2024-11-15T14:18:42-06:00 2023-12-31 990 2023-01-01 391029998 ST FRANCIS HOME OF FOND DU LAC WISCONSIN INC STFR 9209265519 33 EVERETT STREET FOND DU LAC WI 54935 STEPHANIE KING VP-FINANCE 9209265519 2024-11-15 0 2023 2024-10-15 13:58:12Z CHRIS THORNOCK 33 EVERETT STREET FOND DU LAC WI 54935 14030240 0 0928 X HTTPS://WWW.SSMHEALTH.COM/LOCATIONS/LOCATION-DETA X 1978 WI TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO ALL WE SERVE. THE ORGANIZATION PROVIDES SKILLED NURSING CARE, INDEPENDENT LIVING AND ASSISTED LIVING FACILITIES. ST. FRANCIS HOME IS THE HEART OF ITS CARE CAMPUS. 1 0 0 20 0 0 3325 10990 11078301 13989569 -92855 0 41500 29681 11030271 14030240 0 793 0 0 8980283 8865972 0 0 0 5503069 7099909 14483352 15966674 -3453081 -1936434 17769918 18065636 5610797 7750592 12159121 10315044 TO PROVIDE COMPASSIONATE CARE THAT BRINGS HOPE, HEALTH AND WHOLENESS TO ALL WE SERVE. THE ORGANIZATION PROVIDES SKILLED NURSING CARE, INDEPENDENT LIVING AND ASSISTED LIVING FACILITIES. ST. FRANCIS HOME IS THE HEART OF ITS CARE CAMPUS. 0 0 14240563 793 13989569 ST. FRANCIS HOME OF FOND DU LAC, WISCONSIN, INC. OPERATES A NURSING HOME AND RELATED HEALTH CARE FACILITIES PROVIDING VARIOUS PROGRAMS FOR THE CARE OF THE ELDERLY, INJURED, AND SICK. THIS MEDICARE-CERTIFIED SKILLED NURSING FACILITY SPECIALIZES IN LONG-TERM CARE FOR THE ELDERLY. IT PROVIDES THE LATEST IN NURSING HOME CARE, STRESSING A HOME-LIKE ATMOSPHERE FOR RESIDENTS AND OFFERING A SPECIAL UNIT DEDICATED TO THE CARE OF RESIDENTS WITH ALZHEIMER'S DISEASE. ST. CLARE TERRACE OFFERS INDEPENDENT LIVING OPTIONS. THIS SAFE, SECURE COMMUNITY LIVING ENVIRONMENT PROVIDES RESIDENTS A FULFILLING LIFESTYLE IN THEIR RETIREMENT YEARS. ST. FRANCIS TERRACE OFFERS ASSISTED LIVING CARE. THIS IS AN INTERIM CARE OPTION THAT PROVIDES SOME NURSING SUPPORT AND ASSISTANCE, YET ALLOWS PEOPLE TO LIVE INDEPENDENTLY. 14240563 1 1 0 0 0 0 0 0 0 0 1 0 1 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 0 0 0 1 X 0 0 0 0 0 0 0 0 0 0 0 0 0 X 1 0 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 0 0 0 X THE ORGANIZATION 9209265519 33 EVERETT STREET FOND DU LAC WI 54935 CAROL HYLAND PT YR DIRECTOR 1.00 3.00 X 0 0 0 STEVE FRANKE PT YR DIRECTOR, ASST SEC/TREAS 1.00 3.00 X X 0 0 0 SR STEPHEN BLOESL PT YR DIRECTOR 1.00 3.00 X 0 0 0 DAVE KUSEK PT YR DIRECTOR, CHAIRPERSON 1.00 3.00 X X 0 0 0 BARB SENN PT YR DIRECTOR, VICE CHAIRPERSON 1.00 3.00 X X 0 0 0 DG GLOEDE DIRECTOR, PRESIDENT-POST ACUTE 1.00 40.00 X X 0 352791 181038 SUE BUWALDA PT YR DIRECTOR 1.00 3.00 X 0 0 0 RICK VANT HOFF PT YR DIRECTOR 1.00 3.00 X 0 0 0 JENNY KNUTH PT YR DIRECTOR 1.00 3.00 X 0 0 0 MARILYN MULDER PT YR DIRECTOR 1.00 3.00 X 0 0 0 CHRIS THORNOCK PT YR DIRECTOR, VP MEDICAL GROUP 1.00 40.00 X X 0 583387 263637 RANDY COMBS TREASURER, CFO OF SSM HEALTH 1.00 50.00 X 0 2182354 1238074 DOUGLAS LONG SECRETARY, GENERAL COUNSEL AT SSM HEALTH 1.00 50.00 X 0 1425239 777013 STEVE SMOOT VICE PRESIDENT, COO OF SSM HEALTH 1.00 50.00 X 0 2054358 1204489 0 6598129 3664251 0 0 1 0 VAYA