SUMNER COMMUNITY CLUB: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- SUMNER COMMUNITY CLUB (EIN 42-0670596)
- Tax period
- 2016-01-01 to 2016-12-31
- Filed
- 2017-08-07
- IRS object ID
- 201712199349301171
- Schema version
- 2016v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-08-07T16:53:31-05:00 | ReturnTs |
| Tax Period End | 2016-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 476097913 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SEIM JOHNSON LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18081 BURT STREET SUITE 200 | AddressLine1Txt |
| City | OMAHA | CityNm |
| State Abbreviation | NE | StateAbbreviationCd |
| ZIP | 680224722 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 420670596 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SUMNER COMMUNITY CLUB | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | SUMN | BusinessNameControlTxt |
| Phone | 5635783275 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 W 1ST STREET PO BOX 148 | AddressLine1Txt |
| City | SUMNER | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 506740148 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | STEVE SLESSOR | PersonNm |
| Person Title | INTERIM CEO | PersonTitleTxt |
| Phone | 5635783275 | PhoneNum |
| Signature | 2017-08-01 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | WENDY R COOLEY | PreparerPersonNm |
| PTIN | P01523804 | PTIN |
| Phone | 4023302660 | PhoneNum |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 209.34.201.180 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2017-08-01 | IPDt |
| IP Tm | 10:51:10 | IPTm |
| IP Timezone | CD | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | FCEDDD786A52D146CD6D5AF04BB3D8B974087028 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | FCEDDD786A52D146CD6D5AF04BB3D8B974087028 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | STEVE SLESSOR | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 W 1ST STREET PO BOX 148 | AddressLine1Txt |
| City | SUMNER | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 506740148 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $12,301,633 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CMHSUMNER.ORG | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1950 | FormationYr |
| Legal Domicile State | IA | LegalDomicileStateCd |
| Activity Or Mission | COMMUNITY MEMORIAL HOSPITAL SERVES THE AREA THROUGH ITS HEALTHCARE AND EDUCATIONAL SERVICES. WE EMPHASIZE CONCERN FOR THE QUALITY OF A PERSON'S LIFE, THROUGH EVERY MEASURE INTENDED TO PRESERVE LIFE WITH DIGNITY AND RESPECT. WE ARE DEDICATED TO CREATING AND MAINTAINING AN ENVIRONMENT SUPPORTING EXCELLENCE IN HEALTHCARE. WE PROVIDE QUALIFIED AND PROPERLY TRAINED PERSONNEL AND MEDICAL STAFF IN AN ATMOSPHERE WHICH INSPIRES A CREATIVE APPROACH TO THE COMPLEX HEALTHCARE CHALLENGES OF TODAY AND TOMORROW. | ActivityOrMissionDesc |
| Voting Members Governing Body | 11 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 11 | VotingMembersIndependentCnt |
| Total Employee | 0 | TotalEmployeeCnt |
| Total Volunteers | 7 | TotalVolunteersCnt |
| Total Gross UBI | $1,526 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | -$1,206 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $180,538 | PYContributionsGrantsAmt |
| CY Contributions Grants | $122,358 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $11,917,881 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $12,058,125 | CYProgramServiceRevenueAmt |
| PY Investment Income | $38,773 | PYInvestmentIncomeAmt |
| CY Investment Income | $39,817 | CYInvestmentIncomeAmt |
| PY Other Revenue | $74,341 | PYOtherRevenueAmt |
| CY Other Revenue | $81,333 | CYOtherRevenueAmt |
| PY Total Revenue | $12,211,533 | PYTotalRevenueAmt |
| CY Total Revenue | $12,301,633 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $5,646,893 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $6,223,207 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $7,200,580 | PYOtherExpensesAmt |
| CY Other Expenses | $7,124,795 | CYOtherExpensesAmt |
| PY Total Expenses | $12,847,473 | PYTotalExpensesAmt |
| CY Total Expenses | $13,348,002 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$635,940 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$1,046,369 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $29,572,705 | TotalAssetsBOYAmt |
| Total Assets EOY | $27,799,099 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $19,884,839 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $19,270,547 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $9,687,866 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $8,528,552 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO PROVIDE QUALITY HEALTH CARE TO THE PEOPLE OF SUMNER AND SURROUNDING AREAS, WHILE COORDINATING OTHER NEEDED SERVICES. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $7,784,535 | ExpenseAmt |
| Revenue | $6,292,447 | RevenueAmt |
| Desc | REVENUE AND EXPENSES RELATING TO OUTPATIENT DEPARTMENTS THAT OPERATE WITHIN COMMUNITY MEMORIAL HOSPITAL. THESE DEPARTMENTS INCLUDE, BUT ARE NOT LIMITED TO, LABORATORY, RADIOLOGY, OPERATING AND RECOVERY ROOM, AND PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY SERVICES. EACH OF THESE OUTPATIENT DEPARTMENTS PROVIDES STATISTICAL INFORMATION BASED ON VOLUME RELATED TO THE SPECIFIC SERVICE ARE AND WORKS IN CONJUNCTION WITH SERVICES PROVIDED IN THE CMH MEDICAL CLINIC, EMERGENCY DEPARTMENT AND ACUTE NURSING SERVICES. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,450,447 | ExpenseAmt |
| Revenue | $3,187,118 | RevenueAmt |
