TY 2012 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(1) SISTER KATHLEEN HOFER........................................................................ BOARD CHAIR	1.4 .......................12.6	X	X		0	0
(2) SISTER SARAH SMEDMAN........................................................................ BOARD DIRECTOR	1.4 .......................8.6	X			0	0
(3) JOSEPH BIANCO MD........................................................................ BOARD DIRECTOR	1.4 .......................58.6	X			279,780	43,532
(4) DAVID GADDIE........................................................................ BOARD TREASURER	1.4 .......................10.6	X	X		33,600	0
(5) ALAN HODNIK........................................................................ BOARD DIRECTOR	1.4 .......................8.6	X			0	0
(6) SHERRY MATTSON........................................................................ BOARD DIRECTOR	1.4 .......................8.6	X			10,700	0
(7) SISTER DONNA SHROEDER........................................................................ BOARD DIRECTOR	1.4 .......................8.6	X			0	0
(8) SUSAN STREITZ MD........................................................................ BOARD DIRECTOR	1.4 .......................58.6	X			309,934	26,923
(9) SISTER MARY JOSEPHINE TORBORG........................................................................ BOARD DIRECTOR	1.4 .......................8.6	X			0	0
(10) MICHAEL VAN SCOY MD........................................................................ BOARD SECRETARY	1.4 .......................58.6	X	X		343,740	51,932
(11) CHUCK WALT........................................................................ BOARD DIRECTOR	1.4 .......................8.6	X			7,400	0
(12) MELISSA NAJARIAN MD........................................................................ BOARD DIRECTOR THRU 4/13	1.4 .......................58.6	X			461,675	52,386
(13) DANIEL NIKCEVICH MD........................................................................ PRESIDENT & CMO	1.4 .......................58.6	X	X		591,992	75,433
(14) DANIEL MARKHAM........................................................................ BOARD DIRECTOR	1.4 .......................8.6	X			0	0
(15) BARBARA JOHNSON........................................................................ CHIEF FINANCIAL OFFICER	1.4 .......................58.6		X		377,389	57,391
(16) BARBARA WESSBERG........................................................................ SMDCMC ADMINISTRATOR	1.4 .......................58.6			X	167,145	25,415
(17) MICHAEL METCALF........................................................................ EVP CLINICAL OPERATIONS	1.4 .......................58.6			X	456,142	89,937

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	674	674
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	0
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	5,603,599	5,581,160	22,439
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	241,825	240,720	1,105
9	Other employee benefits .......	1,011,543	988,977	22,566
10	Payroll taxes ...........	407,571	399,369	8,202
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	0
c	Accounting ...........	0
d	Lobbying ...........	0
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	39,244		39,244
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	142,100	141,439	661
12	Advertising and promotion ....	1,130	1,130
13	Office expenses .......	361,227	360,801	426
14	Information technology ......	5,681	5,681
15	Royalties ..	0
16	Occupancy ...........	380,509	95,089	285,420
17	Travel ............	97,569	97,569
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	10,399	10,399
20	Interest ...........	-10		-10
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	468,504	48,893	419,611
23	Insurance ..............	0
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	AFFILIATE EXP & REV ALLOCATION	1,501,386	218,277	1,283,109
b	AFFILIATE SUPPORT FEE	397,061	112,090	284,971
c	BAD DEBT EXPENSE	307,596	307,596
d	MN CARE TAX	131,244	131,244
e	All other expenses	139,120	128,398	10,722
25	Total functional expenses. Add lines 1 through 24e	11,247,972	8,869,506	2,378,466	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
	1	Cashnon-interest-bearing .............	7,413	1	7,617
2	Savings and temporary cash investments .........	387,406	2	389,695
3	Pledges and grants receivable, net ...........	0	3	0
4	Accounts receivable, net .............	1,502,665	4	1,212,598
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	2,577	8	2,365
9	Prepaid expenses and deferred charges ..........	0	9	0
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	13,763,089
b	Less: accumulated depreciation .....	10b	10,076,225	3,632,971	10c	3,686,864
11	Investments—publicly traded securities ..........	0	11	0
12	Investments—other securities. See Part IV, line 11 .....	5,704,139	12	6,208,513
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............	0	14	0
15	Other assets. See Part IV, line 11 ...........	0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)......	11,237,171	16	11,507,652
	17	Accounts payable and accrued expenses .........	1,045,083	17	1,270,705
18	Grants payable .................	0	18	0
19	Deferred revenue ................	68,822	19	66,653
20	Tax-exempt bond liabilities .............	0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	16,967,963	25	18,391,221
26	Total liabilities. Add lines 17 through 25.........	18,081,868	26	19,728,579
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	-6,850,874	27	-8,227,104
28	Temporarily restricted net assets ...........	6,177	28	6,177
29	Permanently restricted net assets ...........	0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	-6,844,697	33	-8,220,927
34	Total liabilities and net assets/fund balances ........	11,237,171	34	11,507,652

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

Polinsky Medical Rehabilitation Center

Employer identification number

41-0691275

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the supported organization? ................

11g(i)

(ii) A family member of a person described in (i) above? ......................

