2013-08-15T10:10:17-05:00 2012-12-31 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2012-01-01 800015864 LEGACY SENIOR SERVICES LEGA 7635375700 14416 SPRING LAKE ROAD MINNETONKA MN 55345 ERIC LUNDE 7635375700 2013-08-12 1 SARAH VOGT CPA P00978242 6122536500 2013-08-12 2012 2016-02-24 21:20:13Z WAUKESHA SPRINGS HEALTH & REHAB CENTER ERIC LUNDE 14416 SPRING LAKE ROAD MINNETONKA MN 55345 44921100 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. 3 3 1272 573 114742 33191 91071 905228 40793567 44006479 1858 9393 0 0 40886496 44921100 14917 40987 0 0 24470645 24906956 31424 40373 40373 16960076 19040820 41477062 44029136 -590566 891964 18126824 20604252 14275921 14995387 3850903 5608865 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. 1 0 36793580 40987 44006479 LEGACY SENIOR SERVICES IS A MINNESOTA CORPORATION THAT OPERATES A 170 BED SKILLED NURSING FACILITY IN WAUKESHA, WISCONSIN, CALLED WAUKESHA SPRINGS HEALTH & REHABILITATION CENTER. WAUKESHA SPRINGS HEALTH & REHABILITATION CENTER HAD AN AVERAGE DAILY CENSUS OF 141 RESIDENTS DURING 2012. 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 82 DURING 2012.-LSS OF FRAZEE, LLC, A 74 BED SKILLED NURSING FACILITY AND A 19 UNIT ASSISTED 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 102 DURING 2012.-LSS OF MARYCREST, LLC, A 138 UNIT ASSISTED LIVING FACILITY LOCATED IN DENVER, COLORADO. LSS OF MARYCREST, LLC HAD AN AVERAGE DAILY CENSUS OF 136 DURING 2012.-LSS OF SHEBOYGAN, LLC, A 140 BED SKILLED NURSING FACILITY LOCATED IN SHEBOYGAN, WISCONSIN. LSS OF SHEBOYGAN, LLC HAD AN AVERAGE DAILY CENSUS OF 121 DURING 2012.-LSS OF TRAVERSE, LLC, A 50 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 61 DURING 2012.-LSS OF WADENA, LLC, A 75 BED SKILLED NURSING FACILITY LOCATED IN WADENA, MINNESOTA. LSS OF WADENA, LLC HAD AN AVERAGE DAILY CENSUS OF 59 DURING 2012.-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. 36793580 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 1 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 1 122 0 1 1272 1 1 1 0 0 0 0 0 0 0 0 0 X 3 3 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 0 1 0 0 0 MN X HEALTH DIMENSIONS GROUP 7635375700 4400 BAKER ROAD STE 100 MINNEAPOLIS MN 55343 ERIC LUNDE 6.00 X X 8400 0 0 ROGER GREEN 1.00 X X 3600 0 0 CHAR SAMUELSON 1.00 X 3600 0 0 CRAIG ABBOTT 1.00 X 0 0 0 VIRGINIA ANDERSON 4.00 X 0 0 0 15600 0 0 0 0 0 0 HEALTH DIMENSIONS CONSULTING INC 4400 BAKER ROAD MINNEAPOLIS MN 55343 MANAGEMENT FEES, ADMINISTRATION 2108932 HDG-WI LLC 4400 BAKER ROAD MINNEAPOLIS MN 55343 MANAGEMENT FEES, ADMINISTRATION 1279056 BSG MAINTENANCE INC PO BOX 165 NEWBURG WI 53060 LAUNDRY & HOUSEKEEPING SERVICES 849233 AVIANDS LLC NW 5704 PO BOX 1450 MINNEAPOLIS MN 554855704 DIETARY SERVICES 528095 AEGIS THERAPIES INC PO BOX 8103 FORT SMITH AR 72902 THERAPY SERVICES 322584 6 540000 365228 272571 905228 RESIDENT SERVICE REVEN 623000 43377372 43377372 MISCELLANEOUS REVENUE 900099 629107 514365 114742 44006479 9393 9393 44921100 43891737 114742 9393 40987 40987 15600 15600 19997994 18098223 1899771 38156 34504 3652 3020887 2731788 289099 1834319 1658775 175544 2318140 2318140 162730 162730 92841 92841 40373 40373 3063284 2682973 380311 182406 16964 165442 1398807 1142543 256264 221114 16035 205079 3432789 3366010 66779 50958 43424 7534 100964 27919 73045 604361 604361 830006 830006 648270 13331 634939 MEDICAL SUPPLIES 2833708 2833708 MN DHS SURCHARGE/WI PRO 1304872 1304872 FOOD 936969 936969 BAD DEBT EXPENSE 257311 257311 601290 410188 191102 44029136 36793580 7195183 40373 1269652 1875276 39019 39200 51845 4011360 4694003 19426 19426 277220 169350 17329848 3785080 12253702 13544768 3333 833 253112 209551 18126824 20604252 4414608 5440389 