2023-11-03T11:18:02-05:00 2022-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-01-01 410711606 HARMONY COMMUNITY HEALTHCARE HARM 5078866544 815 MAIN AVENUE S HARMONY MN 55939 BRENDA MOSER FINANCE ADMINISTRATOR 5078866544 2023-11-02 1 BRENDA MOSER 999009999 0 MICHAEL J PETERSON CPA P01833529 2187224705 2023-10-31 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z GUNDERSEN HARMONY CARE CENTER BRENDA MOSER 815 MAIN AVENUE S HARMONY MN 55939 3704656 0 X HTTPS://WWW.GUNDERSENHEALTH.ORG/HARMONY-CARE-CENT X 1948 MN TO PROVIDE CARE TO THE ELDERLY. 7 3 81 5 0 0 110302 359256 3170925 3341514 -38297 3886 0 0 3242930 3704656 0 0 0 0 2209230 3294639 0 0 0 1306562 1149052 3515792 4443691 -272862 -739035 2070055 1579135 289192 553104 1780863 1026031 HARMONY COMMUNITY HEALTHCARE IS COMMITTED TO ENHANCING THE QUALITY OF LIFE OF THOSE WE SERVICE. 0 0 3905378 0 3340924 THE ORAGNIZATION PROVIDES HOUSING AND NURSING CARE TO THE ELDERLY BY OPERATING A 42-BED NURSING FACILITY IN HARMONY, MN. DURING 2022, THERE WERE 10,296 RESIDENT DAYS. 3905378 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 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 1 1 0 0 0 1 13 0 1 81 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 3 0 0 1 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 MN X BRENDA MOSER 5078866544 815 MAIN AVENUE S HARMONY MN 55939 BRENDA MOSER FINANCE ADMINISTRATOR 4.00 36.00 X 0 166265 47301 VICKI BAKALARS PRESIDENT 0.50 39.50 X X 0 141983 44693 CHUCK JOHNSON VICE PRESIDENT 0.50 39.50 X X 0 134297 49130 MICHELLE BORRESON ADMINISTRATOR/CEO 20.00 20.00 X 0 124613 53687 JEN BERENDES DIRECTOR 0.50 39.50 X 0 129072 38896 MANDI PERICAK DIRECTOR 0.50 39.50 X 0 107767 37434 SARA CARPENTER DIRECTOR (THRU APR) 0.50 39.50 X 0 51243 15514 LINDA KASTANTIN DIRECTOR (THRU APR) 0.50 39.50 X 0 40442 6290 CHRIS SKAALEN SECRETARY/TREASURER 0.50 X X 0 0 0 BOB PETERS DIRECTOR (THRU FEB) 0.50 X 0 0 0 MICHELLE GATZKE DIRECTOR 0.50 X 0 0 0 DONNA SCHEEVEL DIRECTOR 0.50 X 0 0 0 0 895682 292945 0 0 1 0 0 334736 24520 359256 RESIDENT SERVICE REVEN 623000 3214999 3214999 RENTAL REVENUE 900099 83088 83088 43427 42837 590 3341514 3886 3886 3704656 3340924 0 4476 2946333 2764183 182150 29126 28786 340 200826 188224 12602 118354 114866 3488 99540 99540 352 352 14280 14280 270618 269838 780 4461 1020 3441 33893 22395 11498 161253 155469 5784 1869 1659 210 9232 7956 1276 1662 1330 332 128027 102422 25605 13279 13279 DHS SURCHARGE 121045 121045 FOOD EXPENSE 113568 113568 MEDICAL SUPPLIES 92941 92941 MINOR EQUIPMENT 21454 21454 61578 19267 42311 4443691 3905378 538313 0 534757 142471 253457 234070 34501 36866 3201496 2065307 1175633 1136189 71707 29539 2070055 1579135 282283 288770 0 5848 6411 6636 498 200000 0 51850 289192 553104 X 1735527 996492 45336 29539 1780863 1026031 2070055 1579135 X -739035 -15797 X 0 1 X 1 0 X 4425 14596 339334 110302 359256 827913 3280065 3795367 3402808 3170925 3341514 16990679 3284490 3809963 3742142 3281227 3700770 17818592 0 1300919 1534247 1571306 1365479 1042839 6814790 1300919 1534247 1571306 1365479 