11g(ii)

(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of monetary support
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2012

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2011 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2012. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2011. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) 2012	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2011 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2011 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2012. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2011. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2012

Page 4

Part IV

Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

Polinsky Medical Rehabilitation Center

Employer identification number

41-0691275

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) .....
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2012

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIII and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	333,432		333,432
b	Buildings ................	11,482,301	8,912,959	2,569,342
c	Leasehold improvements ............
d	Equipment ................	1,403,534	1,025,029	378,505
e	Other .................	543,822	138,237	405,585
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				3,686,864

Schedule D (Form 990) 2012

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)	(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
(3)Other (A) POOLED INVESTMENT FUND	6,208,513	F








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)	6,208,513

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes		0
ASSET RETIREMENT OBLIGATION		48,774
PAYABLES TO RELATED TAX-EXEMPT ORGS		18,340,432
UNCLAIMED PROPERTY		2,015






Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		18,391,221
2. Fin 48 (ASC 740) Footnote. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................

Schedule D (Form 990) 2012

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIII.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements ...........		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIII.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIII

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation

Schedule D (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

Polinsky Medical Rehabilitation Center

Employer identification number

41-0691275

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? .......

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

Yes

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2012

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)ROCKLON CHAPINEVP HOSPITAL DIVISION	(i) (ii)	0 0	0 0	0 208,414	0 0	0 4,616	0 213,030	0 14,674
(2)BARBARA WESSBERGSMDCMC ADMINISTRATOR	(i) (ii)	0 154,095	0 12,206	0 844	0 19,441	0 5,974	0 192,560	0 0
(3)ROBERT NORMANCHIEF FINANCIAL OFFICER	(i) (ii)	0 421,115	0 66,529	0 58,181	0 71,277	0 32,263	0 649,365	0 54,041
(4)BARBARA JOHNSONCHIEF FINANCIAL OFFICER	(i) (ii)	0 303,431	0 46,526	0 27,432	0 50,193	0 7,198	0 434,780	0 25,094
(5)MICHAEL METCALFEVP CLINICAL OPERATIONS	(i) (ii)	0 387,434	0 61,425	0 7,283	0 62,400	0 27,537	0 546,079	0 0
(6)ANN WATKINSVP SURGICAL SERVICES	(i) (ii)	0 180,199	0 14,326	0 19,558	0 22,813	0 19,044	0 255,940	0 10,727
(7)THOMAS KAISER MDCLINICAL CHIEF	(i) (ii)	0 654,061	0 0	0 6,339	0 25,000	0 23,829	0 709,229	0 0
(8)JOSEPH BIANCO MDBOARD DIRECTOR	(i) (ii)	0 279,195	0 0	0 585	0 25,000	0 18,532	0 323,312	0 0
(9)THOMAS PATNOE MDPresident & CMO THRU 4/12	(i) (ii)	0 537,506	0 0	0 3,302	0 65,270	0 27,307	0 633,385	0 0
(10)SUSAN STREITZ MDBOARD DIRECTOR	(i) (ii)	0 308,591	0 0	0 1,343	0 25,000	0 1,923	0 336,857	0 0
(11)MICHAEL VAN SCOY MDBOARD SECRETARY	(i) (ii)	0 343,185	0 0	0 555	0 25,000	0 26,932	0 395,672	0 0
(12)SCOTT JOHNSON MDClinical Chief	(i) (ii)	0 619,043	0 0	0 1,464	0 25,000	0 31,828	0 677,335	0 0
(13)MELISSA NAJARIAN MDBOARD DIRECTOR THRU 4/13	(i) (ii)	0 460,859	0 0	0 816	0 25,000	0 27,386	0 514,061	0 0
(14)DANIEL NIKCEVICH MDPRESIDENT & CMO	(i) (ii)	0 589,434	0 0	0 2,558	0 48,529	0 26,904	0 667,425	0 0
(15)SANDRA MCCARTHYCHIEF NURSING OFFICER	(i) (ii)	0 409,405	0 9,384	0 25,741	0 42,921	0 11,129	0 498,580	0 0
(16)VINCENT OHAJU MDCLINICAL CHIEF	(i) (ii)	0 662,587	0 0	0 1,623	0 25,000	0 27,947	0 717,157	0 0

Schedule J (Form 990) 2012

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Identifier	Return Reference	Explanation
Schedule J, Part I Line 3		Establishing CEO's compensation: Essentia Health Polinsky Medical Rehabilitation Center relied on Essentia Health's, supporting organization of Essentia Health Polinsky Medical Rehabilitation Center, methods for establishing Essentia Health Polinsky Medical Rehabilitation Center's President/Chief Medical Officer compensation: a compensation committee, independent compensation consultant, written employment contract, compensation survey or study, and approval by the board or compensation committee.
Schedule J, Part I, Line 4a		Severance payment: Former key employee, Rocklon Chapin, a former employee of related organization Essentia Health Duluth, received payment totaling $194,400 in tax year 2012 related to his termination. The termination terms are from January 31, 2011 until July 31, 2012. Mr. Chapin will receive pay totaling $501,019 & benefits totaling $10,009 related to his termination. All other individuals listed as Formers in Form 990, Part VII, Section A, Line 1a remain employed within Essentia Health and its subsidiaries and are not receiving a termination payment.
Schedule J, Part I, Line 4b		Supplemental nonqualified retirement plan: Essentia Health's nonqualified retirement plan is offered to designated Essentia Health executives. There is a minimum two year vesting date or automatically upon reaching retirement age, death, disability or involuntary termination without cause. Benefits are subject to income taxes upon vesting and payable from Essentia Health's general assets. Reported as Other Reportable Compensation in Schedule J, Part II, Column B (iii), the following individuals listed in Form 990, Part VII, Section A, Line 1a received payment of the vested benefit from the supplemental nonqualified retirement plan during the year: ROBERT NORMAN: $54,041 ANN WATKINS: $10,727 ROCKLON CHAPIN: $14,674 BARBARA JOHNON: $25,094 Reported as Retirement and Other Deferred Compensation in Schedule J, Part II, Column C, Essentia Health made contributions, subject to the vesting terms, during the year into the supplemental nonqualified retirement plan on behalf of the following individuals listed in Form 990, Part VII, Section A, Line 1a: ROBERT NORMAN: $45,627 ANN WATKINS: $2,811 BARBARA JOHNSON: $25,193 BARBARA WESSBERG: $2,397 THOMAS PATNOE, MD: $40,270 DANIEL NIKCEVICH, MD: $23,529 MICHAEL METCALF: $37,400 SANDRA MCCARTHY: $42,921

