURER 1.00 39.00 X X 0 360445 87709 CHRIS BOLDT DIRECTOR 1.00 39.00 X 0 208995 58226 DAVID VANDERGON CEO / ADMINISTRATOR 40.00 0.00 X X 0 108394 31732 CAROL ZETAH CHAIR 1.00 0.00 X X 0 0 0 TOM SHEA VICE CHAIR 1.00 0.00 X X 0 0 0 SANDRA MILLER DIRECTOR 1.00 0.00 X 0 0 0 LOIS NELSON DIRECTOR 1.00 0.00 X 0 0 0 JIM OBERG DIRECTOR 1.00 39.00 X 0 0 0 RICHARD SLIETER DIRECTOR 1.00 0.00 X 0 0 0 BILL THOMPSON DIRECTOR 1.00 0.00 X 0 0 0 0 1170893 314150 5 0 1 0 BENEDICTINE HEALTH SYSTEM 6499 UNIVERSITY AVENUE NE SUITE300 MINNEAPOLIS MN 55432 MANAGEMENT SERVICES 690251 RTG MEDICAL 1005 E 23RD STREET FREMONT NE 68025 TEMP NURSING STAFFING 122155 2 SKILLED NURSING 623000 11796439 11796439 MEAL REVENUE 623000 16061 16061 PHONE, CABEL, INTERNET REVENUE 623000 11275 11275 11823775 1271 1271 21906 -21906 -21906 -21906 MISCELLANEOUS INCOME 900099 6538 6538 6538 11809678 11823775 0 -14097 47584 47584 7132 7132 5752149 5223205 528944 64669 58722 5947 886523 805002 81521 418181 379727 38454 690251 690251 20771 20771 18225 18225 482993 441975 41018 32763 32763 57198 11226 45972 471238 465401 5837 43639 29829 13810 2863 623 2240 321393 321393 537123 537123 121696 121696 MEDICAL SUPPLY EXPENSE 446761 446761 FOOD 332217 332217 LEASE EXPENSE 317152 296982 20170 SURCHARGE 222385 222385 146916 16457 130459 11441822 9798203 1643619 0 116180 435149 1495779 1411198 94434 86459 13757989 1307474 12917813 12450515 893869 800000 552642 518421 16070717 15701742 908251 753827 14133856 13619589 39233 19991 385552 293662 469000 374107 0 69795 15935892 15130971 X 95021 462877 39804 107894 134825 570771 16070717 15701742 X 367856 68090 X X 0 1 X 1 0 X 9449 82251 40372 3218729 0 3350801 7907285 8805472 10948086 10969942 11823775 50454560 7916734 8887723 10988458 14188671 11823775 53805361 0 0 0 53805361 133 231 1083 1603 1271 4321 133 231 1083 1603 1271 4321 4720380 6538 4726918 7916867 8887954 10989541 18910654 11831584 58536600 0.91920 0.91590 0.00010 0.00010 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: INCOME FROM FORGIVEN DEBT - 2017 AMOUNT: $ 4,720,380. MISCELLANEOUS INCOME - 2018 AMOUNT: $ 6,538. 0 1 X 710000 710000 11447123 490228 10956895 708000 106200 601800 892866 711046 181820 12450515 DUE TO AFFILIATES 69795 69795 X PART IV, LINE 2B: CARETAKER OF RESIDENT TRUST FUNDS AND SECURITY DEPOSITS IN A SEPARATE ACCOUNT. PART X, LINE 2: INCOME TAXES KODA LIVING COMMUNITY HAS BEEN GRANTED EXEMPT STATUS RELATIVE TO FEDERAL AND MINNESOTA CORPORATE INCOME TAXES UNDER SECTION 501 (C) (3) OF THE INTERNAL REVENUE CODE. KODA LIVING COMMUNITY FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. KODA LIVING COMMUNITY INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. KODA LIVING COMMUNITY IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. KODA LIVING COMMUNITY FILES ALL APPLICABLE RETURNS FOR ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OF EXCISE OR OTHER TAXES. THE TAX RETURNS FOR THE FISCAL YEARS 2012 THROUGH 2014 REMAIN OPEN TO EXAMINATION BY FEDERAL, LOCAL AND STATE AUTHORITIES. 