2017-10-04T07:15:04-05:00 2016-12-31 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2016-01-01 800015864 Legacy Senior Services LEGA 7635375700 14416 Spring Lake Road Minnetonka MN 55345 Eric Lunde President 7635375700 2017-09-26 1 Deb Nelson CPA P01264758 6122536500 2017-09-26 199.116.173.125 2017-09-26 11:43:12 CD P 6C9B1A35775087DBDB8A6D25ECA509C7F6C27838 29C631FCBD7EE613918B5A80576D837C30D7D376 2016 2021-01-29 14:40:06Z Waukesha Springs Health & Rehab Center Eric Lunde 14416 Spring Lake Road Minnetonka MN 55345 42596298 0 X N/A X 2001 MN To operate skilled nursing facilities and senior housing communities. 4 4 1260 430 114935 22718 30937 31419 44454506 42520892 -40230 42233 191935 -651 44637148 42593893 6991 14804 0 0 25840441 25384028 10364 0 0 19533060 20004687 45390856 45403519 -753708 -2809626 18889540 18391646 12825120 15136852 6064420 3254794 X Legacy Senior Services' mission is to create communities of dignity, passion, and respect for adults and to partner with other not for profit organizations across the country. Through its efforts, Legacy Senior Services seeks to provide broad continuums of care to promote health, mind, and spirit of those we serve. 0 0 38730612 14804 42520892 Legacy Senior Services is a Minnesota corporation that operates a 150 bed skilled nursing facility in Waukesha, Wisconsin, called Waukesha Springs Health & Rehabilitation Center. Waukesha Springs Health & Rehabilitation Center had an average daily census of 116 residents during 2016. Legacy Senior Services is organized to own and operate facilities with the intent of housing elderly and other vulnerable persons and meeting their healthcare, residential, physical and social needs. Legacy Senior Services is the sole member of six other limited liability companies which operate as skilled nursing, assisted living, and/or independent living facilities as follows: -LSS of Madison, LLC, a 90 bed skilled nursing facility located in Madison, Wisconsin. LSS of Madison, LLC had an average daily census of 72 during 2016.-LSS of Frazee, LLC, a 74 bed skilled nursing facility, a 19 unit assisted living facility, and an 8 unit independent living facility located in Frazee, Minnesota and a 15 unit assisted living facility located in Vergas, Minnesota. LSS of Frazee, LLC had an average daily census of 96 during 2016.-LSS of Marycrest, LLC, a 138 unit assisted living facility located in Denver, Colorado. LSS of Marycrest, LLC had an average daily census of 133 during 2016.-LSS of Sheboygan, LLC, a 121 bed skilled nursing facility located in Sheboygan, Wisconsin. LSS of Sheboygan, LLC had an average daily census of 101 during 2016.-LSS of Traverse, LLC, a 49 bed skilled nursing facility and a 20 unit independent living facility located in Wheaton, Minnesota. LSS of Traverse, LLC had an average daily census of 43 during 2016.-LSS of Wadena, LLC, a 75 bed skilled nursing facility and a 32 unit independent living facility located in Wadena, Minnesota. LSS of Wadena, LLC had an average daily census of 76 during 2016.All of the skilled nursing facilities are Medicare and Medicaid certified. 38730612 1 1 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 125 0 1 1260 1 1 1 0 0 0 0 0 0 0 0 0 X 4 4 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 0 0 0 MN CO X Health Dimensions Group 7635375700 4400 Baker Road Ste 100 Minneapolis MN 55343 Eric Lunde President/Treasurer 8.00 X X 11000 0 0 Roger Green Secretary 1.00 X X 4800 0 0 Robert Beck Director 1.00 X 4800 0 0 Joel Jensen Director 2.00 X 4800 0 0 Megan Simpson Administrator - LSS of Madison 40.00 X 0 0 0 Debra Pitsch Administrator - LSS of Madison 40.00 X 0 0 0 Ben Prince Administrator - LSS of Frazee 40.00 X 0 0 0 Jonathan Stone Administrator - LSS of Frazee 40.00 X 0 0 0 Mike Anderson Administrator - LSS of Wadena 40.00 X 0 0 0 Linda Sebenaler Administrator - LSS of Wadena 40.00 X 0 0 0 Julie Callender Administrator - LSS of Marycrest 40.00 X 0 0 0 Calista Taffe Administrator - LSS of Traverse 40.00 X 0 0 0 Dennis Videtic Administrator - LSS of Sheboygan 40.00 X 0 0 0 Vicki GrantAdministrator Waukesha Springs