Schedule J (Form 990) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2012

Open to Public
Inspection

Name of the organization

Polinsky Medical Rehabilitation Center

Employer identification number

41-0691275

Identifier	Return Reference	Explanation
Form 990, Part B		Amended Return: Additional wording has been added to the "Form 990, Part VI, Line 7B Continued" disclosure in Schedule O.
Form 990, Part C		Essentia Health Polinsky Medical Rehabilitation Center
Form 990, Part I, Line 1		Organization's mission or most significant activities: Throughout Essentia Health, we are called to make a healthy difference in people's lives. As a member of the Essentia Health family, Essentia Health Polinsky Medical Rehabilitation Center's mission as a Catholic, Benedictine sponsored facility is to promote Christ's ministry of holistic healing for all human life with special concern for the poor and powerless.
Form 990, Part III, Line 1		Organization's mission: Throughout Essentia Health, we are called to make a healthy difference in people's lives. As a member of the Essentia Health family, Essentia Health Polinsky Medical Rehabilitation Center's mission as a Catholic, Benedictine sponsored facility is to promote Christ's ministry of holistic healing for all human life with special concern for the poor and powerless.
Form 990, Part III, LINE 4		Program service accomplishments: Polinsky Medical Rehabilitation Center dba Essentia Health Polinsky Medical Rehabilitation Center provides comprehensive outpatient rehabilitation services to children and adults. Polinsky care focuses on each individual's needs with the goal of maximizing independence within our community. Polinsky Medical Rehabilitation Center offers a broad range of outpatient services for its patients, including comprehensive evaluation and treatment for brain injuries and neurological conditions and psychological and neuropsychological services. The center also offers screenings and evaluations as well as physical therapy, occupational therapy and speech-language therapy. Beyond its rehabilitation and therapy services, Polinsky Medical Rehabilitation Center also leads support groups, advocates for their patients and families, and coordinates with other agencies and community services to help connect the patient to additional resources. During the fiscal year, the center provided almost 63,000 outpatient visits. Polinsky Medical Rehabilitation Center also paid over $131,000 in MNCare Tax and Medicaid Surplus and provided over $29,000 in Education and Workforce Development during the fiscal year ended June 30, 2013.
Form 990, Part V, LINE 1A		1099 Reporting: Vendor payments and Form 1099's were processed through Essentia Health on behalf of certain legal entities comprising Essentia Health system.
Form 990, Part VI, Line 6		Members of Organization: Essentia Health ST.MARY'S MEDICAL CENTER is the sole member of ESSENTIA HEALTH POLINSKY MEDICAL REHABILITATION CENTER AND may elect one or more members of the governing body as described in Schedule O Part VI Line 7a. Members, Essentia Health, Benedictine Sisters Benevolent Association, AND ESSENTIA HEALTH EAST, have reserved powers with respect to Essentia Health Polinsky Medical Rehabilitation Center as described in Schedule O Part VI Line 7b.
Form 990, Part VI, Line 7A		Member with right to elect governing body: Essentia Health ST. MARY'S MEDICAL CENTER appoints and removes Essentia Health Polinsky Medical Rehabilitation Center's governing body. Form 990, Part VI, Line 7B Governance, Management, and Disclosure: Essentia Health Polinsky Medical Rehabilitation Center is a subsidiary of Essentia Health, whose Board of Directors has reserved powers with respect to this corporation and its subsidiaries, and all of the other direct and indirect subsidiaries of Essentia Health (collectively, the "System"). Essentia Health's reserved powers are as follows: Strategic and Business Plans. Authority to create, and to approve, the System's strategic and business plans. Mission. Authority to create, and to approve, the mission, purpose and vision statements for all entities in the System by the affirmative vote of at least 67% of the Essentia Health board of directors. Debt. Approval of the incurrence of debt by, and the creation of all mortgages, liens, security interests, or other encumbrances on the assets of, all entities in the System in excess of the single or annual aggregate dollar limits prescribed in writing by the Essentia Health board of directors, and the authority to cause all entities in the System to participate in System borrowing. Governing Instruments. Authority to cause, and to approve, amendments of the articles of incorporation and bylaws of all entities in the System. Mergers and Acquisitions. Authority to cause, and to approve, all mergers, consolidations, and dissolutions of all entities in the System. Affiliations and Joint Ventures. Authority to cause, and to approve, all affiliations, joint ventures and other alliances with third parties of all entities in the System. Transfer of Assets Within the System. Authority to transfer assets, including cash, between and among entities within the System; provided, however, that Essentia Health shall not have authority to require any entity in the System to transfer assets (a) that would cause such entity to be in default of its covenants or obligations under any bond or other financing documents; (b) from the Catholic entities to the secular entities or from the secular entities to the Catholic entities in a manner or to an extent that would cause the Catholic entities to be in violation of the Ethical and Religious Directives for Catholic Health Care Services (ERDs) in the judgment of the local ordinary; or (c) such that money generated by services at secular facilities within the System by procedures that are contrary to the ERDs would be used at the Catholic entities or money generated by Catholic entities would be used in the providing of services contrary to the ERDs at secular facilities within the System. Transfer of Assets Outside the System. Authority to cause, and to approve, the