WORKFORCE SOLUTIONS 5930 CORNERSTONE CT SAN DIEGO CA 92121 STAFFING SERVICES 1146445 SYSCO FOOD SERVICES 1350 W TECUMSEH RD NORMAN OK 73069 DIETARY SERVICES 504369 PRN HEALTH SERVICES 1101 E SOUTH RIVER ST APPLETON WI 54915 THERAPY 385667 HEALTH DIMENSIONS CONSULTING INC 12900 WHITEWATER DRIVE MINNEAPOLIS MN 55343 CONSULTING 371576 WISCONSIN POWER & LIGHT PO BOX 52406 CEDAR RAPIDS WI 52406 UTILITIES 301446 5 8409 2581 10990 NET PATIENT SERVICE REVENUE 623110 13989569 13989569 13989569 BEAUTY SHOP 900099 26646 26646 CAFETERIA REVENUE 722210 3035 3035 29681 14030240 13989569 0 29681 X 793 793 6780616 6653977 126639 363103 356321 6782 1170455 1148595 21860 551798 541492 10306 1290886 78411 1212475 2268 2268 2593123 2480866 112257 1108 1108 667362 650102 17260 36078 36078 679372 678226 1146 4219 2970 1249 7934 7674 260 318222 318222 840535 685584 154951 89985 39584 50401 MEDICAL SUPPLIES 282463 282295 168 LICENSES AND TAXES 200159 200159 OTHER EXPENSES 52977 52977 LICENSES DUES & SUBSCRI 32938 24849 8089 280 280 15966674 14240563 1726111 0 46103 10304 549425 1778612 78449 63881 20969687 7347944 14507294 13621743 2588647 2591096 17769918 18065636 831039 1376373 92021 414705 4687737 5959514 5610797 7750592 X 9570474 7723948 2588647 2591096 12159121 10315044 17769918 18065636 X -1936434 92357 X 0 1 X 1 0 X 65165 384266 600430 3325 10990 1064176 13638564 13348707 10723588 11078301 13989569 62778729 47484 33288 61269 39569 29681 211291 13751213 13766261 11385287 11121195 14030240 64054196 0 0 0 64054196 4318 142776 122864 1931 0 271889 4318 142776 122864 1931 271889 13755531 13909037 11508151 11123126 14030240 64326085 0.99580 0.99520 0.00420 0.00000 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1340000 1340000 16584666 5188400 11396266 266631 218175 48456 2736952 1941369 795583 41438 41438 13621743 BENEFICIAL INTEREST IN FOUNDATION 2591096 C 2591096 DUE TO AFFILIATES 5035699 OTHER LIABILITIES 859816 THIRD PARTY PAYOR 63999 5959514 X PART X, LINE 2: ST. FRANCIS HOME OF FOND DU LAC WISCONSIN, INC.'S FINANCIAL INFORMATION IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF A RELATED ORGANIZATION, SSM HEALTH (SSMH). SSMH EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS. A TAX BENEFIT FROM AN UNCERTAIN TAX POSITION MAY BE RECOGNIZED WHEN IT IS MORE LIKELY THAN NOT THAT THE POSITION WILL BE SUSTAINED UPON EXAMINATION, INCLUDING RESOLUTIONS OF ANY RELATED APPEALS OR LITIGATION PROCESSES, BASED ON THE TECHNICAL MERITS. THERE HAVE BEEN NO UNCERTAIN TAX POSITIONS RECORDED IN 2022 OR 2023. X 1 1 0 1 0 0 0 0 0 0 0 RANDY COMBS TREASURER, CFO OF SSM HEALTH 0 1242308 0 669269 0 270777 0 1203989 0 34085 0 3420428 0 669269 STEVE SMOOT VICE PRESIDENT, COO OF SSM HEALTH 0 1173646 0 737192 0 143520 0 1164125 0 40364 0 3258847 0 878090 DOUGLAS LONG SECRETARY, GENERAL COUNSEL AT SSM HE 0 759270 0 495539 0 170430 0 753634 0 23379 0 2202252 0 495539 CHRIS THORNOCK PT YR DIRECTOR, VP MEDICAL GROUP 0 466669 0 112038 0 4680 0 228224 0 35413 0 847024 0 101538 DG GLOEDE DIRECTOR, PRESIDENT-POST