4310917 4078934 184665 191487 4960625 4829471 405106 455106 14275921 14995387 X 1208974 5608865 2641929 0 3850903 5608865 18126824 20604252 891964 865998 0 X X 0 1 X 1 0 X 25985 14754 38914 91071 905228 1075952 34641309 38965370 39732833 40765252 43891737 197996501 34667294 38980124 39771747 40856323 44796965 199072453 0 0 0 199072453 30037 8064 9116 1858 9393 58468 30037 8064 9116 1858 9393 58468 34697331 38988188 39780863 40858181 44806358 199130921 0.99970 0.99950 0.00030 0.00050 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 1413200 1413200 12315668 2262916 10052752 737710 31737 705973 2503153 1463727 1039426 360117 26700 333417 13544768 X 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. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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. X X X X 1 MULLEN COMPANY LLC 4825 S AMMONS ST 127 DENVER CO 80123 GRANT WRITING AND FUND SOLICITATION 0 611277 40373 570904 611277 40373 570904 CO MN 1 SCHOLARSHIPS 13 39432 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION PROVIDES FUNDS UNDER SCHOLARSHIP AND TUITION ASSISTANCE PROGRAMS FOR ITS EMPLOYEES. EMPLOYEES MUST MEET CERTAIN CRITERIA TO QUALIFY. THE ORGANIZATION EITHER REIMBURSES THE EMPLOYEE FOR EDUCATIONAL EXPENSES OR PAYS THE EDUCATIONAL INSTITUTION DIRECTLY. A CITY OF FRAZEE MN 416005174 2007-08-01 4850000 HEALTH CARE FACILITY ACQUISITION IN FRAZEE, MN 0 0 0 A 771065 4882400 133384 4749016 2008 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0 0 0 A 0 0 0 1 1 0 0 0 0 A 0 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. SCHEDULE K, PART IV, LINE 2C: A REBATE CALCULATION WAS COMPLETED ON SEPTEMBER 11, 2012 SHOWING THAT NO REBATE WAS DUE FOR THE APPLICABLE COMPUTATION DATE. X 1 272571 FMV 0 0 0 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 EFFECTIVE MAY 1, 2012, LEGACY SENIOR SERVICES BECAME THE SOLE MEMBER OF 2 NEW LLCS LSS HOME HEALTH & HOSPICE, LLC AND LSS OF WADENA, LLC. LSS OF WADENA, LLC IS A SKILLED NURSING FACILITY LOCATED IN WADENA, MN. LSS HOME HEALTH & HOSPICE, LLC IS A NEW SERVICE OFFERING FOR LEGACY. THIS LLC PROVIDES HOSPICE, HOME HEALTH AND NURSING SERVICES IN WADENA, MN. 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. 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. THE CEO AND VICE PRESIDENT OF FINANCIAL SERVICES ARE COMPENSATED AND EMPLOYED 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 XII, LINE 2C: HEALTH DIMENSIONS GROUP (HDG), AS LEGACY SENIOR SERVICES' MANAGEMENT COMPANY, HAS RESPONSIBILITY FOR THE OVERSIGHT OF THE AUDIT AND PREPARATION OF THE MONTHLY FINANCIAL STATEMENTS. THE LEGACY SENIOR SERVICES' BOARD PRESIDENT, HDG'S FINANCIAL SERVICES MANAGER, AND HDG'S VP OF FINANCIAL SERVICES WERE INVOLVED TOGETHER IN SELECTION OF AN INDEPENDENT ACCOUNTANT FOR AUDIT/TAX SERVICES. LSS OF MADISON LLC 110 BELMONT ROAD MADISON WI 53714 201209404 NURSING HOME WI 7075745 1440694 LEGACY SENIOR SERVICES LSS OF SHEBOYGAN LLC 3014 ERIE AVENUE SHEBOYGAN WI 53081 208658381 NURSING HOME WI 9610017 3702363 LEGACY SENIOR SERVICES LSS OF FRAZEE LLC 219 W MAPLE AVENUE FRAZEE MN 56544 208729268 NURSING HOME & ASSISTED LIVING MN 5837528 5087123 LEGACY SENIOR SERVICES LSS OF MARYCREST 2850 COLUMBINE ROAD DENVER CO 80221 262181659 ASSISTED LIVING CO 3721196 6952412 LEGACY SENIOR SERVICES LSS OF TRAVERSE LLC 303 7TH STREET SOUTH WHEATON MN 56296 273274611 NURSING HOME & INDEPENDENT LIVING MN 3145320 362615 LEGACY SENIOR SERVICES LSS OF WADENA LLC 201 SHADY LANE DRIVE WADENA MN 56482 454632615 NURSING HOME MN 2984169 1698161 LEGACY SENIOR SERVICES LSS HOME HEALTH & HOSPICE LLC 201 SHADY LANE DRIVE WADENA MN 56482 454700887 HOME HEALTH AND HOSPICE AGENCY MN 819290 440691 LEGACY SENIOR SERVICES