| Desc | COMMUNITY MEMORIAL HOSPITAL (CMH) MEDICAL CLINIC CONTINUED TO SERVE SUMNER, IA AND THE SURROUNDING AREA IN THE YEAR 2016. CMH CLINIC WAS STAFFED WITH 4 PROVIDERS. THE CMH CLINIC HAS TWO NURSE PRACTITIONERS AND TWO PHYSICIANS. PATIENTS WERE SERVED IN MANY CAPACITIES INCLUDING, BUT NOT LIMITED TO, WELL CHILD VISITS, IMMUNIZATIONS, ROUTINE PEDIATRIC CARE, SHARED MATERNITY CARE, WOUND CARE, THERAPEUTIC INJECTIONS AND MANIPULATION TREATMENTS. PATIENTS RANGED FROM NEWBORN TO GERIATRIC. A 50-MILE RADIUS OF SUMNER WAS SERVED WITH A TOTAL PATIENT VOLUME OF 12,800 FOR 2016. IN ADDITION TO CLINIC VISITS, OUR PROVIDERS CONTINUE THEIR SERVICE TO SURROUNDING NURSING HOMES AND ASSISTED LIVING FACILITIES WITH PATIENTS SEEN MONTHLY AT HILLCREST HOME IN SUMNER, MAPLECREST MANOR IN FAYETTE, TRIPOLI NURSING & REHAB IN TRIPOLI, AND COBBLESTONE ASSISTED LIVING IN SUMNER. OTHER SERVICES TO THE COMMUNITY WERE PHYSICALS FOR AREA FIREFIGHTERS AND EMS AGENCIES AND POST-JOB OFFER PHYSICALS FOR FIVE LOCAL BUSINESSES. PROVIDERS CONTINUE TO TAKE CALL FOR THE EMERGENCY DEPARTMENT ON A REGULAR SCHEDULED BASIS IN THE EVENING AND ON WEEKENDS THROUGHOUT EACH MONTH. IN THE PAST, CLINICAL STAFF FROM THE HOSPITAL WENT TO THE AREA BANK ON THE FIRST TUESDAY OF EACH MONTH TO OFFER FREE BLOOD PRESSURE CHECKS TO ANYONE ON A WALK-IN BASIS. INDIVIDUALS ARE NOW ALLOWED TO WALK INTO THE CLINIC FOR THIS SAME SERVICE ONSITE AS OPPOSED TO BEING LOCATED AT THE BANK. PROVIDERS AVIDLY PRECEPT FOR STUDENT'S VARIOUS PROGRAMS WITH UNIVERSITY OF IOWA, IOWA CITY, IA, ALLEN COLLEGE IN WATERLOO, IA, DES MOINES UNIVERSITY IN DES MOINES, IA AND KAPLAN UNIVERSITY IN CEDAR FALLS, IA TAKING ADVANTAGE OF THIS IN 2016. THE CLINIC HOURS WERE EXPANDED IN 2016 TO MONDAY THROUGH THURSDAY STARTING AT 7 AM AND ENDING AT 8 PM AND HOURS ON FRIDAY ARE 7 AM TO 5 PM. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,140,656 | ExpenseAmt |
| Revenue | $1,295,196 | RevenueAmt |
| Desc | ACUTE NURSING HAD 139 ADMISSIONS IN 2016. CMH UTILIZES A COMPANY CALLED MCKESSON'S INTERQUAL FOR QUALIFYING PATIENTS TO DETERMINE IF THEY MEET INPATIENT ADMISSION CRITERIA. THE AVERAGE LENGTH OF STAY FOR ACUTE WAS 58.73 HOURS. THIS IS WELL BELOW THE 96 HOURS THRESHOLD FOR CRITICAL ACCESS. THERE WERE A TOTAL OF 379 ACUTE PATIENT DAYS AND 546 SWING BED DAYS IN 2016. | Desc |
Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,049,974 | ExpenseAmt |
| Revenue | $1,283,364 | RevenueAmt |
| Desc | THE CMH EMERGENCY DEPARTMENT SERVED 1,377 PATIENTS IN 2016. THIS IS A DECREASE OF 59 PATIENT VISITS FROM 1,436 VISITS IN 2015. THE NUMBER OF PHYSICIAN HOURS SPENT IN THE EMERGENCY DEPARTMENT INCREASED FROM 2,907 IN 2015 TO 2,984 IN 2016.IN 2016, THE EMERGENCY DEPARTMENT IMPLEMENTED CQI PROJECTS FOR PATIENT BARCODE SCANNING, MEDICATION BARCODE SCANNING, TRAUMA ALERTS, TEMPERATURES, AND EDUCATIONAL TRAUMA WEBINARS. THE EDUCATIONAL FOCUS FOR 2016 ONCE AGAIN CENTERED ON MONTHLY TRAUMA TRAINING TRACC'S PROVIDED BY HENNEPIN COUNTY HOSPITAL. OTHER AREAS OF EDUCATION WERE THE CONTINUATION OF MONTHLY MOCK CODES, C.Q.I: CONTINUOUS QUALITY IMPROVEMENT PROGRAM, SAFE AT HOME PROGRAM, TRAUMA ALERTS, ITP TELE-MEDICINE, AND MENTAL HEALTH. NURSING COMPETENCIES INCLUDED: ACLS, CPR, FALL PREVENTION, PICC AND MEDPORT CARE, WOUND DOCUMENTATION, CODE BLUE DOCUMENTATION, CAPNOGRAPHY, CPI (CRISIS PREVENTION INTERVENTIONS), ORGAN AND TISSUE DONATION, HAZ MAT, AND ANKLE-BRACHIAL INDEX TRAINING. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Prog Srvc Expense | $1,049,974 | TotalOtherProgSrvcExpenseAmt |
| Total Other Prog Srvc Revenue | $1,283,364 | TotalOtherProgSrvcRevenueAmt |
| Total Program Service Expenses | $11,425,612 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | Yes (1) | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | Yes (1) | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | Yes (1) | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (1) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 9 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 0 | EmployeeCnt |
| Unrelated Bus Incm Over Limit | Yes (1) | UnrelatedBusIncmOverLimitInd |
| Form990 T Filed | Yes (1) | Form990TFiledInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 11 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 11 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DAWN EVERDING | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 5635783275 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 WEST 1ST STREET PO BOX 148 | AddressLine1Txt |
| City | SUMNER | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 50674 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (21 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| CONNIE LEICHER | ||||||||
| BOARD MEMBER - CHAIR | 1.30 | 0.80 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| WILLIAM SCHWAKE | ||||||||
| BOARD MEMBER - VICE CHAIR | 1.30 | 0.80 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| LUARA NECKER | ||||||||
| BOARD MEMBER - SEC/TREAS | 1.30 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| DEBRA TOENGES | ||||||||
| BOARD MEMBER - SEC/TREAS THRU 03/16 | 0.80 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| DUANE HILDEBRANDT | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DONNA TREMAINE | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DIANE PAGEL | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| ANGELA LEETE | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| MARK SEEHASE | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| GENE RHEA | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| BRENDA WINZENBURG | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| LAVERNE BUHR | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| HOLLY SCHEMMEL | ||||||||
