2016-12-19T12:12:29-06:00 2016-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2015-07-01 410839343 Divine Providence Community Home DIVI 5077943011 700 3rd Avenue NW Sleepy Eye MN 560851036 Jayna Groebner Administrator 5077943011 2016-12-13 1 Deb Nelson CPA P01264758 6122536500 2016-12-13 2015 2017-02-10 21:41:12Z Jayna Groebner 700 3rd Avenue NW Sleepy Eye MN 560851036 3555172 0 0928 X www.divineprovidencehome.org X 1960 MN Provide professional care at the highest level to the aged and physically impaired. 6 6 133 12 0 0 46638 69794 3111795 3468275 11548 3573 7758 7233 3177739 3548875 0 11470 0 0 2198395 2439756 0 0 0 1283912 1394927 3482307 3846153 -304568 -297278 2284016 1927422 316369 264584 1967647 1662838 Religious organization whose purpose is the care of the aged and physically impaired by providing professional care at the highest level. 0 0 3599343 11470 3468275 Divine Providence provides services to seniors by creating a haven of Christian love and commitment that speaks loudly of the dignity of life. The 53 bed nursing home provided 17,151 days of resident care. This includes professional nursing care, coordinated rehabilitation services, daily mass and rosary, weekly protestant services, nutritious meals, and engaging activities. The 21 senior living apartments provided housing services for 24 tenants. The purpose is to help seniors who are continuing life's journey with the help of family, friends, and professionals in all areas of long term care. 3599343 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 6 0 1 133 1 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 MN X Jayna Groebner 5077943011 700 Third Avenue NW Sleepy Eye MN 560851036 Sr Rita Butler President 40.00 X X 0 0 0 Sr Bernadine Ugolini Vice President 40.00 X X 0 0 0 Sr Brenda McHugh Treasurer 40.00 X X 0 0 0 Sr Mary Walker Secretary 40.00 X X 0 0 0 Sr Janet Kosman Director 40.00 X 0 0 0 Sr Barbara Moerman Director 40.00 X 0 0 0 Jayna Groebner Administrator 40.00 X 63008 0 2205 63008 0 2205 0 0 0 0 US Foods NW 6059 PO Box 1450 Minneapolis MN 55485 Food and Dietary Supplies 157654 1 2677 4500 62617 4500 69794 Nursing Home Care 623000 3181547 3181547 Senior Living Apartmen 623000 227258 227258 Other Revenue 900099 59470 59470 3468275 3573 3573 8060 4500 2266 5794 5794 5470 4031 1439 1439 3548875 3468275 0 10806 11470 11470 79196 79196 2009622 1914286 95336 51443 49003 2440 149507 142392 7115 149988 137618 12370 200 200 18145 18145 331861 324310 7551 2247 2247 244772 232623 12149 44 44 313701 313701 1733 1733 8565 8355 210 559 559 156548 156548 43851 43851 Nursing Facility Surcha 148022 148022 Medical Supplies 96379 96379 Auxiliary 7921 7921 Licensing and Permits 6497 6497 13882 5808 8074 3846153 3599343 246810 0 397874 172837 166078 250074 41232 47104 3065538 1930700 1203724 1134838 452922 300013 22186 22556 2284016 1927422 252025 216963 37927 8384 22186 22556 4231 16681 316369 264584 X 1967647 1662838 1967647 1662838 2284016 1927422 X -297278 -148 -7383 X 0 1 X 0 0 X 21702 55016 46709 46638 69794 239859 3747713 3491233 3475789 3111795 3468275 17294805 21522 19337 17245 14137 13530 85771 3790937 3565586 3539743 3172570 3551599 17620435 0 842533 799751 912254 848096 1138524 4541158 842533 799751 912254 848096 1138524 4541158 13079277 16281 13078 12985 11548 3425 57317 16281 13078 12985 11548 3425 57317 3807218 3578664 3552728 3184118 3555024 17677752 0.73990 0.75800 0.00320 0.00410 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 15180 18570 11188 22562 1 X 1532849 717236 815613 1391295 1100907 290388 141394 112557 28837 1134838 Capitalized Lease Obligations 16681 16681 X 3533422 -148 1000 852 3532570 16305 16305 3548875 3838231 3266 3266 3834965 11188 11188 3846153 Part IV, Line 1b: The Organization holds assets for the Auxiliary. Part IV, Line 2b: The Home acts as custodian for the funds of the residents and holds tenant security deposits. Part X, Line 2: The Home 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). The Home is required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS annually. In addition, the Home is subject to income tax on any net income that is derived from business activities that are unrelated to their exempt purpose. The Home believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and, as such, does not have any uncertain tax positions that are material to the financial statements. The Home 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. Part XI, Line 2d - Other Adjustments: Donations from Auxiliary included on the Financial Statements. 1,000. Part XI, Line 4b - Other Adjustments: Revenue from the Auxiliary not included on the Financial Statements. 18,571. Auxiliary fundraising expense moved from revenues to expenses -2,266. Part XII, Line 2d - Other Adjustments: Auxiliary fundraising expense moved from revenues to expenses. 2,266. Donations from Auxiliary included on the Financial Statements. 1,000. Part XII, Line 4b - Other Adjustments: Expenses from the Auxiliary not included on the Financial Statements. 11,188. 1 Scholarships 15 11470 Part I, Line 2: Employees who receive a scholarship must provide receipts for tuition, books, mandatory fees, and required supplies and equipment expense. Recipent must be employed at Divine Providence for at least 90 days and continue working at least 20 hours per week. The individual must seek career advancement within the facility or the long-term care field in general. In order to receive the scholarship, the employee will need to submit a copy of their semester or quarter transcript with a GPA of 2.5 or higher. Form 990, Part VI, Section A, line 7a The Board of Directors are appointed by the Provincial of the U.S.A. Province of the Daughters of St. Mary of Providence. Form 990, Part VI, Section A, line 8b The organization does not have a committee with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The required annual Form 990 filing is completed from the financial records provided by the non-profit organization upon completion of an annual audit by an independent CPA. After the review by the Board, the information tax return forms are then submitted to an officer for signature and submission. Form 990, Part VI, Section B, line 12c The policy covers the Board of Directors and prohibits contracting for services with agencies owned in part or entirely by persons employed by Divine Providence and/or related to managerial employees, including the Board of Directors. However, since Divine is located in the small town of Sleepy Eye, and since the choice of providers is limited in this rural setting, such contracts may be necessary. The Board of Directors would determine if a conflict exists and make review of the terms. Form 990, Part VI, Section B, line 15a The Board of Directors annually determines the administrators's compensation based on other nursing home administrators in Southwestern Minnesota. Form 990, Part VI, Section C, line 19 The Organization makes these documents available to the public upon request. Form 990, Part XI, line 9: Net Loss on Auxiliary not Included in Financial Statements -7,383. The Daughters of St Mary Providence 4200 North Austin Avenue Chicago IL 60634 510219736 Charity IL 501(c)(3) Line 1 N/A 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0