Health 40.00 X 0 0 0 Darlene EinersonAdministrator Waukesha Springs Health 40.00 X 0 0 0 Maxine BergmanAdministrator Waukesha Springs Health 40.00 X 0 0 0 25400 0 0 0 0 0 0 Health Dimensions Consulting Inc 4400 Baker Road Minneapolis MN 55343 Mgmt fees, Admin. salaries, consulting 1918104 HDG-WI LLC 4400 Baker Road Minneapolis MN 55343 Management fees 655524 BSG Maintenance Inc PO Box 165 Newburg WI 53060 Laundry & Housekeeping Services 571055 Pro Rehab 200 Lewis Ave S 210 Watertown MN 55388 Therapy Services 542931 annLeo Inc 1905 Okoboji Avenue Milford IA 51351 Nursing contract labor 259782 11 31419 31419 Resident Service Revenue 623000 41995258 41995258 Miscellaneous Revenue 900099 525634 410699 114935 42520892 42233 42233 8340 2405 5935 5935 5935 Sale of Subsidiary 900099 -6586 -6586 -6586 42593893 42405957 114935 41582 14804 14804 25400 25400 20740345 18838071 1902274 51236 46480 4756 2826504 2564121 262383 1740543 1578969 161574 1655068 1655068 128220 128220 110796 110796 3434161 2946161 488000 145184 145184 1232257 970983 261274 483999 28851 455148 3515977 3425845 90132 18669 3259 15410 111776 18659 93117 437066 437066 928911 928911 734036 13788 720248 Medical Supplies 2907959 2907959 Food 1451638 1451638 MN DHS Surcharge/WI Pro 1285308 1285308 Bad Debt Expense 311885 311885 1111777 957854 153923 45403519 38730612 6672907 0 1017629 1186398 36957 36987 4201652 4289801 18942 18942 237702 143394 19603481 7360001 12599963 12243480 776695 472644 18889540 18391646 3154462 5316687 190440 190440 3176861 2900665 235307 230414 5972804 6223646 95246 275000 12825120 15136852 X 6064420 3254794 6064420 3254794 18889540 18391646 -2809626 0 X 0 1 X 1 0 X 905228 42518 86937 30937 31419 1097039 43891737 46429715 46606155 44321115 42405957 223654679 44796965 46472233 46693092 44352052 42437376 224751718 0 0 0 224751718 9393 5049 1660 2447 50573 69122 9393 5049 1660 2447 50573 69122 34191 38606 43264 31261 23718 171040 185000 -6586 178414 44840549 46515888 46738016 44570760 42505081 225170294 0.99810 0.99840 0.00030 0.00010 X Schedule A, Part III, Line 12, Explanation of Other Income: Gain/Loss on Sale of Subsidiary - 2015 Amount: $ 185,000. 2016 Amount: $ -6,586. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 1413200 1413200 14586307 4875658 9710649 3159114 2420729 738385 444860 63614 381246 12243480 X 42596298 0 42596298 -2405 -2405 42593893 45405924 2405 2405 45403519 0 45403519 Part IV, Line 2b: The organization acts as custodian for the funds of the residents of the nursing facilities and holds tenant security deposits for tenants of the assisted living facilities. Part X, Line 2: Legacy Senior Services 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). Each of the controlled limited liability corporations maintains exempt status under Legacy Senior Services' exemption since Legacy Senior Services is the sole member of each entity. The Organization is required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS annually. In addition, the Organization is subject to income tax on any net income that is derived from business activities that are unrelated to their exempt purpose. The Organization files an Exempt Organization Business Income Tax Return (Form 990T) with the IRS to report its unrelated business taxable income. The Organization believes that it has appropriate support for any tax positions taken affecting filing requirements, and, as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Organization 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. The Organization's federal Form 990T filings are no longer subject to federal tax examinations by tax authorities for years before 2013. Part XI, Line 4b - Other Adjustments: Rental expenses reported in expenses on financial statements -2,405. Part XII, Line 2d - Other Adjustments: Rental expenses reported in expenses on financial statements 2,405. 