1 BENEDICTINE HEALTH SYSTEM 6499 UNIVERSITY AVENUE NE SUITE 300 300 MINNEAPOLIS MN 55432 411531892 501(C)(3) 27164 N/A N/A CAPITAL FUND/SUPPORT BENEDICTINE HEALTH SYSTEM FOUNDATION 503 E THIRD ST STE 400 DULUTH MN 55805 411513014 501(C)(3) 20420 N/A N/A GENERAL OPERATING SUPPORT 2 SCHOLARSHIPS 7 7132 0 N/A N/A PART I, LINE 2: KODA LIVING COMMUNITY OFFERS EMPLOYEES TUITION PAYMENT THROUGH AN EDUCATIONAL ASSISTANCE PLAN THAT COMPLIES WITH SECTION 127 OF THE INTERNAL REVENUE CODE AND THE MINNESOTA NURSING FACILITY EMPLOYEE SCHOLARSHIP FUND (BULLETIN #01-62-05). TO PROVIDE PAYMENT FOR EXPENSES INCURRED BY ELIGIBLE SENIOR CARE EMPLOYEES FOR THE SUCCESSFUL COMPLETION OF APPROVED COURSES THAT LEAD TO CAREER ADVANCEMENT. TRANSFERS BETWEEN RELATED ORGANIZATIONS ARE ACCOUNTED FOR IN INTERNAL FINANCIAL STATEMENTS, OF WHICH ALL ARE UNDER COMMON CONTROL. 0 0 0 0 0 0 0 0 0 JERRY CARLEY CEO OF BHS 0 450000 0 0 0 43059 0 99000 0 37483 0 629542 0 0 KEVIN RYMANOWSKI SECRETARY/TREASURER 0 295734 0 36609 0 28102 0 61741 0 25968 0 448154 0 0 CHRIS BOLDT DIRECTOR 0 192256 0 13138 0 3601 0 36826 0 21400 0 267221 0 0 PART III - ADDITIONAL INFORMATION BENEDICTINE HEALTH SYSTEM'S (EIN: 41-1531892) CEO AND CFO, JERRY CARLEY AND KEVIN RYMANOWSKI, SHARE THEIR TIME BETWEEN THE REPORTING ORGANIZATION AND RELATED ORGANIZATIONS. THE CEO IS COMPENSATED BY BENEDICTINE HEALTH SYSTEM, A RELATED ORGANIZATION. THIS ORGANIZATION USES THE FOLLOWING TO SET CEO/ ADMINISTRATIVE COMPENSATIONS: 1. COMPENSATION COMMITTEE 2. INDEPENDENT COMPENSATION CONSULTANT 3. WRITTEN EMPLOYMENT CONTRACT 4. COMPENSATION SURVEY OR STUDY 5. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. A STEELE COUNTY MN 416005901 2017-12-28 9581263 REFUNDING 0 0 0 B CITY OF OWATONNA MN 416005444 2017-12-28 4809545 REFUNDING BOND 0 0 0 A 469265 9581263 9581263 116669 2017 0 1 1 1 B 235559 4809545 2017 0 1 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 1 0 0 0 0 1 A 1 B 1 OFFICER COMPENSATION BENEDICTINE HEALTH SYSTEM'S (EIN: 41-1531892) CEO AND CFO, JERRY CARLEY AND KEVIN RYMANOWSKI, SHARE THEIR TIME BETWEEN THE REPORTING ORGANIZATION AND RELATED ORGANIZATIONS. SEE SCHEDULE R FOR INFORMATION ON RELATED ORGANIZATIONS. FORM 990, PART VI, SECTION A, LINE 3 THE CORPORATION CONTRACTS WITH BENEDICTINE HEALTH SYSTEM, A RELATED ORGANIZATION, OR MANAGEMENT SERVICES. BENEDICTINE HEALTH SYSTEM EMPLOYED THE ADMINISTRATOR/CEO OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 6 BENEDICTINE HEALTH SYSTEM, A MINNESOTA NONPROFIT CORPORATION, IS THE SOLE MEMBER OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A EACH DIRECTOR OF THE CORPORATION IS APPOINTED BY BENEDICTINE HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS OF THIS CORPORATION ARE RESERVED TO THE MEMBERS WHICH MAY ONLY ACT ON UNANIMOUS APPROVAL OF THE MEMBERS. GOVERNING INSTRUMENTS. MERGER, CONSOLIDATION, LIQUIDATION, DISOLUTION. ISSUANCE AND TRANSFER OF MEMBERBERSHIP INTEREST. DISTRUIBTIONS. FORM 990, PART VI, SECTION B, LINE 11B AN ELECTRONIC COPY OF THE FORM 990 WAS DISTRIBUTED PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, INTERESTED PERSONS ARE REQUIRED TO DISCLOSE ANY RELATIONSHIPS THAT CONSTITUTE OR MIGHT LEAD TO A CONFLICT OF INTEREST BY COMPLETING THE CONFLICT OF INTEREST AND GIFT DISCLOSURE STATEMENT. THE BHS COMPLIANCE DEPARTMENT WILL DISTRIBUTE THE STATEMENTS AND COLLECT AND MAINTAIN THE COMPLETED STATEMENTS. THE BHS COMPLIANCE MANAGER WILL REVIEW THE STATEMENTS AND PROVIDE