sale, lease or other transfer of assets of all entities in the System to parties outside of the System when the asset's value exceeds the single or annual aggregate dollar limits prescribed in writing by the Essentia Health board of directors. Services. Authority to cause, and to approve, the addition of new services and service locations and the discontinuance of services and service locations within all entities in the System. Budgets. Approval of capital and operating budgets of all entities in the System. Professional Services. Selection of the general legal counsel and external auditors of all entities in the System. Acquisitions. Authority to cause, and to approve, all acquisitions by and formations of entities in the System. Marketing. Authority to implement System-wide marketing and promotional activities. Compliance Plans. Authority to create, and to approve, corporate compliance, safety and risk management plans for entities within the System. Quality Plan. Authority to create, and to approve, the System's quality plan. Non-Budgeted Purchases. Approval of non-budgeted capital purchases and leases in excess of the single or annual aggregate dollar limits prescribed in writing by Essentia Health for entities within the System. Human Resources. Authority to create human resource policies and procedures within the System. Reserved Powers. Authority to create additional Essentia Health reserved powers by the affirmative vote of at least 80% of the Essentia Health board of directors (excluding the Essentia Health CEO); provided, however, that any additional Essentia Health reserved powers shall not contravene or hinder the reserved powers of Benedictine Sisters Benevolent Association.
Form 990, Part VI, Line 7B Continued		The Benedictine Sisters Benevolent Association ("BSBA") also has certain reserved powers over Essentia Health's Catholic facilities. BSBA's reserved powers are as follows: Mission. Authority to approve the mission, purpose and vision statements for Catholic facilities and entities within the System. Adherence to Ethical and Religious Directives for Catholic Health Care Services (ERDs). Authority to approve the methods, policies and procedures pertaining to the adherence of Catholic facilities and entities within the System to the ERDs, and to require the use of religious symbols, distinguishing elements and prayers. Official Catholic Directory. Authority to request the listing of qualified entities and facilities within the System in The Official Catholic Directory, subject to the approval of applicable Catholic authorities. Catholic Health Association. Authority to require Catholic facilities and entities within the System to join the membership of the Catholic Health Association of the United States. Alienation of Stable Patrimony or Ecclesiastical Goods. Authority to approve alienation of either stable patrimony or other ecclesiastical goods in the System if such goods involved in a specific transaction approved by Essentia Health pursuant to Section 2.8(g) or 2.8(h) of the Affiliation Agreement have a dollar value equal to or greater than 70% of the amount established from time to time that requires approval from the Holy See; provided, however, that it is the intent of the parties that this provision not be applied to restrict or to impede Essentia from acting and making decisions on behalf of the system in the ordinary course of business but be applied to prevent the transfer of substantial assets of Catholic entities within the system to support the secular entities within the system without the prior approval of BSBA. Amendments. Authority to approve any amendments to the Articles of Incorporation or Bylaws of this corporation that would alter the number of Benedictine Sisters of St. Scholastica Monastery of Duluth or BSBA board of director members serving as members of such entity's board of directors; authority to approve any amendments to the Articles of Incorporation or Bylaws of Essentia's Catholic Subsidiaries which could materially affect such entity's identity as a Catholic institution, including without limitation any amendment that would alter the number of Benedictine Sisters of St. Scholastica Monastery of Duluth BSBA board of director members serving as members of such entity's board of directors; and authority to cause Essentia Health to make amendments to the Articles of Incorporation or Bylaws of Essentia's Catholic Subsidiaries, which amendments BSBA in good faith are necessary to preserve such entity's identity as a Catholic institution. Mission Effectiveness. Authority to approve annual plans and evaluations relating to mission effectiveness and chaplaincy for the Catholic facilities and entities within the System. Mergers and Dissolution. Subject to the approval of the Benedictine Sisters of St. Scholastica Monastery of Duluth, authority to approve a proposed merger, consolidation, liquidation, dissolution, or the disposition of all or substantially all the assets. Essentia Health East also has certain reserved powers over all East facilities within Essentia Health. Essentia Health East's reserved powers are as follows: Quality, Safety and Service. Authority to recommend quality and safety initiatives and to review and execute approved quality and safety plans for the East Region. Mission, Vision and Values. Authority to create a mission and a vision that support the mission and vision of Essentia Health; responsibility to oversee the mission performance, including charity care, of all facilities within the East Region; responsibility to adopt the values of Essentia Health. Operating and Financial Performance. Responsibility to oversee the operating and financial performance of the East Region. Development of Budgets, Strategic Plans and Strategy Map. Authority to develop and recommend, based on Essentia Health targets, capital and operating budgets for the East Region and its facilities; authority to recommend, within the Essentia Health context, regional and local strategic plans for the East Region; authority to develop East Region governance strategy map and balanced scorecard within Essentia