| BOARD MEMBER | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| RICK PEDERSON | ||||||||
| BOARD MEMBER THRU 03/16 | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DAVE VOSS | ||||||||
| BOARD MEMBER THRU 03/16 | 0.80 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| DUSTIN WRIGHT | ||||||||
| CEO | 38.00 | 2.00 | Yes (X) | $133,388 | $0 | $13,209 | ||
| DAWN EVERDING | ||||||||
| CFO | 39.50 | 0.50 | Yes (X) | $116,691 | $0 | $7,411 | ||
| LYNNE NIEMANN | ||||||||
| DIRECTOR OF NURSING & PATI | 39.70 | 0.30 | Yes (X) | $100,680 | $0 | $10,756 | ||
| KYLE TEELING | ||||||||
| DIRECTOR OF SUPPORT SERV. THRU 05/16 | 38.00 | 2.00 | Yes (X) | $33,350 | $0 | $5,136 | ||
| TROY BUCHHOLZ MD | ||||||||
| PHYSICIAN | 40.00 | 0.00 | $385,035 | $0 | $34,846 | Yes (X) | ||
| JEFFREY ROSKE DO | ||||||||
| PHYSICIAN | 40.00 | 0.00 | $375,422 | $0 | $29,016 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,144,566 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $100,374 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 5 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| EMERGENCY PRACTICE ASSOCIATES | |||||
| PO BOX 1260 | WATERLOO | IA | 50704 | ER COVERAGE | $424,472 |
| PERFORMANCE REHAB LLC | |||||
| 909 W 1ST ST | SUMNER | IA | 50674 | REHAB SERVICES | $423,469 |
| UNITYPOINT HEALTH | |||||
| PO BOX 83381 | CHICAGO | IL | 60691 | IT SUPPORT | $339,832 |
| HEALTH ENTERPRISES OF IOWA | |||||
| 5825 DRY CREEK LANE NE | CEDAR RAPIDS | IA | 52402 | RADIOLOGY/CRNA SERVICES | $286,412 |
| UNITYPOINT HEALTH - ALLEN MEMORIAL HOSPI | |||||
| PO BOX 83381 | CHICAGO | IL | 60691 | MEDICAL SERVICES | $241,287 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 8 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $7,449 | RelatedOrganizationsAmt |
| Government Grants | $17,986 | GovernmentGrantsAmt |
| All Other Contributions | $96,923 | AllOtherContributionsAmt |
| Total Contributions | $122,358 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (5 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| MEDICARE/MEDICAID PAYMENTS | 621400 | $5,920,889 | $5,920,889 |
| PATIENT REVENUE - PRIVATE PAY | 621400 | $5,659,953 | $5,659,953 |
| 340B INCOME | 621990 | $229,445 | $229,445 |
| AMH OPERATING AGREEMENT INCOME | 561000 | $200,000 | $200,000 |
| COMMUNITY WELLNESS | 621990 | $26,605 | $26,605 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $21,233 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $21,233 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $12,058,125 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $38,399 | TotalRevenueColumnAmt |
| Exclusion | $38,399 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $43,627 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $43,627 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $43,627 | TotalRevenueColumnAmt |
| Exclusion | $43,627 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $1,418 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $1,418 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,418 | TotalRevenueColumnAmt |
| Exclusion | $1,418 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt | Unrelated Business RevenueUnrelatedBusinessRevenueAmt |
|---|---|---|---|---|
| CAFETERIA EMPLOYEES | 900099 | $36,180 | $36,180 | |
| CATERING | 722320 | $1,526 | $1,526 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $37,706 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $12,301,633 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $12,058,125 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $1,526 | UnrelatedBusinessRevenueAmt |
| Exclusion | $119,624 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $420,621 | TotalAmt |
| Management And General | $420,621 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,543,597 | TotalAmt |
| Program Services | $4,095,534 | ProgramServicesAmt |
| Management And General | $448,063 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $913,984 | TotalAmt |
| Program Services | $790,813 | ProgramServicesAmt |
| Management And General | $123,171 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $345,005 | TotalAmt |
| Program Services | $287,279 | ProgramServicesAmt |
| Management And General | $57,726 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $36,000 | TotalAmt |
| Management And General | $36,000 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $20,451 | TotalAmt |
| Management And General | $20,451 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $94,076 | TotalAmt |
| Management And General | $94,076 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,141,134 | TotalAmt |
| Program Services | $2,049,904 | ProgramServicesAmt |
| Management And General | $91,230 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $42,407 | TotalAmt |
| Program Services | $42,407 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $489,170 | TotalAmt |
| Program Services | $443,317 | ProgramServicesAmt |
| Management And General | $45,853 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $222,914 | TotalAmt |
| Management And General | $222,914 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $199,813 | TotalAmt |
| Program Services | $171,802 | ProgramServicesAmt |
| Management And General | $28,011 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $49,765 | TotalAmt |
| Program Services | $42,406 | ProgramServicesAmt |
| Management And General | $7,359 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $711,881 | TotalAmt |
| Program Services | $612,086 | ProgramServicesAmt |
| Management And General | $99,795 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,620,146 | TotalAmt |