A SUMMARY OF THE IDENTIFIED CONFLICTS OF INTEREST TO THE BHS CHIEF COMPLIANCE OFFICER, WHO WILL ALERT THE BHS CEO AND THE CHAIR OF THE BHS BOARD OF DIRECTORS TO ANY ITEMS OF CONCERN. AN "INTERESTED PERSON" IS ANY PERSON IN A POSITION TO EXERCISE SUBSTANTIAL INFLUENCE OVER THE SYSTEM, INCLUDING BUT NOT LIMITED TO A BOARD MEMBER, BOARD COMMITTEE MEMBER, OR OFFICER OR DIRECTOR OF BHS OR A FACILITY (SUCH AS FACILITY CEO/ADMINISTRATORS AND BHS SENIOR LEADERS AND DIRECTORS). FOR INTERESTED PERSONS WHO ARE EMPLOYEES (OTHER THAN THE BHS CEO), FOLLOWING DISCLOSURE OF THE ACTUAL OR POTENTIAL CONFLICT OF INTEREST AND ALL MATERIAL FACTS,THE INTERESTED PERSON'S SUPERVISOR WILL DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. FOR THE BHS CEO AND BOARD AND COMMITTEE MEMBERS, FOLLOWING DISCLOSURE OF THE ACTUAL OR POTENTIAL CONFLICT OF INTEREST AND ALL MATERIAL FACTS, THE INTERESTED PERSON WILL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE REMAINING MEMBERS OF THE BOARD OR COMMITTEE DETERMINE IF A CONFLICT OF INTEREST EXISTS. THE INTERESTED PERSON MAY PARTICIPATE IN DELIBERATION REGARDING THE TRANSACTION IF THE APPLICABLE SUPERVISOR, BOARD, OR COMMITTEE DETERMINES A CONFLICT OF INTEREST DOES NOT EXIST. AN INTERESTED PERSON WHO HAS BEEN DETERMINED TO HAVE A CONFLICT OF INTEREST MAY NOT PARTICIPATE IN THE DELIBERATION OR DECISION REGARDING THE TRANSACTION OR ARRANGEMENT INVOLVING THE CONFLICT OF INTEREST AND MAY NOT BE PRESENT DURING SUCH DELIBERATION OR DECISION MAKING. THE INTERESTED PERSON MAY BE ALLOWED TO MAKE A PRESENTATION TO THE SUPERVISOR, BOARD, OR COMMITTEE CONSIDERING THE TRANSACTION OR ARRANGEMENT AS TO WHICH THE CONFLICT OF INTERESTS REFERS PRIOR TO THE DELIBERATION AND DECISION. FORM 990, PART VI, SECTION C, LINE 19 NOT AVAILABLE TO PUBLIC FORM 990, PART XI, LINE 9: CHANGE IN TEMPORARILY RESTRICTED NET ASSETS 68,090. FORM 990, PART XII, LINE 2C: THE BENEDICTINE HEALTH SYSTEM AUDIT/ FINANCE COMMITTEE OVERSEES THE SELECTION OF THE INDEPENDENT AUDITOR AND OVERSEES THE ANNUAL CONSOLIDATED AUDIT OF BENEDICTINE HEALTH SYSTEM AND AFFILIATES WHICH INCLUDES THE ORGANIZATION. PARK PLACE SENIOR LIVING LLC 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 384050146 ASSISTED LIVING MN 1715681 0 KODA LIVING COMMUNITY BENEDICTINE HEALTH SYSTEM 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411531892 SUPPORTING ORGANIZATION MN 501(C)(3) LINE 10 N/A 0 BENEDICTINE HEALTH SYSTEM FOUNDATION 503 E THIRD STREET DULUTH MN 55805 411513014 FUND DEVELOPMENT MN 501(C)(3) LINE 10 BHS 0 BENEDICTINE CARE CENTERS 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411907571 NURSING HOMES MN 501(C)(3) LINE 10 BHS 0 BENEDICTINE HEALTH CENTER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411381401 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 CITY OF LAKES CARE CENTER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411985663 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 BENEDICTINE LIVING COMMUNITIES 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411639687 NURSING HOMES MN 501(C)(3) LINE 10 BHS 0 BLC OF ST PETER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 861113231 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 STEEPLE POINTE SENIOR LIVING