Health's system strategy to meet system goals. Execution of Approved Budgets and Strategic Plans. Responsibility to execute the approved capital and operating budgets and strategic and business plans for the East Region. Non-budgeted Expenditures. Authority to approve non budgeted capital purchases and leases for East Region facilities within dollar limits defined by Essentia Health. Accreditation and Licensure. Responsibility to oversee accreditation and licensure compliance for the facilities of the East Region. Affiliations, Acquisitions and Joint Ventures. Authority to recommend proposed affiliations, acquisitions, joint ventures and other alliances; responsibility to oversee negotiation and implementation of approved acquisitions and operation of all approved affiliations, joint ventures and other alliances with third parties within the East Region. Appointment of Directors. Authority to appoint or elect directors of the Direct Subsidiaries, and to remove such directors, with or without cause. President. Authority to advise the CEO of Essentia Health regarding the appointment, removal and periodic evaluation of the President of SMDC. Satisfaction. Responsibility to execute, evaluate and oversee patient, family and customer satisfaction with respect to services provided within the East Region and to ensure established goals are met. Job Satisfaction. Responsibility to oversee job satisfaction and staff morale within the East Region facilities. Human Resources. Responsibility to oversee implementation of Essentia Health human resource policies and procedures throughout the East Region. Compliance. Responsibility to execute the approved Essentia Health corporate compliance and risk management plans for the East Region. Credentialing. Responsibility to perform medical staff credentialing for the East Region facilities. Nominations. Authority to nominate persons for appointment to the SMDC Board of Directors by Benedictine Sisters Benevolent Association and Essentia Health. Amendments. Authority to suggest proposed amendments to the Articles of Incorporation and Bylaws of this corporation, the Direct Subsidiaries, and any subsidiaries thereof. Compensation Plans. Responsibility to review and approve compensation of East Region executives and physicians for reasonableness and consistency with the law and Essentia Health's compensation philosophy. President/Chief Medical Officer. By action of the President of this corporation, authority to appoint and remove, with or without cause, the President/Chief Medical Officer of any of the Direct Subsidiaries. Public Policy. Responsibility to support Essentia Health public policy and advocacy plans. Marketing. Responsibility to coordinate regional marketing and promotional activities consistent with Essentia Health marketing plans. Philanthropy. Responsibility to coordinate philanthropy within the East Region consistent with Essentia Health foundation policies. Professional Services. Responsibility to oversee East Region management's cooperation with external auditors and general legal counsel selected by Essentia Health and coordination of legal services through the Essentia Health Office of General Counsel. Catholic Facilities. Responsibility to oversee implementation of BSBA-approved methods, policies and procedures pertaining to adherence by the East Region Catholic facilities with the Ethical and Religious Directives for Catholic Health Care Services and use of religious symbols, distinguishing elements and prayers. Projects Involving Real Estate. Authority to recommend facility development projects, subject to the approval of Essentia Health; responsibility to oversee execution of approved development projects according to Essentia Health policies.
Form 990, Part VI, Line 11A		Form 990 review process: The 2012 Form 990 including all schedules was reviewed by Essentia Health Polinsky Medical Rehabilitation Center's management and governing body on March 5, 2014 prior to filing with the Internal Revenue Service. Each current director of the governing body received a copy of the 2012 Form 990. Essentia Health Polinsky Medical Rehabilitation Center's Chief Financial Officer led the review of the form and schedules and any questions were discussed.
Form 990, Part VI, Line 12C		Monitoring and enforcing Conflict of Interest policy: Essentia Health's comprehensive conflict of interest program prevents, detects and resolves actual conflicts of interests or the actual or potential appearance of such. Fiduciaries, defined as an Essentia Health board member/trustee, officer, board committee member, senior management employee, or any others considered to be in a position of influence, are covered under Essentia's conflict of interest program. Upon initial appointment, each fiduciary must complete an initial conflict of interest statement and disclosure questionnaire. At the conclusion of each fiscal year, each fiduciary must complete an annual conflict of interest statement and disclosure questionnaire. As needed, a fiduciary will update his/her most recently completed questionnaire each time the fiduciary becomes aware of a financial interest, a potential conflict, or change to any information that the fiduciary previously reported. Essentia Health's Chief Compliance Officer will collect the questionnaires and evaluate the disclosures. If a fiduciary has a potential conflict of interest, the Chief Compliance Officer or designee may request additional information from the fiduciary, the management team, and others. During the evaluation process, the Chief Compliance Officer may also consult with Essentia Health's Board and Audit Committee Chairs, senior management, legal department, or appropriate representatives from Essentia Health. The Chief Compliance Officer reports to the Essentia Health Audit Committee and the Essentia Health Board of Directors any actual or potential conflicts of interest disclosed by the fiduciary, along with recommended actions. The Essentia Health Board of Directors (or designee) will then determine whether to approve the situation or to implement special controls to manage the potential