| Program Services | $1,393,026 | ProgramServicesAmt |
| Management And General | $227,120 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $72,119 | TotalAmt |
| Program Services | $72,119 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt |
|---|---|---|
| MEDICAL SUPPLIES | $1,033,558 | $1,033,558 |
| PROVISION FOR BAD DEBT | $174,059 | $174,059 |
| DUES AND SUBSCRIPTIONS | $154,667 | $154,667 |
| FOOD | $52,387 | $52,387 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $10,248 | TotalAmt |
| Program Services | $10,248 | ProgramServicesAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,348,002 | TotalAmt |
| Program Services | $11,425,612 | ProgramServicesAmt |
| Management And General | $1,922,390 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $100 | BOYAmt |
| EOY | $100 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,527,265 | BOYAmt |
| EOY | $7,943,948 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,175,613 | BOYAmt |
| EOY | $1,526,767 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $175,940 | BOYAmt |
| EOY | $208,097 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $164,201 | BOYAmt |
| EOY | $237,625 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $21,747,165 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $8,038,215 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $15,067,537 | BOYAmt |
| EOY | $13,708,950 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,954,520 | BOYAmt |
| EOY | $3,841,575 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $507,529 | BOYAmt |
| EOY | $332,037 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $29,572,705 | BOYAmt |
| EOY | $27,799,099 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,279,716 | BOYAmt |
| EOY | $1,249,727 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,179,805 | BOYAmt |
| EOY | $16,995,253 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,425,318 | BOYAmt |
| EOY | $1,025,567 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $19,884,839 | BOYAmt |
| EOY | $19,270,547 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,733,346 | BOYAmt |
| EOY | $4,686,977 | EOYAmt |
Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,954,520 | BOYAmt |
| EOY | $3,841,575 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,687,866 | BOYAmt |
| EOY | $8,528,552 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $29,572,705 | BOYAmt |
| EOY | $27,799,099 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | -$1,046,369 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$112,945 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $3,954,520 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | -$112,945 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $3,841,575 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $4,139,591 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | -$185,071 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $3,954,520 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $4,483,296 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | -$343,705 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $4,139,591 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $4,171,601 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $563,439 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $251,744 | OtherExpendituresAmt |
| End Year Balance | $4,483,296 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $3,544,459 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $858,953 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $231,811 | OtherExpendituresAmt |
| End Year Balance | $4,171,601 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated Balance EOY | 0.00000 | BoardDesignatedBalanceEOYPct |
| Prmnnt Endowment Balance EOY | 1.00000 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.00000 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | Yes (1) | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | 0 | EndowmentsHeldRelatedOrgInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $100,421 | OtherCostOrOtherBasisAmt |
| Book Value | $100,421 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,358,930 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,338,372 | DepreciationAmt |
| Book Value | $10,020,558 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $6,190,677 | OtherCostOrOtherBasisAmt |
| Depreciation | $4,152,257 | DepreciationAmt |
| Book Value | $2,038,420 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,097,137 | OtherCostOrOtherBasisAmt |
| Depreciation | $547,586 | DepreciationAmt |
| Book Value | $1,549,551 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $13,708,950 | TotalBookValueLandBuildingsAmt |
Other Securities OtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | PERPETUAL TRUST | Desc |
| Book Value | $3,841,575 | BookValueAmt |
| Method Valuation | F | MethodValuationCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Securities | $3,841,575 | TotalBookValueSecuritiesAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| CAPITAL LEASE OBLIGATIONS | $383,641 |
| ESTIMATED THIRD-PARTY PAYOR SETTLEMENT | $641,926 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $1,025,567 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART V, LINE 4: | THE HOSPITAL IS BENEFICIARY OF A DONOR CREATED PERPETUAL TRUST. ASSETS HELD BY THE TRUST INCLUDE CASH AND CASH EQUIVALENTS, CDS, EQUITIES, AND FARMLAND. A PROVISION OF THE TRUST REQUIRES THAT INCOME EARNED BE DISTRIBUTED AT LEAST ANNUALLY TO THE HOSPITAL. INCOME DISTRIBUTIONS FROM THE TRUST ARE UNRESTRICTED AND CAN BE USED FOR ANY PURPOSE DEEMED BENEFICIAL. IN 2015, THE GRAIN, LIVESTOCK AND EQUIPMENT THAT WERE PREVIOUSLY HELD BY THE TRUST WERE LIQUIDATED IN FULL AND THE FARMLAND IS BEING OPERATED ON A CASH BASIS RENTAL AGREEMENT. |