COMMUNITY 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411852273 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 BRIDGES CARE CENTER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 262620983 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 ELLENDALE EVERGREEN PLACE 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411796445 ASSISTED LIVING MN 501(C)(3) LINE 10 BHS 0 LIVING COMMUNITY OF ST JOSEPH 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 412011661 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 MADONNA MEADOWS OF ROCHESTER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 470855891 ASSISTED LIVING MN 501(C)(3) LINE 10 BHS 0 MADONNA TOWERS OF ROCHESTER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411809914 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 ROSEWOOD COURT 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 412011389 ASSISTED LIVING MN 501(C)(3) LINE 10 BHS 0 SAINT ANNE OF WINONA 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 410850791 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 ARROWHEAD SENIOR LIVING COMMUNITIES 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411978619 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 ST GERTRUDE'S HEALTH CENTER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411848720 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 BLC OF BISMARCK 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 264376543 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 NAZARETH LIVING CENTER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 431450394 NURSING FACILITY MN 501(C)(3) LINE 10 N/A 0 BLC OF NEW LONDON 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 274218436 NURSING HOME WI 501(C)(3) LINE 10 BHS 0 BLC OF WINSTED 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 274219293 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 BSLC OF ST PETER 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 272716531 ASSISTED LIVING MN 501(C)(3) LINE 10 BHS 0 BLC OF RED WING 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 454929398 NURSING HOME MO 501(C)(3) LINE 10 BHS 0 BLC OF WAHPETON 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 454274091 ASSISTED LIVING MN 501(C)(3) LINE 10 BHS 0 CATHOLIC RESIDENTIAL SERVICES 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 390982340 NURSING HOME WI 501(C)(3) LINE 10 BHS 0 REGINA SENIOR LIVING 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 463700475 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 BLC OF BYRON 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 471538777 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 CERENITY SENIOR CARE 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411983267 NURSING HOME MN 501(C)(3) LINE 10 N/A 0 CERENITY CARE CENTER - WHITE BEAR LAKE 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411983267 NURSING HOME MN 501(C)(3) LINE 10 N/A 0 VILLA ST BENEDICT 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 364343235 NURSING HOME MN 501(C)(3) LINE 10 N/A 0 VILLA ST VINCENT 6499 UNIVERSITY AVE NE SUITE 300 MINNEAPOLIS MN 55432 411352227 NURSING HOME MN 501(C)(3) LINE 10 BHS 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0