conflict of interest. The Chief Compliance Officer will then officially notify the fiduciary in writing of the board's decision. The decision of whether or not the disclosure constitutes a conflict or not will be at the Essentia Health Board of Director's (or designee) sole discretion, and its concern must be the welfare of Essentia Health and its affiliate(s) and the advancement of its purposes. When the Essentia Health Board of Directors (or designee) considers a Fiduciary's disclosure as a Conflict of Interest, special controls will be identified to manage, eliminate or reduce the likelihood and/or appearance of a conflict arising. Controls may include but are not limited to: A.If the conflict involves an on-going matter or relationship, the Fiduciary must not participate in Board, Board committee or management discussions related to the conflict and must recuse themselves and if appropriate, withdraw, from any Board meeting or portion thereof where the matter is being discussed and during the vote on the potential Conflict of Interest. The Fiduciary may answer questions at the Board's or the Board Committee's request. B.If the conflict involves a specific transaction or decision, the Fiduciary will fully disclose their interest and all related material facts. The Board or committee of the Board will determine whether the contemplated transaction may be authorized as just, fair, and reasonable to Essentia Health or its affiliate(s). If the Board determines a conflict does not exist, the Fiduciary may proceed with the transaction; however, he or she will not be eligible to vote on related issues should they arise. If the Board determines a conflict does exist, the Fiduciary will be notified of the decision regarding whether the contemplated transaction will be authorized as just, fair, and reasonable.
Form 990, PART VI, LINE 15A & B		Process for determining compensation: The Executive Compensation Committee of Essentia Health's board of directors is authorized to fulfill the board's responsibilities regarding executive compensation consistent with Essentia's mission, values and tax-exempt status, and the Executive Compensation Committee's Charter. The Executive Compensation Committee meets at least twice annually to carry out its responsibilities, which include, but are not limited to, establishing, reviewing and modifying, as appropriate, reasonable compensation and benefits for designated Essentia executives who are officers or key employees of Essentia or any of its affiliates which may be paid by related organizations. The Executive Compensation Committee engages qualified independent compensation advisors to provide objective and impartial comparative data and to express opinions on total compensation reasonableness. The Executive Compensation Committee may request its independent advisors to: monitor comparability data and marketplace trends; make appropriate recommendations regarding salary ranges; and periodically review the market competitiveness of Essentia executive compensation packages. Prior to establishing or adjusting executive compensation, the Executive Compensation Committee will obtain and rely upon appropriate data as to comparability of the proposed compensation or adjustments. The Executive Compensation Committee will adequately document the basis for its determination concurrently with making those determinations. The Executive Compensation Committee minutes will include: the terms of the approved compensation and the date approved; the Executive Compensation Committee members present during the review, discussion and approval of the proposed compensation and those who voted on the proposed compensation; identification of the comparability data obtained and relied upon by the Executive Compensation Committee and how the data was obtained; any actions by a member of the Executive Compensation Committee having a conflict of interest; and documentation of the basis for the determination. The year this process was last undertaken for Essentia Health EAST REGION's President/CHIEF MEDICAL OFFICER, CHIEF FINANCIAL OFFICER, SMDCMC AdministratOR, EXECUTIVE VICE PRESIDENT Clinic OPERATIONS, VICE PRESIDENT Surgical SERVICES , AND CHIEF NURSING OFFICER was 2012.
Form 990, PART VI, LINE 19		Availability of governing documents, conflict of interest policy, & financial statements to the public: Essentia Health Polinsky Medical Rehabilitation Center makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Essentia Health Polinsky Medical Rehabilitation Center is part of Essentia Health's consolidated financial statements which are included in Essentia Health's annual report posted on Essentia Health's web site.
FORM 990, PART IX, LINE 24A		Affiliate expense and revenue allocation represents the portion of Essentia Health Duluth, Essentia Health St. Mary's Medical Center, and The Duluth Clinic, Ltd. revenue and expense related to Essentia Health Polinsky Medical Rehabilitation Center, a related organization, which is allocated directly to Essentia Health Polinsky Medical Rehabilitation Center. Net affiliate (revenue) and expense allocation of $1,501,386 includes the following: Program Service Revenue ($137), Investment Income ($11,626), Realized gain ($16,049), Miscellaneous Revenue ($18,227), Contributions $13,724, Compensation $473,622, PAYROLL TAXES $31,773, PENSION PLAN CONTRIBUTIONS $24,535, Accounting Fees $23, Legal Fees $5,792, Investment Management Fees $2,505, Interest $237,440, Other Purchased Services $90,454, Advertising $8,945, CONFERENCE/CONVENTIONS/MEETINGS $5,256, Depreciation & Amortization $95,959, Information Technology $84,863, Insurance $10,648, Medical Supplies $8,299, Occupancy $202,603, Office Expenses $73,459, Travel $8,822, Unrelated Business Income Taxes $2,383, GAIN/LOSS ON REFINANCING $4,896, Other Expenses $60,816, AND OTHER EMPLOYEE BENEFITS $100,609.
FORM 990, PART XI, LINE 9		OTHER CHANGES IN NET ASSETS: The total amount of other changes in net assets includes: NET ASSET TRANSFER WITH RELATED ORGANIZATION; REALLOCATED INCOME STATEMENT ITEM TRANSFERRED TO ALIGN WITH ORGANIZATIONAL STRUCTURE ($36,176)