| PART X, LINE 2: | THE HOSPITAL AND FOUNDATION ARE NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE SERVICE AND ARE EXEMPT FROM FEDERAL INCOME TAXES IN RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN THE HOSPITAL'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE THE HOSPITAL TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC TOPIC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2016 AND 2015, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
Discounted Care Oth Percentage DiscountedCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Discounted Care Other | 600.000000000000 | DiscountedCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $28,176 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $0 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $28,176 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00210 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,070,584 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $745,245 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $325,339 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02470 | TotalExpensePct |
Unreimbursed Costs UnreimbursedCostsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $19,478 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $13,205 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $6,273 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00050 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,118,238 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $758,450 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $359,788 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02730 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $27,018 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,371 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $23,647 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00180 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $55,537 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $55,537 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00420 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $303,129 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $34,040 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $269,089 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02040 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,112 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $6,112 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00050 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $391,796 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $37,411 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $354,385 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02690 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,510,034 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $795,861 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $714,173 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05420 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $174,059 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $27,000 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $5,695,953 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $5,692,736 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $3,217 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SUMNER COMMUNITY CLUB DBA COMMUNITY | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | MEMORIAL HOSP 909 W 1ST ST PO BOX | AddressLine1Txt |
| Address Line2 | 148 | AddressLine2Txt |
| City | SUMNER | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 50674 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.CMHSUMNER.ORG | WebsiteAddressTxt |
| State License | 090086H | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
| Other | PROVIDER-BASED MEDICAL CLINIC | OtherDesc |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 16 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.CMHSUMNER.ORG | OwnWebsiteURLTxt |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 16 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.CMHSUMNER.ORG | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 600.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Other Method | Yes (X) | OtherMethodInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | WWW.CMHSUMNER.ORG | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | WWW.CMHSUMNER.ORG | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | WWW.CMHSUMNER.ORG | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Prospective Medicare Medicaid | Yes (X) | ProspectiveMedicareMedicaidInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 5: THE 28-QUESTION SURVEY OPPORTUNITY WAS PUBLICIZED IN AREA NEWSPAPERS AND ONLINE. THE MEDIA RELEASE WAS SENT OUT TO PRINT, RADIO, CABLE AND TELEVISION CONTACTS. IN ADDITION, EMAILS WERE SENT WITH A LINK TO THE SURVEY (OR HARD COPY WAS MADE AVAILABLE) TO AREA CHURCHES, AREA SCHOOL CONTACTS, AND LOCAL ORGANIZATIONS. THE INFORMATION WAS ALSO INCLUDED IN THE SCHOOL NEWSLETTERS. THERE WERE 715 INDIVIDUALS THAT RESPONDED TO THE NEEDS ASSESSMENT SURVEY THAT WAS CONDUCTED. THIS SURVEY SAMPLE REPRESENTED A LARGE CROSS-SECTION OF THE POPULATION AREAS IN THE COMMUNITIES INCLUDED IN THE ASSESSMENT. THE SERVICE AREA THAT WAS SURVEYED INCLUDED 3 COUNTIES THAT ARE ALL SERVED BY THE HOSPITALS AND AGENCIES THAT COLLABORATED IN THE NEEDS ASSESSMENT PROCESS. |
| COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 6A: WAVERLY HEALTH CENTER, WAVERLY, IA |
| COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 6B: BREMER COUNTY PUBLIC HEALTH AGENCY, WAVERLY, IAWAVERLY-SHELL ROCK AREA UNITED WAY, WAVERLY, IA |
| COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 11: THE BOARD OF DIRECTORS REVIEWED THE LIST OF NEEDS IDENTIFIED BY REVIEWING THE NUMBER OF RESPONSES RECEIVED FOR EACH INDIVIDUAL NEED. THIS PROCESS IDENTIFIED THE TOP 4 NEEDS THAT WERE RECOGNIZED BY COMMUNITY MEMORIAL HOSPITAL BOARD OF DIRECTORS TO DEVELOP A PLAN AND CREATE AN IMPLEMENTATION PLAN. THE NEEDS THAT HAVE BEEN CHOSEN TO BE ADDRESSED INCLUDE: ACCESS TO HEALTHCARE, CHRONIC DISEASE MANAGEMENT, WELLNESS INITIATIVES (INCLUDING OBESITY, AFFORDABLE WELLNESS AND FITNESS, HEALTHY BEHAVIOR LIFESTYLES AND EMPLOYEE WELLNESS) AND ACCESS TO MENTAL HEALTH SERVICES. THE BOARD OF DIRECTORS HAS ACKNOWLEDGED THAT THESE NEEDS FALL WITHIN THE SCOPE OF THE MISSION AND EACH COVERS A BROAD SPECTRUM AND OFFER ONGOING OPPORTUNITIES FOR IMPROVEMENT. THE BOARD OF DIRECTORS IS COMMITTED TO THE SUCCESS AND SUSTAINABILITY OF QUALITY LOCAL HEALTHCARE AND PLACING A FOCUS ON THESE NEEDS HELPS ACHIEVE THIS. COMMUNITY MEMORIAL HOSPITAL HAS INCLUDED FUNDS IN THE OPERATING BUDGET TO CONTINUE TO SUPPORT THE NEEDS ASSESSMENT MOVING FORWARD.THE REMAINING NEEDS IDENTIFIED INCLUDE RISKY BEHAVIORS (SUCH AS TEXTING AND DRIVING), CHILDREN'S HEALTH (INCLUDING TOO MUCH SCREEN TIME), PHYSICAL ACTIVITY AND LACK OF MOTIVATION, AFFORDABLE FOOD OPTIONS, AND SOCIAL ISSUES RELATED TO PARENTING AND HOUSING OPTIONS. IT IS NOT TO SAY THAT THESE NEEDS WILL NOT BE ADDRESSED OR FOLLOWED BY THE HOSPITAL, BUT INSTEAD ARE NOT INCLUDED IN THE CHNA IMPLEMENTATION STRATEGY. THE HOSPITAL WILL MONITOR THE OVERALL NEEDS OF THE COMMUNITY SERVED AND REASSESS AS WE MOVE FORWARD. IN ADDITION, THERE ARE SERVICES, ORGANIZATIONS AND BUSINESSES WITHIN THE SERVICE AREA THAT ARE IDENTIFIED TO FOCUS ON THESE NEEDS CURRENTLY. |
| COMMUNITY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 15E: COMMUNITY MEMORIAL HOSPITAL PATIENT STATEMENTS INCLUDES INFORMATION ON HOW TO APPLY FOR FINANCIAL ASSISTANCE. IN ADDITION TO THE STANDARD INFORMATION, COMMUNITY MEMORIAL HOSPITAL ALSO HAS A DESIGNATED STAFF MEMBER THAT MONITORS PATIENT ACCOUNTS THAT ARE RECEIVING A SECOND OR THIRD STATEMENT. THIS STAFF MEMBER MAKES CONTACT WITH THE INDIVIDUAL PATIENTS TO DETERMINE IF A FINANCIAL ASSISTANCE APPLICATION SHOULD BE MAILED OUT FOR COMPLETION. THE FINANCIAL ASSISTANCE APPLICATION PROVIDES A LISTING OF THE INFORMATION THAT WILL BE NEEDED IN ORDER TO PROCEED WITH ITS REVIEW. |
Supplemental Information Detail SupplementalInformationDetail (16 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | NOT APPLICABLE |
| PART I, LINE 6A: | THE REPORT IS PREPARED BY THE STAFF OF COMMUNITY MEMORIAL HOSPITAL. |
| PART I, LINE 7: | THE COST TO CHARGE RATIO PER IRS WORKSHEET 2 WAS USED TO CALCULATE THE AMOUNTS IN THE UPPER PORTION OF THE TABLE. COSTING OF THE "OTHER BENEFITS" PORTION OF THE TABLE WAS CALCULATED PER GUIDANCE PROVIDED BY THE IOWA HOSPITAL ASSOCIATION IN TERMS OF PROPER REPORTING OF COMMUNITY BENEFITS. |
| PART I, LINE 7G: | NO COSTS ASSOCIATED WITH PHYSICIAN CLINICS WERE INCLUDED. |
| PART I, LN 7 COL(F): | THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $174,059. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | COMMUNITY MEMORIAL HOSPITAL DID NOT REPORT ANY COMMUNITY BUILDING ACTIVITIES IN PART II OF SCHEDULE H. |
| PART III, LINE 2: | THE ALLOWANCES REFLECT MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED IN THE FUTURE AND ARE BASED ON REVIEWS OF PATIENT BALANCES BY PAYER CLASSES. PERCENTAGES ARE APPLIED TO EACH PAYER CLASS BASED ON CONTRACTUAL AGREEMENTS AND HISTORICAL COLLECTION AND RECOVERY INFORMATION TO DETERMINE THAT NET REALIZABLE VALUE OF THE PATIENT RECEIVABLES. |
| PART III, LINE 3: | THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. PATIENTS WHO QUALIFY FOR CHARITY CARE ARE GIVEN A PERCENTAGE DISCOUNT FROM ESTABLISHED CHARGES BASED ON A SLIDING SCALE USING POVERTY GUIDELINES. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN NET OPERATING REVENUE OR IN THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON THE OVERALL COST TO CHARGE RATIO FOR THE HOSPITAL. |
| PART III, LINE 4: | THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT CONTAIN A SPECIFIC FOOTNOTE DESCRIBING BAD DEBT. HOWEVER, PAGES 8, 9 & 10 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS INCLUDE FOOTNOTES TITLED "PATIENT RECEIVABLES, NET" "NET PATIENT SERVICE REVENUE, AND "CHARITY CARE". |
| PART III, LINE 9B: | COMMUNITY MEMORIAL HOSPITAL'S COLLECTIONS POLICY STATES THAT THE HOSPITAL WILL "REFRAIN FROM INITIATING EXTRAORDINARY COLLECTION ACTIONS FOR 120 DAYS FROM THE DATE OF THE PATIENT'S FIRST POST DISCHARGE BILLING STATEMENT" IF ELIGIBILITY FOR FINANCIAL ASSISTANCE IS UNDETERMINED. IN ADDITION, "IF THE PATIENT SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION AT ANY TIME WITHIN THE APPLICATION PERIOD, THE HOSPITAL MUST SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS, DETERMINE THE ELIGIBILITY, AND NOTIFY THE PATIENT". ONCE A DECISION IS MADE ON THE FINANCIAL ASSISTANCE APPLICATION, COLLECTION EFFORTS WILL STOP IF IT IS APPROVED OR CONTINUE WHERE THE EFFORTS LEFT OFF IF THE APPLICATION IS DECLINED. |