1 Tuition Reimbursement 28 14804 Part I, Line 2: The organization pays tuition for employees continuing their education. Guidelines from Minnesota Medicaid are followed. The funds are either paid directly to the school or to the employee. The employee must provide proof of cost from the school. A City of Frazee MN 416005174 2007-08-01 4850000 Health care facility acquisition in Frazee, MN 0 0 0 A 1947543 4882400 133384 4749016 2008 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 1 0 0 0 0 A 0 Date Rebate Computation Performed Issuer Name: City of Frazee, MN Date the Rebate Computation was Performed: 09/11/2012 Schedule K Supplental Information The amount reported as bonds retired for the privately placed tax-exempt revenue notes is the original issue price less the outstanding principal balance of the underlying bank loan as of the end of the Schedule K reporting period. Schedule K, Part II, Lines 3 and 10: These amounts include interest earned during the construction period. Schedule K, Part III, Line 9: The organization does not have a formal board adopted policy, but the organization does ensure post-issuance compliance through their management practices and procedures. Form 990, Part VI, Section A, line 3 Legacy Senior Services has a management agreement with Health Dimensions Consulting, Inc. (dba Health Dimensions Group) and HDG-WI, LLC to provide management services to Legacy Senior Services and the following wholly owned single-member LLC's: LSS of Madison, LLC; LSS of Sheboygan, LLC; LSS of Frazee, LLC; LSS of Traverse, LLC, LSS of Marycrest, LLC, and LSS of Wadena, LLC. The following individuals provided services as administrators of the facilities that included day to day management of functional operations, management of facility personnel, and execution of policies governing facility operations. Megan Simpson LSS of Madison, LLC $48,491 Debra Pitsch LSS of Madison, LLC $55,830 Ben Prince LSS of Frazee, LLC $36,093 Jonathan Stone LSS of Frazee, LLC $56,004 Mike Anderson LSS of Wadena, LLC $102,913 Julie Callender LSS of Marycrest, LLC $103,812 Calista Taffe LSS of Traverse, LLC $67,546 Dennis Videtic LSS of Sheboygan, LLC $86,795 Darlene Einerson Waukesha Springs Health & Rehab $58,744 Vicki Grant Waukesha Springs Health & Rehab $38,056 Maxine Bergman Waukesha Springs Health & Rehab $24,857 Form 990, Part VI, Section A, line 8b The organization has no committees. The full board handles all meetings. Form 990, Part VI, Section B, line 11b The 990 is reviewed by the Director of Financial Services and Senior Accountant of the management company prior to filing. The 990 is also provided to the Legacy Senior Services board for review and approval prior to filing. Form 990, Part VI, Section B, line 12c The policy covers all board directors and officers of the organization. Individuals are required to disclose any actual or possible conflicts of interest to the board of directors considering the proposed transaction or arrangement. The board of directors determines whether or not a conflict exists. If the individual with a conflict is a board member, the remaining board members determine whether a conflict exists. If an individual has a conflict of interest, they must leave the meeting while the transaction or agreement is discussed and voted upon. Form 990, Part VI, Section B, line 15 The administrators' compensation is determined by an unrelated management company, Health Dimensions Group. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy and financial statements are available upon request. LSS of Madison LLC 110 Belmont Road Madison WI 53714 201209404 Nursing Home WI 6513503 1368642 Legacy Senior Services LSS of Sheboygan LLC 3014 Erie Avenue Sheboygan WI 53081 208658381 Nursing Home WI 7602712 2682352 Legacy Senior Services LSS of Frazee LLC 219 W Maple Avenue Frazee MN 56544 208729268 Nursing Home & Assisted Living MN 5880749 4773531 Legacy Senior Services LSS of Marycrest 2850 Columbine Road Denver CO 80221 262181659 Assisted Living CO 4071140 6574326 Legacy Senior Services LSS of Traverse LLC 303 7th Street South Wheaton MN 56296 273274611 Nursing Home & Independent Living MN 3607852 833972 Legacy Senior Services LSS of Wadena LLC 201 Shady Lane Drive Wadena MN 56482 454632615 Nursing Home & Independent Living MN 5275800 1611898 Legacy Senior Services