1042839 6814790 11003802 2275 2858 2935 2564 3886 14518 2275 2858 2935 2564 3886 14518 3286765 3812821 3745077 3283791 3704656 17833110 0.61700 0.63320 0.00080 0.00070 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 24650 24650 2554653 1528465 1026188 622193 536842 85351 1136189 DUE TO AFFILIATES 40806 ADVANCE COVID PAYMENTS 11044 51850 X PART X, LINE 2: GUNDERSEN HEALTH SYSTEM HAS REVIEWED TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS. THE SYSTEM'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2016 AND PRIOR YEARS. 0 0 0 0 0 0 0 0 0 BRENDA MOSER FINANCE ADMINISTRATOR 0 159798 0 5347 0 1120 0 24607 0 22694 0 213566 0 0 VICKI BAKALARS PRESIDENT 0 138991 0 401 0 2591 0 21199 0 23494 0 186676 0 0 CHUCK JOHNSON VICE PRESIDENT 0 127121 0 216 0 6960 0 20636 0 28494 0 183427 0 0 MICHELLE BORRESON ADMINISTRATOR/CEO 0 124102 0 511 0 0 0 19185 0 34502 0 178300 0 0 JEN BERENDES DIRECTOR 0 123104 0 3962 0 2006 0 18269 0 20627 0 167968 0 0 PART I, LINE 3 A RELATED ORGANIZATION OF THE FILING ORGANIZATION USES ONE OR MORE OF THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY, AND -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PLEASE REFER TO THE FORM 990, PART VI, LINE 15A DISCLOSURE IN SCHEDULE O FOR ADDITIONAL DETAILS ON HOW COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS ESTABLISHED. FORM 990, PART VI, SECTION A, LINE 4 GUNDERSEN AND BELLIN HEALTH SYSTEMS, INC. (BELLIN), EACH A WISCONSIN NONPROFIT, NON-STOCK CORPORATION, ENTERED INTO A COMBINATION AGREEMENT DATED JULY 29, 2022 (THE AGREEMENT), TO ALIGN THEIR RESPECTIVE OPERATIONS AND TO FORM A SINGLE NONPROFIT HEALTH SYSTEM THROUGH THE CREATION OF BELLIN GUNDERSEN HEALTH SYSTEM, INC., A WISCONSIN NONPROFIT, NON-STOCK CORPORATION (BELLIN GUNDERSEN). ON DECEMBER 1, 2022, UPON CONSUMMATION OF THE ALIGNMENT OF THE TWO SYSTEMS (THE AFFILIATION), BELLIN GUNDERSEN BECAME THE SOLE CORPORATE MEMBER OF BOTH BELLIN AND GUNDERSEN. BELLIN AND GUNDERSEN AND THEIR RESPECTIVE AFFILIATES ARE EXPECTED TO MAINTAIN THEIR RESPECTIVE CORPORATE EXISTENCE. IN DECEMBER 2022, THE BYLAWS OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. WERE AMENDED AND RESTATED TO UPDATE THE SOLE CORPORATE MEMBER TO BELLIN GUNDERSEN HEALTH SYSTEM, INC. THE BYLAWS WERE ALSO UPDATED TO SPECIFY THE POWERS RETAINED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE CHIEF EXECUTIVE OFFICER OF BELLIN GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. RETAINS AUTHORITY TO APPROVE ANY SIGNIFICANT CHANGES TO THE CORPORATION. SUBJECT TO THE RESERVED POWERS SPECIFIED IN THE BYLAWS, THE AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY ITS BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE VOTING MEMBER OF HARMONY COMMUNITY HEALTHCARE, INC. IS GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7A FOUR OUT OF THE SEVEN DIRECTORS SHALL BE ELECTED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC.'S BOARD OF GOVERNORS AND BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B GUNDERSEN LUTHERAN HEALTH SYSTEM, INC.'S FINANCE COMMITTEE APPROVES THE BUDGET AND CAPITAL BUDGET. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 11B THE DRAFT FORM 990 WILL FIRST BE REVIEWED BY THE CEO/ADMINISTRATOR AND FINANCE ADMINISTRATOR. THE RETURN WILL THEN BE PROVIDED TO THE BOARD OF DIRECTORS AFTER FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS BOARD MEMBERS AND OFFICERS. BOARD MEMBERS ARE ASKED TO DISCLOSE ANY POTENTIAL CONFLICTS AS THEY ARISE. IF THE BOARD OF DIRECTORS DETERMINES THERE IS A CONFLICT THE BOARD MEMBER WITH THE CONFLICT MUST REFRAIN FROM VOTING. A STATEMENT OF CONFLICT OF INTEREST DISCLOSURE IS MADE ON AN ANNUAL BASIS BY OFFICERS AND DIRECTORS. THE DISCLOSURE FORMS ARE REVIEWED BY HARMONY COMMUNITY HEALTHCARE'S COMPLIANCE COMMITTEE ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15A THE ADMINISTRATOR IS COMPENSATED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE HARMONY BOARD OF DIRECTORS APPROVES THE COMPENSATION FOR THE ADMINISTRATOR AND USES THE AGING SERVICE OF MINNESOTA SALARY SURVEY. THERE IS A WRITTEN CONTRACT IN PLACE FOR THE ADMINISTRATOR. COMPENSATION IS REVIEWED ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE UPON REQUESTS. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN FOUNDATION -15,797. BELLIN GUNDERSEN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 920504278 PARENT WI 501(C)(3) LINE 12B, II N/A 0 BELLIN HEALTH SYSTEMS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512904 SUPPORT OF HEALTHCARE ORGANIZATIONS WI 501(C)(3) LINE 12B, II BELLIN GUNDERSEN HEALTH SYSTEMS INC 1 BELLIN COLLEGE INC 3201 EATON ROAD GREEN BAY WI 54311 391620530 NURSING AND RADIOLOGIC SCIENCE COLLEGE WI 501(C)(3) LINE 2 BELLIN HEALTH SYSTEMS INC 1 LAKE MICHIGAN HEALTH SERVICES INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391512903 SUPPORT PURPOSES OF BELLIN MEMORIAL HOSPITAL WI 501(C)(3) LINE 12B, II BELLIN HEALTH SYSTEMS INC 1 THE BELLIN HEALTH FOUNDATION INC PO BOX 23400 GREEN BAY WI 54301 391809171 FOUNDATION WI 501(C)(3) LINE 7 BELLIN HEALTH SYSTEMS INC 1 BELLIN PSYCHIATRIC CENTER INC PO BOX 23725 GREEN BAY WI 54305 391657627 PSYCHIATRIC HOSPITAL WI 501(C)(3) LINE 3 BELLIN HEALTH SYSTEMS INC 1 BELLIN MEMORIAL HOSPITAL INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 390884478 HEALTH CARE WI 501(C)(3) LINE 3 BELLIN HEALTH SYSTEMS INC 1 OCONTO HOSPITAL & MEDICAL CENTER INC 820 ARBUTUS AVENUE OCONTO WI 54153 061745397 HEALTH CARE WI 501(C)(3) LINE 3 BELLIN MEMORIAL HOSPITAL INC 1 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391866425 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 12B, II BELLIN GUNDERSEN HEALTH SYSTEMS INC 1 GUNDERSEN LUTHERAN MEDICAL CENTER INC 1910 SOUTH AVENUE LA CROSSE WI 54601 390813416 HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 GUNDERSEN CLINIC LTD 1910 SOUTH AVENUE LA CROSSE WI 54601 391028657 HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES INC 1910 SOUTH AVENUE LA CROSSE WI 54601 391606449 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 12B, II GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 GUNDERSEN LUTHERAN MEDICAL FOUNDATION INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391249705 FOUNDATION WI 501(C)(3) LINE 7 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 GUNDERSEN LUTHERAN CREDENTIALING SERVICES INC 1910 SOUTH AVENUE LA CROSSE WI 54601 391856898 CREDENTIALING SERVICE WI 501(C)(3) LINE 12C, III-FI GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 TWEETEN LUTHERAN HEALTHCARE CENTER INC 125 FIFTH AVENUE SE SPRING GROVE MN 55974 411565003 HEALTH CARE MN 501(C)(3) LINE 10 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 TRI-STATE AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE WI 54601 391965415 MEDICAL TRANSPORTATION WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 TRI-STATE REGIONAL AMBULANCE INC 235 CAUSEWAY BLVD LA CROSSE WI 54603 391962965 MEDICAL TRANSPORTATION WI 501(C)(3) LINE 11 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 LUTHERAN REAL ESTATE HOLDING CORP 1910 SOUTH AVENUE LA CROSSE WI 54601 391480826 HOUSING WI 501(C)(3) LINE 12C, III-FI GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 COMMUNITY HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391586700 INDEPENDENT LIVING WI 501(C)(3) LINE 10 LUTHERAN REAL ESTATE HOLDING CORP 1 LUTHERAN HOUSING OF LA CROSSE INC 1900 SOUTH AVENUE LA CROSSE WI 54601 391751934 INDEPENDENT LIVING WI 501(C)(3) LINE 10 LUTHERAN REAL ESTATE HOLDING CORP 1 ST JOSEPH'S MEMORIAL FOUNDATION INC 400 WATER AVE HILLSBORO WI 54634 391455787 FOUNDATION WI 501(C)(3) LINE 12A, I ST JOSEPH'S HEALTH SERVICES INC 1 TRI-COUNTY MEMORIAL HOSPITAL INC 18601 LINCOLN STREET WHITEHALL WI 54773 390704510 HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 TRI-COUNTY MEMORIAL FOUNDATION INC 18601 LINCOLN STREET WHITEHALL WI 54773 300093022 FOUNDATION WI 501(C)(3) LINE 12A, I TRI-COUNTY MEMORIAL HOSPITAL INC 1 MEMORIAL HOSPITAL OF BOSCOBEL 205 PARKER STREET BOSCOBEL WI 53805 390845590 HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 PALMER LUTHERAN HEALTH CENTER 112 JEFFERSON STREET WEST UNION IA 52175 421320763 HEALTH CARE IA 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 MEMORIAL HEALTHCARE FOUNDATION INC PO BOX 40 FRIENDSHIP WI 53934 391775074 FOUNDATION WI 501(C)(3) LINE 12A, I MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC 1 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS INC 402 W LAKE STREET FRIENDSHIP WI 53934 390944012 HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 SAINT ELIZABETH'S HOSPITAL OF WABASHA 1200 GRANT BLVD WEST WABASHA MN 55981 410693877 HEALTH CARE MN 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 ST JOSEPH'S HEALTH SERVICES PO BOX 527 400 WATER AVENUE HILLSBORO WI 54634 390929538 HEALTH CARE WI 501(C)(3) LINE 3 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1 GUNDERSEN LUTHERAN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI N/A C 1 BEL-REGIONAL HOME MEDICAL INC 617 S ROOSEVELT GREEN BAY WI 54301 391504766 DURABLE MEDICAL EQUIPMENT, RETAIL PHARMACY, FITNESS WI N/A C 1 BELLIN INVESTMENTS INC 744 SOUTH WEBSTER AVE GREEN BAY WI 54301 391564939 OTHER WI N/A C 1 0 0 0 1 0 0 0 0 0 1 0 1 1 1 1 1 1 0 0