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2012

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2012

Open to Public Inspection

Name of the organization

Polinsky Medical Rehabilitation Center

Employer identification number

41-0691275

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) BRAINERD LAKES INTEGRATED HEALTH SYSTEM 2024 S 6TH ST BRAINERD,MN56401 37-1532145	SUPPORT ORG	MN	501(c)(3)	11 TYPE II	Essentia	Yes
(2) BRAINERD MEDICAL CENTER INC 2024 S 6TH ST BRAINERD,MN56401 37-1532148	CLINIC	MN	501(c)(3)	3	BLIHS	Yes
(3) BRIDGES MEDICAL CENTER 201 9th ST W ADA,MN56510 20-0479568	Clinic/Hosp	MN	501(c)(3)	3	Innovis	Yes
(4) CLEARWATER VALLEY HOSP & CLINICS INC 301 CEDAR OROFINO,ID83544 82-0497771	Clinic/Hosp	ID	501(c)(3)	3	CAG	Yes
(5) DL SURGERY CENTER (thru 73112) 1027 WASHINGTON AVE DETROIT LAKES,MN56501 26-3837203	ASC	MN	501(c)(3)	3	CAG	Yes
(6) Critical Access Group 503 E 3RD ST SUITE 400 DULUTH,MN55805 26-1219624	SUPPORT ORG	MN	501(c)(3)	11 Type II	ESSENTIA	Yes
(7) FIRST CARE MEDICAL SERVICES 900 HILLIGOSS BLVD SE FOSSTON,MN56542 41-0706143	Clinic/Hosp	MN	501(c)(3)	3	Innovis	Yes
(8) MINNESOTA VALLEY HEALTH CENTER INC 621 S 4TH ST LE SUEUR,MN56058 41-0837659	HOSPITAL/Nurs	MN	501(c)(3)	3	CAG	Yes
(9) ST JOSEPHS MEDICAL CENTER 523 N 3RD ST BRAINERD,MN56401 41-0695602	Clinic/Hosp	MN	501(c)(3)	3	BLIHS	Yes
(10) ST MARYS EMS 1027 WASHINGTON AVE DETROIT LAKES,MN56501 41-1805811	EMERG SrvCs	MN	501(c)(3)	9	SMRHC	Yes
(11) ST MARYS HOSPITAL INC PO BOX 137 COTTONWOOD,ID83522 82-0226453	Clinic/Hosp	ID	501(c)(3)	3	CAG	Yes
(12) ST MARYS INNOVIS HEALTH 1027 WASHINGTON AVE DETROIT LAKES,MN56501 26-2861321	CLINIC	MN	501(c)(3)	3	Innovis	Yes
(13) ST MARYS REGIONAL HEALTH CENTER 1027 WASHINGTON AVE DETROIT LAKES,MN56501 41-1620386	Clinic/Hosp	MN	501(c)(3)	3	Innovis	Yes
(14) ESSENTIA HEALTH 502 E 2ND ST DULUTH,MN55805 20-0360007	SUPPORT ORG	MN	501(c)(3)	11TypeIIIFI	NA		No
(15) ESSENTIA INSTITUTE OF RURAL HEALTH 502 E 2ND ST DULUTH,MN55805 27-1291124	RESEARCH	MN	501(c)(3)	4	ESSENTIA	Yes
(16) INNOVIS HEALTH LLC 3000 32nd Avenue FARGO,ND58103 26-1175213	Clinic/Hosp	DE	501(c)(3)	3	ESSENTIA	Yes
(17) Essentia HEALTH FOUNDATION 502 E 2ND ST DULUTH,MN55805 27-1984704	FOUNDATION	MN	501(c)(3)	7	Essentia	Yes
(18) MIDWEST MEDICAL EQUIPMENT & SUPPLY INC 4418 HAINES RD DULUTH,MN55811 41-1674021	MEDICAL EQUIP	MN	501(c)(3)	9	SMMC	Yes
(19) PINE MEDICAL CENTER 109 COURT AVE S SANDSTONE,MN55072 41-1884597	Hospital/Nurs	MN	501(c)(3)	3	SMDCHS	Yes
(20) SMDC MEDICAL CENTER 502 E 2ND ST DULUTH,MN55805 41-1878730	Clinic/Hosp	MN	501(c)(3)	3	SMDCHS	Yes
(21) ST MARYS DULUTH CLINIC HEALTH SYSTEM 407 E 3RD ST DULUTH,MN55805 41-1836633	Support Org	MN	501(c)(3)	11 Type II	ESSENTIA	Yes
(22) ST MARYS HOSPITAL OF SUPERIOR 3500 TOWER AVE SUPERIOR,WI54880 41-1811073	Clinic/Hosp	WI	501(c)(3)	3	SMMC	Yes
(23) ST MARYS MEDICAL CENTER 407 E 3RD ST DULUTH,MN55805 41-0695604	Hospital	MN	501(c)(3)	3	SMDCHS	Yes
(24) THE DULUTH CLINIC LTD 400 E 3RD ST DULUTH,MN55805 41-0883623	Clinic	MN	501(c)(3)	3	SMDCHS	Yes
(25) Northern Pines Medical Center 5211 Hwy 110 Aurora,MN55705 41-0841441	Hospital/Nurs	MN	501(c)(3)	3	SMDCHS	Yes
(26) Graceville Health Center 115 West Second St Graceville,MN56240 41-0726173	Clinic/Hosp	MN	501(c)(3)	3	Innovis	Yes
(27) DEER RIVER HEALTHCARE CENTER INC 115 10TH AVE NE DEER RIVER,MN56636 41-0844574	HOSPITAL/NURS	MN	501(c)(3)	3	SMDCHS	Yes

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2012

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) PMC GATEWAY IMAGING LLC 109 COURT AVE S SANDSTONE,MN55072 26-1634764	IMAGING SERVI	MN	NA	N/A	0	0			0			0 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets		Yes	No
(1) ESSENTIA HEALTH INSURANCE SRVS SPC LTD 94 Solaris Ave PO Box 69 GRAND CAYMAN,CAYMAN ISLANDSKY1-1102 CJ 000000000	INSURANCE	CJ	NA	FOREIGN CORP	0	0	0 %	Yes
(2) EAST RANGE CLINICS LTD 910 6TH AVE N VIRGINIA,MN55792 41-0909915	CLINICS	MN	NA	C CORP	0	0	0 %	Yes

Schedule R (Form 990) 2012

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) ESSENTIA HEALTH	M	397,061	ACTUAL COSTS
(2) ESSENTIA HEALTH	P	78,265	ACTUAL COSTS
(3) SMDC MEDICAL CENTER	P	1,939,682	ACTUAL COSTS
(4) ST MARY'S MEDICAL CENTER	P	598,550	ACTUAL COSTS
(5) ST MARY'S MEDICAL CENTER	Q	109,453	ACTUAL COSTS