| PART VI, LINE 2: | COMMUNITY MEMORIAL HOSPITAL COMPLETED THE CHNA PROCESS IN 2016. THE CHNA IS CURRENTLY POSTED ON THE HOSPITAL WEBSITE (WWW.CMHSUMNER.ORG). THE FOUR AREAS OF FOCUS CHOSEN BY COMMUNITY MEMORIAL HOSPITAL FROM THE CHNA INCLUDE: ACCESS TO HEALTHCARE, CHRONIC DISEASE MANAGEMENT, WELLNESS INITIATIVES (INCLUDING OBESITY, AFFORDABLE WELLNESS AND FITNESS, HEALTHY BEHAVIOR LIFESTYLES AND EMPLOYEE WELLNESS), AND ACCESS TO MENTAL HEALTH SERVICES.MANY OF THE BOARD OF DIRECTORS ARE INVOLVED IN VARIOUS GROUPS AND BUSINESSES IN THE COMMUNITY AND RECEIVE INPUT FROM COMMUNITY MEMBERS. THIS COMMUNITY INVOLVEMENT IS INCREASED WITH ANOTHER GROUP OF INDIVIDUALS WHO ARE INVOLVED IN THE HOSPITAL AUXILIARY AND FOUNDATION. IN A SMALLER TOWN, PEOPLE ARE AWARE OF WHO SERVES ON THE HOSPITAL BOARD AND FOUNDATION BOARDS, IN THE AUXILIARY AND HOSPITAL ADMINISTRATION. COMMUNITY MEMBERS FEEL COMFORTABLE APPROACHING THEM WITH THE NEEDS THAT THEY SEE AS A BENEFIT TO THE COMMUNITY, SUCH AS, IMPROVING ACCESS TO SPECIALIST SERVICES WITH INCREASED OFFERINGS OF OUTPATIENT CLINICS WITHIN THE HOSPITAL.THE HOSPITAL SEES ITS ROLE AS CARE OF ILLNESS BUT ALSO IMPROVEMENT OF HEALTH AND WELLNESS. IN REGARD TO THESE GOALS, ALMOST MONTHLY THERE ARE OPPORTUNITIES FOR EDUCATION ON VARIOUS HEALTH TOPICS OFFERED IN THE COMMUNITY. THE HOSPITAL ADDITIONALLY SPONSORS LOCAL INDUSTRY-HOSTED HEALTH FAIRS AND COMMUNITY WELLNESS TESTING. THE WELLNESS TESTING OFFERINGS HAVE SEEN INCREASING PARTICIPATION BY COMMUNITY MEMBERS AND PRESENT THE OPPORTUNITY FOR ADDITIONAL COMMUNITY INPUT.AS THE HOSPITAL PLANNED FOR THE NEW REPLACEMENT FACILITY, A GREAT DEAL OF PREPARATION WORK WAS DONE TO BE SURE TO BUILD FOR THE PRESENT NEEDS AS TO HEALTH SERVICES BUT TO ALSO MAKE SURE THAT WE CAN ADDRESS FUTURE NEEDS. WE KNEW THAT DIAGNOSTIC SERVICES WOULD BE AN INCREASING FOCUS AS TO STANDARDS OF CARE. THE IMPLEMENTATION STRATEGY FOR THE CHNA IS ALSO LOCATED WITHIN THE CHNA REPORT LOCATED ON THE WWW.CMHSUMNER.ORG WEBSITE. THIS STRATEGY WAS ALSO IMPLEMENTED IN 2016. |
| PART VI, LINE 3: | CMH HAS A PAYMENT BROCHURE THAT IS LOCATED AT THE REGISTRATION DESK FOR ALL PATIENTS TO TAKE WITH THEM EXPLAINING OUR PAYMENT TERMS AND THE AVAILABILITY OF FINANCIAL ASSISTANCE. THERE IS ALSO AN AREA ON THE STATEMENTS SENT TO PATIENTS THAT ALLOWS FOR MESSAGES TO BE PRINTED. THE MESSAGE INDICATES THE AVAILABILITY FOR ASSISTANCE FOR THOSE WHO QUALIFY. IN ADDITION, A DESIGNATED STAFF MEMBER WORKS DIRECTLY WITH PATIENTS WITH OPEN ACCOUNT BALANCES TO PROVIDE PAYMENT PLANS, FINANCIAL ASSISTANCE APPLICATIONS OR ADDITIONAL INSURANCE COVERAGE POSSIBILITIES. |
| PART VI, LINE 4: | CMH'S PRIMARY SERVICE AREA CONSISTS OF CITIES FROM THE FOLLOWING SEVEN ZIP CODES, WHICH INCLUDE SUMNER (50674), TRIPOLI (50676), FREDERICKSBURG (50630), HAWKEYE (52147), WESTGATE (50681), FAIRBANK (50629) AND FAYETTE (52142). THE COMMUNITIES THAT ARE INCLUDED IN THE CMH SERVICE AREA PRIMARILY CONSIST OF FARMING BACKGROUNDS AND RURAL AREAS. THE PRIMARY POPULATION IS LOCATED IN A RURAL SETTING WITH SUMNER BEING THE LARGEST CITY WITH A POPULATION OF APPROXIMATELY 2,000. |
| PART VI, LINE 5: | COMMUNITY MEMORIAL HOSPITAL (CMH) IS A PILLAR IN THE COMMUNITY AND STRIVES TO BE A STRONG COMMUNITY PARTNER. CMH CONTINUES TO REACH OUT AND PARTNER WITH THE COMMUNITY IN MANY AREAS. CMH HELPS TO PROMOTE HEALTH AND WELLNESS BY SUPPORTING COMMUNITY GROUPS AND INITIATIVES AND CONSISTENTLY OFFERS "HEALTH HIGHLIGHTS," WHICH PROVIDE FREE EDUCATION ON VARIOUS HEALTH-RELATED TOPICS. IN ADDITION, CMH STAFF OFFER MATTER OF BALANCE CLASSES TWO TIMES A YEAR AIMED AT CREATING AN ACTIVE LIFESTYLE FOR THE OLDER GENERATION. CMH CONTINUES TO HELP COORDINATE AND PLAN PREPAREDNESS TRAINING AND DRILLS FOR THE COMMUNITY, WORKING WITH SEVERAL LOCAL AND COUNTY AGENCIES. THE RELATIONSHIPS AND COLLABORATION CREATED IS BENEFICIAL FOR ALL INVOLVED AND THE RESIDENTS WE SERVE. IN ADDITION, HOSPITAL PREPAREDNESS STAFF HAVE PARTNERED WITH COUNTY RESOURCES TO INTRODUCE ALICE TRAINING TO AREA BUSINESSES. LASTLY, CRITICAL INCIDENT STRESS DEBRIEFING (CISD) TRAINED STAFF HAVE BEEN UTILIZED ON MULTIPLE OCCASIONS TO LEAD DEBRIEFINGS FOR AREA EMERGENCY RESPONSE AGENCIES FOLLOWING FIRES, DEATHS, ETC. CMH IS INVOLVED WITH A GROUP OF COMMUNITY PROVIDERS (KNOWN IN THE COMMUNITY AS C2T2) THAT MEETS QUARTERLY TO SERVE AS A NETWORK TO MEET THE NEEDS OF THE COMMUNITY. THIS ORGANIZED GROUP INCLUDES INDIVIDUALS FROM THE HOSPITAL, LONG-TERM CARE FACILITIES, HOME HEALTH, AND PUBLIC HEALTH. |
| PART VI, LINE 6: | COMMUNITY MEMORIAL HOSPITAL IS NOT PART OF AN AFFILIATED HEALTH CARE SYSTEM. |
| PART VI, LINE 7, REPORTS FILED WITH STATES | IA |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (2 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| TROY BUCHHOLZ MD | ||||||||||||||
| PHYSICIAN | $341,475 | $0 | $43,250 | $0 | $310 | $0 | $13,250 | $0 | $21,596 | $0 | $419,881 | $0 | $0 | $0 |
| JEFFREY ROSKE DO | ||||||||||||||
| PHYSICIAN | $341,722 | $0 | $33,250 | $0 | $450 | $0 | $13,250 | $0 | $15,766 | $0 | $404,438 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 3 | FormAndLineReferenceDesc |
| Explanation | THE ORGANIZATION IS JOINTLY OPERATED WITH UNITYPOINT HEALTH-WATERLOO, FORMERLY KNOW AS ALLEN HEALTH SYSTEM. THE CEO OF UNITYPOINT HEALTH-WATERLOO IS RESPONSIBLE FOR SETTING THE SALARY FOR DUSTIN WRIGHT, CEO OF CMH. THE CEO OF UNITYPOINT HEALTH-WATERLOO, USES SALARY SURVEY INFORMATION FROM THE IOWA HOSPITAL ASSOCIATION TO DETERMINE A REASONABLE RANGE FOR THE CEO'S COMPENSATION. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JUSTIN TRAINOR | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | SPOUSE OF SARA TRAINOR, FORMER CFO | RelationshipDescriptionTxt |
| Transaction | $423,469 | TransactionAmt |
| Transaction | PERFORMANCE REHAB IS 40% OWNED BY JUSTIN TRAINOR, THE SPOUSE OF SARA TRAINOR, FORMER CFO. THIS ENTITY PROVIDES PHYSICAL AND OCCUPATIONAL THERAPIES AT CMH. PERFORMANCE REHAB'S COMPENSATION FROM CMH IS CALCULATED AS A PERCENTAGE OF CMH'S NET REIMBURSEMENT FOR THERAPY SERVICES. | TransactionDesc |
