2015-11-09T13:20:24-06:00 2014-12-31 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2014-01-01 800015864 LEGACY SENIOR SERVICES LEGA 7635375700 14416 SPRING LAKE ROAD MINNETONKA MN 55345 ERIC LUNDE PRESIDENT 7635375700 2015-11-04 1 SARAH VOGT CPA P00978242 6122536500 2015-11-04 2014 2016-03-07 17:11:31Z WAUKESHA SPRINGS HEALTH & REHAB CENTER ERIC LUNDE 14416 SPRING LAKE ROAD MINNETONKA MN 55345 46993262 0 X N/A X 2001 MN TO OPERATE SKILLED NURSING FACILITIES AND SENIOR HOUSING COMMUNITIES THAT PROVIDE FOR THE LONG-TERM CARE OF THE AGED, INFIRMED, INJURED AND SICK. 4 4 1091 485 152019 42264 42518 86937 46573131 46896325 5049 1660 0 6934 46620698 46991856 35828 3465 0 0 25977834 27020053 41898 35889 35889 19850869 19251354 45906429 46310761 714269 681095 20661735 20729749 14338601 13911621 6323134 6818128 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 38893965 3465 46896325 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 137 RESIDENTS DURING 2014. 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 SEVEN 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 81 DURING 2014.-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 101 DURING 2014.-LSS OF MARYCREST, LLC, A 138 UNIT ASSISTED LIVING FACILITY LOCATED IN DENVER, COLORADO. LSS OF MARYCREST, LLC HAD AN AVERAGE DAILY CENSUS OF 135 DURING 2014.-LSS OF SHEBOYGAN, LLC, A 121 BED SKILLED NURSING FACILITY LOCATED IN SHEBOYGAN, WISCONSIN. LSS OF SHEBOYGAN, LLC HAD AN AVERAGE DAILY CENSUS OF 105 DURING 2014.-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 68 DURING 2014.-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 105 DURING 2014.-LSS HOME HEALTH AND HOSPICE, LLC, PROVIDES HOSPICE, HOME HEALTH AND NURSING SERVICES IN WADENA, MINNESOTA.ALL OF THE SKILLED NURSING FACILITIES ARE MEDICARE AND MEDICAID CERTIFIED. 38893965 1 1 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 1 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 0 1 132 0 1 1091 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 12000 0 0 ROGER GREEN SECRETARY 1.00 X X 4800 0 0 CHAR SAMUELSON DIRECTOR (THRU 12/29/14) 1.00 X 4800 0 0 ROBERT BECK DIRECTOR 1.00 X 4800 0 0 JOEL JENSEN DIRECTOR 1.00 X 4800 0 0 MEGAN SIMPSON ADMINISTRATOR - LSS OF MADISON 40.00 X 0 0 0 ANDREW HUHTA ADMINISTRATOR - LSS OF FRAZEE 40.00 X 0 0 0 RICHARD BLANCHARD ADMINISTRATOR - LSS OF WADENA 40.00 X 0 0 0 DANIEL PETERSON ADMIN. - LSS HOME HEALTH & HOSPICE 40.00 X 0 0 0 JULIE CALLENDER ADMINISTRATOR - LSS OF MARYCREST 40.00 X 0 0 0 CHELSY STATTELMAN ADMINISTRATOR - LSS OF TRAVERSE 40.00 X 0 0 0 DENNIS VIDETIC ADMINISTRATOR - LSS OF SHEBOYGAN 40.00 X 0 0 0 BARTON SMITH ADMINISTRATOR WAUKESHA SPRINGS HEALTH & 40.00 X 0 0 0 31200 0 0 0 0 0 0 HEALTH DIMENSIONS CONSULTING INC 4400 BAKER ROAD MINNEAPOLIS MN 55343 MGMT FEES, ADMIN. SALARIES, CONSULTING 3932558 HDG-WI LLC 4400 BAKER ROAD MINNEAPOLIS MN 55343 MANAGEMENT FEES 1438881 BSG MAINTENANCE INC PO BOX 165 NEWBURG WI 53060 LAUNDRY & HOUSEKEEPING SERVICES 858119 OGDEN CONSTRUCTION GROUP LLC 2123 W MICHIGAN STREET MILWAUKEE WI 53233 CONSTRUCTION 806202 PRO REHAB 200 LEWIS AVE S 210 WATERTOWN MN 55388 THERAPY SERVICES 673790 6 86937 86937 RESIDENT SERVICE REVENUE 623000 46342354 46342354 MISCELLANEOUS REVENUE 900099 553971 408886 145085 46896325 1660 1660 8340 1406 6934 6934 6934 46991856 46751240 152019 1660 3465 3465 31200 31200 21373733 19366853 2006880 66638 60293 6345 3720650 3366387 354263 1827832 1653794 174038 2566615 2566615 54459 54459 105265 105265 35889 35889 2357057 1984753 372304 163396 13650 149746 1493125 