ACUTE 0 307772 0 43403 0 1616 0 151034 0 30004 0 533829 0 30403 PART I, LINE 1A SEVERAL INDIVIDUALS LISTED ON PART VII, SECTION A, RECEIVED TAX INDEMNIFICATION/GROSS UP PAYMENTS IN 2023, WHICH WERE INCLUDED IN THEIR TAXABLE COMPENSATION. PART I, LINE 3 THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL (PRESIDENT-POST ACUTE) IS COMPENSATED BY A RELATED ORGANIZATION THAT UTILIZED THE FOLLOWING TO DETERMINE COMPENSATION: (1) INDEPENDENT COMPENSATION CONSULTANT; (2) COMPENSATION SURVEY OR STUDY; (3) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4B PENSION RESTORATION PLAN: SSM HEALTH (SSMH) PROVIDES THIS SUPPLEMENTAL DEFINED BENEFIT NONQUALIFIED RETIREMENT PLAN TO ANY EMPLOYEE WHO IS A PARTICIPANT IN THE SSMH QUALIFIED DEFINED BENEFIT PLAN WHO EARNS OVER THE INTERNAL REVENUE SERVICE COMPENSATION LIMIT. THE PLAN "RESTORES" THE BENEFITS TO THESE EMPLOYEES THAT WOULD HAVE BEEN PROVIDED UNDER THE SSMH QUALIFIED PLAN IF THE REGULATIONS DID NOT IMPOSE COMPENSATION LIMITS. AN INDIVIDUAL CAN TAKE A DISTRIBUTION FROM THE PLAN AT (1) AGE 65 OR OLDER IF THE INDIVIDUAL IS STILL EMPLOYED BY SSMH OR (2) AGE 55 OR OLDER IF THE INDIVIDUAL IS NO LONGER EMPLOYED BY SSMH. NO INDIVIDUAL LISTED ON PART VII OF FORM 990 RECEIVED DISTRIBUTIONS FROM THE PLAN IN 2023. CAPITAL ACCUMULATION PLAN: SSMH PROVIDES THIS SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN TO EXECUTIVE LEVEL EMPLOYEES. THE ORGANIZATION CONTRIBUTED A PERCENTAGE OF THE EMPLOYEE'S BASE SALARY INTO THEIR CHOICE OF A SELECT LIST OF INVESTMENTS. THE DEPOSITS AND EARNINGS OF THE PLAN ARE OWNED BY SSMH AND ARE TAX-DEFERRED UNTIL A DISTRIBUTION IS MADE TO THE EMPLOYEE. IN ADDITION, THE PLAN HAS SPECIAL SAFEGUARDS IN PLACE TO PROTECT THE FUNDS FROM CONTINGENCIES, OTHER THAN INSOLVENCY. FOR CONTRIBUTIONS MADE TO THE PLAN IN 2014 OR AFTER, THE DISTRIBUTION WILL OCCUR AFTER THE COMPLETION OF FOUR PLAN YEARS FOR ALL EXECUTIVES THAT ARE STILL ACTIVELY EMPLOYED ON THE DISTRIBUTION DATE. ANY ACTIVE PARTICIPANT 65 YEARS OR OLDER WILL RECEIVE THE CONTRIBUTION IN THE CURRENT YEAR. THE FOLLOWING INDIVIDUALS LISTED ON PART VII OF THE FORM 990 RECEIVED DEFERRALS FROM THIS PLAN IN 2023: STEVE SMOOT - $249,972 RANDALL COMBS $261,633 DOUGLAS LONG $161,286 DG GLOEDE $28,146 CHRIS THORNOCK $45,375 THE FOLLOWING INDIVIDUALS LISTED ON PART VII OF THE FORM 990 RECEIVED DISTRIBUTIONS FROM THIS PLAN IN 2023. ALL DISTRIBUTIONS RECEIVED FROM THE PLAN IN THE CURRENT YEAR WERE INCLUDED IN THE INDIVIDUAL'S TAXABLE COMPENSATION. STEVE SMOOT $140,898 FORM 990, PART V, LINE 1A ALL APPLICABLE 1099 AND 1096 IRS TAX FORMS ARE REPORTED AND FILED BY A RELATED ORGANIZATION, SSM HEALTH CARE CORPORATION, 46-6029223. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION IS AGNESIAN HEALTHCARE INC. AGNESIAN HEALTHCARE INC IS A NONPROFIT 501 (C)(3) ORGANIZATION. BOTH ST. FRANCIS HOME OF FOND DU LAC WISCONSIN, INC. AND AGNESIAN HEALTHCARE INC ARE PART OF THE INTEGRATED HEALTH CARE SYSTEM KNOWN AS SSM HEALTH. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBER HAS THE POWER TO APPOINT ADDITIONAL, SUCCESSOR OR REPLACEMENT MEMBERS AND TO APPOINT AND REMOVE THE APPOINTED DIRECTORS AND THE EX OFFICIO DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING POWERS ARE RESERVED FOR THE MEMBER: A. TO ESTABLISH AND CHANGE THE MISSION, PHILOSOPHY AND VALUES OF THE CORPORATION; B. TO APPOINT ADDITIONAL, SUCCESSOR OR REPLACEMENT MEMBERS; C. TO APPOINT AND REMOVE THE DIRECTORS; D. TO APPOINT AND REMOVE THE PRESIDENT OF THE CORPORATION AND THE CHIEF EXECUTIVE OFFICER OF ANY OPERATING DIVISION OF THE CORPORATION; E. TO APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION OF THE CORPORATION AS PROVIDED THEREIN; F. TO APPROVE AMENDMENTS TO THE BYLAWS OF THE CORPORATION; G. TO APPROVE THE MERGER, CONSOLIDATION OR DISSOLUTION OF THE CORPORATION; H. TO APPROVE THE FORMATION OF A CONTROLLED SUBSIDIARY OR A REMOTELY CONTROLLED SUBSIDIARY; I. TO APPROVE THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION; J. TO APPROVE THE ACQUISITION OR DISPOSITION BY THE CORPORATION OF ANOTHER LEGAL ENTITY OR AN INTEREST IN ANOTHER LEGAL ENTITY; K. TO AUTHORIZE OR APPROVE THE ACQUISITION OR DISPOSITION BY THE CORPORATION OF REAL PROPERTY OR ANY INTEREST IN REAL PROPERTY; L. TO ESTABLISH CENTRALIZED EMPLOYEE BENEFIT, INSURANCE, INVESTMENT, FINANCING, CORPORATE RESPONSIBILITY, PERFORMANCE ASSESSMENT AND IMPROVEMENT AND OTHER OPERATIONAL AND SUPPORT PROGRAMS; TO REQUIRE THE PARTICIPATION OF THE CORPORATION IN SUCH PROGRAMS; AND TO AUTHORIZE THE OPENING AND CLOSING OF BANK ACCOUNTS AND INVESTMENT ACCOUNTS IN THE NAME OF THE CORPORATION IN CONNECTION WITH SUCH PROGRAMS; M. TO APPROVE THE STRATEGIC, FINANCIAL AND HUMAN RESOURCES PLAN OF THE CORPORATION; N. TO APPOINT THE AUDITOR AND CORPORATE COUNSEL FOR THE CORPORATION; O. TO AUTHORIZE AND APPROVE BORROWING MONEY AND ENTERING INTO FINANCIAL GUARANTIES BY THE CORPORATION, INCLUDING ACTIONS RELATING TO THE FORMATION, JOINING, OPERATION, WITHDRAWAL FROM AND TERMINATION OF A CREDIT GROUP OR AN OBLIGATED GROUP AND THE GRANTING OF SECURITY INTERESTS IN THE PROPERTY OF THE CORPORATION; P. TO REQUIRE THE CORPORATION TO TRANSFER ASSETS, INCLUDING BUT NOT LIMITED TO CASH, TO SSMHCC OR TO ANY OTHER ENTITY EXEMPT FROM FEDERAL INCOME TAX AS AN ORGANIZATION DESCRIBED IN 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED, OR THE CORRESPONDING PROVISION OF ANY FUTURE UNITED STATES INTERNAL REVENUE LAW, WHICH IS CONTROLLED BY SSMHCC, TO THE EXTENT NECESSARY TO ACCOMPLISH THE MISSION, GOALS AND OBJECTIVES OF SSMHCC AS DETERMINED BY SSMHCC; Q. TO APPROVE THE TRANSFER OF ASSETS BY THE CORPORATION TO ANY ENTITY OTHER THAN SSMHCC, OTHER THAN TRANSFERS MADE IN THE ORDINARY COURSE OF OPERATIONS OF THE CORPORATION WHICH WILL NOT REQUIRE MEMBER APPROVAL; AND R. TO DETERMINE THE EXTENT TO WHICH AND THE MANNER IN WHICH THE POWERS DESCRIBED IN THIS SECTION WHICH ARE RESERVED TO SSMHCC WITH RESPECT TO THE CORPORATION ARE TO BE INCLUDED IN THE GOVERNING DOCUMENTS OF ANY CONTROLLED SUBSIDIARY, REMOTELY CONTROLLED SUBSIDIARY OR NON-CONTROLLED SUBSIDIARY AND EXERCISED WITH RESPECT TO ANY CONTROLLED SUBSIDIARY, ANY REMOTELY CONTROLLED SUBSIDIARY OR ANY NONCONTROLLED SUBSIDIARY. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY THE TAX DEPARTMENT OF THE PARENT ORGANIZATION, SSM HEALTH CARE CORPORATION (SSM). THE FORM 990 IS REVIEWED BY CERTAIN MEMBERS OF SENIOR MANAGEMENT. ANY QUESTIONS ARE ADDRESSED TO THE TAX DIRECTOR OF SSM PRIOR TO FILING THE FORM 990 WITH THE INTERNAL REVENUE SERVICE. A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C A WRITTEN CONFLICT OF INTEREST AND INSIDER TRANSACTION POLICY EXISTS WHICH REQUIRES EACH DIRECTOR, PRINCIPAL OFFICER, TRUSTEE OR COMMITTEE MEMBER TO DISCLOSE ON A ANNUAL BASIS TO THE DESIGNATED AUTHORITY A CONFLICT OF INTEREST DISCLOSURE STATEMENT. THE DESIGNATED AUTHORITY ENSURES THAT ALL STATEMENTS ARE COMPLETED, REVIEWS THEM FOR CONFLICTS, AND SUBMITS TO THE BOARD FOR REVIEW ANY CONFLICT OF INTEREST DISCLOSURE STATEMENTS THAT DISCLOSE ACTUAL OR POTENTIAL CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 A RELATED ORGANIZATION UTILIZED THE FOLLOWING TO DETERMINE COMPENSATION: (1) INDEPENDENT COMPENSATION CONSULTANT; (2) COMPENSATION SURVEY OR STUDY; (3) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 THE YEAR-END AUDITED CONSOLIDATED FINANCIAL STATEMENTS AND UNAUDITED QUARTERLY CONSOLIDATED FINANCIAL STATEMENTS FOR THE SSM HEALTH SYSTEM ARE MADE AVAILABLE TO THE PUBLIC ON SSM HEALTH'S WEBSITE. THE ORGANIZATION'S ARTICLES OF INCORPORATION ARE AVAILABLE ON THE WISCONSIN SECRETARY OF STATE'S WEBSITE. COPIES OF THE FORM 990 AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER: PROGRAM SERVICE EXPENSES 2,480,866. MANAGEMENT AND GENERAL EXPENSES 112,257. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,593,123. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN FOUNDATION 92,356. ROUNDING 1. SSM HEALTH CARE CORPORATION 12800 CORPORATE HILL DRIVE ST LOUIS MO 63131 466029223 HEALTH CARE MO 501(C)(3) LINE 12A, I SSM HEALTH MINISTRIES 0 SSMHC LIABILITY TRUST I 12800 CORPORATE HILL DRIVE ST LOUIS MO 63131 436331003 INSURANCE MO 501(C)(3) LINE 12A, I SSM HEALTH CARE CORPORATION 0 SSM CONSOLIDATED HEALTH SERVICES 12800 CORPORATE HILL DRIVE ST LOUIS MO 63131 431473657 HEALTH CARE MO 501(C)(3) LINE 10 SSM HEALTH CARE CORPORATION 0 SSM POLICY INSTITUTE 12800 CORPORATE HILL DRIVE ST LOUIS MO 63131 431788151 HEALTH CARE MO 501(C)(4) SSM HEALTH CARE CORPORATION 0 SSM HEALTH CARE PORTFOLIO MANAGEMENT CO 12800 CORPORATE HILL DRIVE ST LOUIS MO 63131 431825256 MANAGEMENT MO 501(C)(3) LINE 12A, I SSM HEALTH CARE CORPORATION 0 SSM CARDINAL GLENNON CHILDREN'S HOSPITAL 12800 CORPORATE HILL DRIVE ST LOUIS MO 63131 430738490 HEALTH CARE MO 501(C)(3) LINE 3 SSM HEALTH CARE ST LOUIS 0 CARDINAL GLENNON CHILDREN'S FOUNDATION 12800 CORPORATE HILL DRIVE ST LOUIS MO 63131 431754347 FUNDRAISING MO 501(C)(3) LINE 7 SSM CARDINAL GLENNON CHILDREN'S HOSPITAL 0 SSM HEALTH FOUNDATION - 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