| Sharing Of Revenues | Yes (1) | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART V, LINE 2A: | ALL CMH EMPLOYEES ARE EMPLOYEES OF UNITYPOINT HEALTH - WATERLOO (FORMERLY ALLEN HEALTH SYSTEMS). UNITYPOINT HEALTH - WATERLOO COMPLETES ALL PAYROLL FUNCTIONS AND CMH REIMBURSES UNITYPOINT HEALTH - WATERLOO FOR ALL WAGE AND BENEFIT EXPENSES INCURRED. |
| FORM 990, PART VI, SECTION A, LINE 3 | THE ORGANIZATION HAS AN EXTENDED MANAGEMENT CONTRACT WITH UNITYPOINT HEALTH - WATERLOO, FORMALLY KNOWN AS ALLEN HEALTH SYSTEMS. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE ORGANIZATION'S ARTICLES OF INCORPORATION PROVIDE THAT THE CORPORATION "HAS NO CAPITAL STOCK AND THE CAPITAL OF THIS ASSOCIATION SHALL BE THE MEMBERSHIP FEES . . . FIXED BY THE BOARD OF DIRECTORS". ANYONE IN THE COMMUNITY MAY BE A MEMBER OF THE CORPORATION UPON PAYMENT OF THE $1 MEMBERSHIP FEE, AS FIXED BY THE BOARD OF DIRECTORS ACCORDING TO THE BYLAWS. THE ORGANIZATION'S MEMBERS ELECT THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7A | EACH BOARD OF DIRECTOR SHALL BE ELECTED BY THE LARGEST VOTE CAST BY THE MEMBERS PRESENT AT THE ANNUAL MEETING. ABSENTEE BALLOTS WILL BE ALLOWED FOR EMPLOYEES WORKING AT COMMUNITY MEMORIAL HOSPITAL DURING THE ACTUAL HOURS OF THE ANNUAL MEETING. |
| FORM 990, PART VI, SECTION A, LINE 7B | IN 2003, COMMUNITY MEMORIAL HOSPITAL (CMH) ENTERED INTO AN OPERATING AGREEMENT WITH ALLEN HEALTH SYSTEM (AHS), NOW REFERRED TO AS UNITYPOINT HEALTH - WATERLOO. UNDER THE TERMS OF THAT AGREEMENT, A JOINT GOVERNANCE STRUCTURE WAS ESTABLISHED, WHEREBY UNITYPOINT HEALTH AND THE BOARD OF DIRECTORS OF CMH EXERCISE JOINT AUTHORITY FOR THE OPERATION OF THE HOSPITAL. WHILE UNITYPOINT HEALTH HAS DAY-TO-DAY OPERATIONAL CONTROL, CERTAIN GOVERNANCE AUTHORITY ACTIONS REQUIRE THE PARTICIPATION OF BOTH UNITYPOINT'S AND CMH'S BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE IRS FORM 990 IS PRESENTED TO THE CMH BOARD OF DIRECTORS AT A REGULARLY SCHEDULED MONTHLY MEETING FOR REVIEW. IT WILL BE NOTED AS AN AGENDA ITEM UNDER "NEW BUSINESS AND REQUIRES THE PROPER APPROVAL FROM THE BOARD PRIOR TO BEING SUBMITTED TO IRS. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE BOARD OF DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY COMPLETE A CONFLICT OF INTEREST DISCLOSURE/QUESTIONNAIRE. THESE ARE REVIEWED BY THE CEO AND BOARD CHAIR. EACH MONTH THERE IS AN AGENDA ITEM AT THE BOARD MEETING FOR ANY CONFLICTS RELATED TO THE REST OF THE AGENDA TO BE DISCLOSED. IF NONE ARE NOTED, BUT THE BOARD CHAIR FEELS ONE EXISTS, IT IS THE CHAIR'S RESPONSIBILITY TO INQUIRE ABOUT IT BEFORE PROCEEDING. WHEN THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT ABSTAINS FROM VOTING. |
| FORM 990, PART VI, SECTION B, LINE 15 | THE ORGANIZATION IS JOINTLY OPERATED WITH UNITYPOINT HEALTH - WATERLOO, F/K/A ALLEN HEALTH SYSTEM. THE CEO OF UNITYPOINT HEALTH IS RESPONSIBLE FOR SETTING THE SALARY FOR DUSTIN WRIGHT, CEO OF CMH. THE CEO OF UNITYPOINT HEALTH USES SALARY SURVEY INFORMATION FROM THE IOWA HOSPITAL ASSOCIATION TO DETERMINE A REASONABLE RANGE FOR THE CEO'S COMPENSATION. THE CMH CEO IS RESPONSIBLE FOR SETTING THE SALARY OF DAWN EVERDING, CFO (OFFICER) AND LYNNE NIEMANN, DIRECTOR OF NURSING. COMPARABILITY DATA IS ALSO USED IN SETTING THE COMPENSATION FOR THE OFFICERS. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. HOWEVER, FINANCIAL STATEMENTS ARE MADE AVAILABLE AT THE SUMNER COMMUNITY CLUB MEETING AND A PERSON MAY BECOME A MEMBER OF THE SUMNER COMMUNITY CLUB BY PAYING THE $1.00 ANNUAL MEMBERSHIP FEE. |
| FORM 990, PART IX, LINE 11G | OUTSIDE SERVICES: PROGRAM SERVICE EXPENSES 546,919. MANAGEMENT AND GENERAL EXPENSES 91,230. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 638,149. EMERGENCY ROOM SPECIALIST FEES: PROGRAM SERVICE EXPENSES 715,015. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 715,015. PHYSICAL THERAPY FEES: PROGRAM SERVICE EXPENSES 433,493. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 433,493. ANESTHESIOLOGIST FEES: PROGRAM SERVICE EXPENSES 210,442. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 210,442. LAB FEES: PROGRAM SERVICE EXPENSES 144,035. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 144,035. |
| FORM 990, PAGE 12, PART XII, LINE 2C: | THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY OF SELECTING THE INDEPENDENT ACCOUNTANT TO COMPLETE THE AUDIT WORK. THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS HAS THE RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE BOARD OF DIRECTORS. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FRIENDS OF CMH SUMNER COMMUNITY MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 W 1ST STREET | AddressLine1Txt |
| City | SUMNER | CityNm |
| State Abbreviation | IA | StateAbbreviationCd |
| ZIP | 50674 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 421408693 | EIN |
| Primary Activities | HOSPITAL FOUNDATION | PrimaryActivitiesTxt |
| Legal Domicile State | IA | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 7 | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | SUMNER COMMUNITY CLUB | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHARITABLE TRUST | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Primary Activities | TRUST | PrimaryActivitiesTxt |
| Legal Domicile State | IA | LegalDomicileStateCd |
| Entity Type | T | EntityTypeTxt |
| Ownership | 1.00000 | OwnershipPct |
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp
Other Organization Name OtherOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHARITABLE TRUST | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionTypeTxt |
| Involved | $92,148 | InvolvedAmt |
| Method Of Amount Determination | CASH TRANSFERRED EQUALS FMV | MethodOfAmountDeterminationTxt |
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