1194815 298310 271199 25642 245557 3580114 3506744 73370 100014 83132 16882 110043 31940 78103 462023 462023 912834 912834 669848 20515 649333 MEDICAL SUPPLIES 2450465 2450465 FOOD 1615285 1615285 MN DHS SURCHARGE/WI PRO 1322588 1322588 BAD DEBT EXPENSE 270106 270106 746918 548681 198237 46310761 38893965 7380907 35889 1996048 1558819 36782 36839 1000 4567226 4636422 19426 18942 485073 532322 18729581 5602561 13310366 13127020 245814 819385 20661735 20729749 5212800 4741382 193140 190440 3832665 3420712 166034 201718 4603856 5095385 330106 261984 14338601 13911621 X 6323134 6818128 6323134 6818128 20661735 20729749 X 681095 -186101 X 0 1 X 1 0 X 38914 91071 905228 42518 86937 1164668 39732833 40765252 43891737 46429715 46751240 217570777 39771747 40856323 44796965 46472233 46838177 218735445 0 0 0 218735445 9116 1858 9393 5049 10000 35416 9116 1858 9393 5049 10000 35416 39780863 40858181 44806358 46477282 46848177 218770861 0.99980 0.99980 0.00020 0.00020 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 1413200 1413200 13013275 3512574 9500701 1005721 1005721 2828988 2043108 785880 468397 46879 421518 13127020 X 46993262 0 46993262 -1406 -1406 46991856 46312167 1406 1406 46310761 0 46310761 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 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 2011. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES REPORTED IN EXPENSES ON FINANCIAL STATEMENTS -1,406. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES REPORTED IN EXPENSES ON FINANCIAL STATEMENTS 1,406. X X X X 1 MULLEN COMPANY LLC 4825 S AMMONS ST 127 DENVER CO 80123 GRANT WRITING AND FUND SOLICITATION 0 35889 42463 -6574 35889 42463 -6574 CO MN A CITY OF FRAZEE MN 416005174 2007-08-01 4850000 HEALTH CARE FACILITY ACQUISITION IN FRAZEE, MN 0 0 0 A 2004664 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) OR 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; LSS OF WADENA, LLC, AND LSS HOME HEALTH AND HOSPICE, 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 $97,901 ANDREW HUHTA LSS OF FRAZEE, LLC $85,546 RICHARD BLANCHARD LSS OF WADENA, LLC $94,288 DANIEL PETERSON LSS HOME HEALTH & HOSPICE, LLC $97,590 JULIE CALLENDER LSS OF MARYCREST, LLC $118,562 CHELSY STATTELMAN LSS OF TRAVERSE, LLC $71,105 DENNIS VIDETIC LSS OF SHEBOYGAN, LLC $99,666 BARTON SMITH WAUKESHA SPRINGS HEALTH & REHAB $132,858 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 11 THE 990 IS REVIEWED BY THE MANAGER OF FINANCIAL SERVICES AND THE VICE PRESIDENT OF FINANCIAL SERVICES 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. FORM 990, PART XI, LINE 9: LOSS ON REFINANCING -186,101. LSS OF MADISON LLC 110 BELMONT ROAD MADISON WI 53714 201209404 NURSING HOME WI 7652835 1830613 LEGACY SENIOR SERVICES LSS OF SHEBOYGAN LLC 3014 ERIE AVENUE SHEBOYGAN WI 53081 208658381 NURSING HOME WI 8178884 3363932 LEGACY SENIOR SERVICES LSS OF FRAZEE LLC 219 W MAPLE AVENUE FRAZEE MN 56544 208729268 NURSING HOME & ASSISTED LIVING MN 6019718 5175026 LEGACY SENIOR SERVICES LSS OF MARYCREST 2850 COLUMBINE ROAD DENVER CO 80221 262181659 ASSISTED LIVING CO 3927865 6903480 LEGACY SENIOR SERVICES LSS OF TRAVERSE LLC 303 7TH STREET SOUTH WHEATON MN 56296 273274611 NURSING HOME & INDEPENDENT LIVING MN 3424594 560057 LEGACY SENIOR SERVICES LSS OF WADENA LLC 201 SHADY LANE DRIVE WADENA MN 56482 454632615 NURSING HOME & INDEPENDENT LIVING MN 5640141 1680952 LEGACY SENIOR SERVICES LSS HOME HEALTH & HOSPICE LLC 201 SHADY LANE DRIVE WADENA MN 56482 454700887 HOME HEALTH AND HOSPICE AGENCY MN 1648554 355721 LEGACY SENIOR SERVICES