Schedule R (Form 990) 2012

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2012

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation
SCHEDULE R, PART II, COLUMN (A)		Name: The following Essentia Health entities have a doing business as name. Legal Name; Doing Business As Name Brainerd Lakes Integrated Health System; Essentia Health Central Brainerd Medical Center, Inc.; Essentia Health Brainerd Specialty Clinic Bridges Medical Center; Essentia Health Ada Deer River Healthcare Center, Inc.; Essentia Health Deer River First Care Medical Services; Essentia Health Fosston Graceville Health Center; Essentia Health Holy Trinity Hospital Innovis Health, LLC; Essentia Health West Midwest Medical Equipment & Supply Inc.; Essentia Health Medical Equipment and Supplies Northern Pines Medical Center; Essentia Health Northern Pines Pine Medical Center; Essentia Health Sandstone Polinsky Medical Rehabilitation Center; Essentia Health Polinsky Medical Rehabilitation Center SMDC Medical Center; Essentia Health Duluth St. Joseph's Medical Center; Essentia Health St. Joseph's Medical Center St. Mary's Duluth Clinic Health System; Essentia Health East St. Mary's Hospital of Superior; Essentia Health St. Mary's Hospital-Superior St. Mary's Medical Center; Essentia Health St. Mary's Medical Center St. Mary's Regional Health Center; Essentia Health St. Mary's-Detroit Lakes

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: SEE SCHEDULE O
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	13
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	9
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ......	5	0
6	Total number of volunteers (estimate if necessary) .............	6	179
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	8,259	539
9	Program service revenue (Part VIII, line 2g) .........	9,062,246	9,238,179
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	128,056	363,130
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	126,026	111,577
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	9,324,587	9,713,425
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	89	674
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	7,017,013	7,264,538
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	4,494,632	3,982,760
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	11,511,734	11,247,972
19	Revenue less expenses. Subtract line 18 from line 12.......	-2,187,147	-1,534,547
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	11,237,171	11,507,652
21	Total liabilities (Part X, line 26).............	18,081,868	19,728,579
22	Net assets or fund balances. Subtract line 21 from line 20.....	-6,844,697	-8,220,927

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 8,869,506 including grants of $ 674 ) (Revenue $ 9,238,179 )
	SEE SCHEDULE O

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses8,869,506

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)			(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) ANN WATKINS........................................................................ VP SURGICAL SERVICES	1.4 .......................58.6	X		0	214,083	41,857
(19) SCOTT JOHNSON MD........................................................................ Clinical Chief	1.4 .......................58.6	X		0	620,507	56,828
(20) SANDRA MCCARTHY........................................................................ CHIEF NURSING OFFICER	1.4 .......................58.6	X		0	444,530	54,050
(21) VINCENT OHAJU MD........................................................................ CLINICAL CHIEF	1.4 .......................58.6	X		0	664,210	52,947
(22) THOMAS PATNOE MD........................................................................ President & CMO THRU 4/12	0.0 .......................60.0		X	0	540,808	92,577
(23) ROBERT NORMAN........................................................................ CHIEF FINANCIAL OFFICER	0.0 .......................60.0		X	0	545,825	103,540
(24) ROCKLON CHAPIN........................................................................ EVP HOSPITAL DIVISION	0.0 .......................0.0		X	0	208,414	4,616
(25) THOMAS KAISER MD........................................................................ CLINICAL CHIEF	0.0 .......................60.0		X	0	660,400	48,829

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	0	6,938,274	878,193

(A) Name and business address	(B) Description of services	(C) Compensation





2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 0

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		539
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			539
			Business Code
2a	PATIENT REVENUE		621400	7,860,792	7,860,792
b	FITNESS & WELLNESS		713940	1,377,387	1,377,387
c
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			9,238,179
3	Investment income (including dividends, interest, and other similar amounts).......			115,718			115,718
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			0
		(i) Real	(ii) Personal
6a	Gross rents	104,133
b	Less: rental expenses
c	Rental income or (loss)	104,133	0
d	Net rental income or (loss).......			104,133			104,133
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	247,522
b	Less: cost or other basis and sales expenses		110
c	Gain or (loss)	247,522	-110
d	Net gain or (loss)..........			247,412			247,412
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a		15,981
b	Less: cost of goods sold ..b		8,537
c	Net income or (loss) from sales of inventory..			7,444			7,444
Miscellaneous Revenue			Business Code
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			0
12	Total revenue. See Instructions......			9,713,425	9,238,179		474,707


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing .............			7,413	1	7,617
2	Savings and temporary cash investments .........			387,406	2	389,695
3	Pledges and grants receivable, net ...........			0	3	0
4	Accounts receivable, net .............			1,502,665	4	1,212,598
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			2,577	8	2,365
9	Prepaid expenses and deferred charges ..........			0	9	0
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	13,763,089
b	Less: accumulated depreciation .....	10b	10,076,225	3,632,971	10c	3,686,864
11	Investments—publicly traded securities ..........			0	11	0
12	Investments—other securities. See Part IV, line 11 .....			5,704,139	12	6,208,513
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............			0	14	0
15	Other assets. See Part IV, line 11 ...........			0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)......			11,237,171	16	11,507,652
17	Accounts payable and accrued expenses .........			1,045,083	17	1,270,705
18	Grants payable .................			0	18	0
19	Deferred revenue ................			68,822	19	66,653
20	Tax-exempt bond liabilities .............			0	20	0
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			16,967,963	25	18,391,221
26	Total liabilities. Add lines 17 through 25.........			18,081,868	26	19,728,579
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			-6,850,874	27	-8,227,104
28	Temporarily restricted net assets ...........			6,177	28	6,177
29	Permanently restricted net assets ...........			0	29	0
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			-6,844,697	33	-8,220,927
34	Total liabilities and net assets/fund balances ........			11,237,171	34	11,507,652