TY 2021 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/1099-NEC)
(1) JO LANGAN...................................................................... DIRECTOR	1.00 ................. 0.20	X			0	0
(2) JAMES RICHARDS...................................................................... DIRECTOR UNTIL 12/31/21	1.00 ................. 0.20	X			0	0
(3) MARY ANN SMITH...................................................................... DIRECTOR BEGIN 1/1/22	1.00 ................. 0.20	X			0	0
(4) BARB SODERBERG...................................................................... DIRECTOR BEGIN 5/1/22	1.00 ................. 0.20	X			0	0
(5) TODD HEIMAN...................................................................... DIRECTOR BEGIN 5/1/22	1.00 ................. 0.20	X			0	0
(6) SCOTT KELLERMAN...................................................................... TREAS. TIL 12/31/21, DIR. BEG 1/1/22	1.00 ................. 0.20	X	X		0	0
(7) MICHAEL PECHECK...................................................................... TREASURER BEGIN 1/1/22	1.00 ................. 0.20	X	X		0	0
(8) KELLY KLUN...................................................................... SECRETARY	1.00 ................. 0.20	X	X		0	0
(9) DEVON LUTHENS...................................................................... DIR. UNTIL 12/31/21, VP BEG 1/1/22	1.00 ................. 0.20	X	X		0	0
(10) SUE EDGINGTON...................................................................... PRESIDENT UNTIL 12/31/21	1.50 ................. 0.20	X	X		0	0
(11) TIM RILEY...................................................................... VP UNTIL 12/31/21. PRES. BEG 1/1/22	1.50 ................. 0.20	X	X		0	0
(12) PATTI BANKS...................................................................... CEO	39.70 ................. 0.30		X		239,279	11,646
(13) CURTIS BACH...................................................................... CFO	39.70 ................. 0.30		X		134,883	19,254
(14) BROCK URIE...................................................................... PHYSICIAN	40.00 ................. 0.00			X	273,843	0
(15) SAM RICE...................................................................... PHYSICIAN	40.00 ................. 0.00			X	150,386	39,537
(16) BETH HARTSHORN...................................................................... PHARMACIST	40.00 ................. 0.00			X	147,910	19,920
(17) JOHN SCHINDELE...................................................................... PHARMACIST	40.00 ................. 0.00			X	147,380	38,619

(A) Name and business address	(B) Description of services	(C) Compensation
ACUTE CARE INC 1609 N ANKENY BLVD STE 200 ANKENY,CA50023	EMERGENCY ROOM PHYSICIAN COVERAGE	1,076,498
CENTRAL MINNESOTA DIAGNOSTIC INC PO BOX 158 MILACA,MN56353	DIAGNOSTIC EQUIP SERVICE	876,926
LAKE COUNTRY ANESTHESIA LLC 2760 BEAR ISLAND RIVER RD ELY,MN55731	ANESTHESIA SERVICES	646,342
ADVANCED SURGICAL ASSOCIATES OF NORTHERN 5034 RED CEDAR ST HERMANTOWN,MN55811	PHYSICIAN SERVICES	314,788
ESSENTIA HEALTH SHARED SERVICES 502 EAST 2ND ST DULUTH,MN55805	EPIC SOFTWARE SERVICES	279,288
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 13

- TIN:

SCHEDULE A
(Form 990)

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.
right arrow

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization

ELY-BLOOMENSON COMMUNITY HOSPITAL

Employer identification number

41-0808719

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 12, 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 (Form 990).)

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 agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

An organization that normally receives: (1) more than 33 1/3% 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 33 1/3% 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 on lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

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

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

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

Cat. No. 11285F

Schedule A (Form 990) 2021

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 failed to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year (or fiscal year beginning in)		(a) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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 VI.)..
11	Total support. Add lines 7 through 10

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

First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here ........................................ right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2021 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2020 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2021. 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—2020. 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—2021. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2020. 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 VI 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) 2021

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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) 2017	(b) 2018	(c) 2019	(d) 2020	(e) 2021	(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 on 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 VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2021 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2020 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2021 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2020 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2021. 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—2020. 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) 2021

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of Part I, complete Sections A, D, and E. If you checked box12d, of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer lines 3b and 3c below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked box 12a or 12b in Part I, answer lines 4b and 4c below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer lines 5b and 5c below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described on line 7? If “Yes,” complete Part I of Schedule L (Form 990).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons, as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined on line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined on line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990) 2021

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described on lines 11b and 11c below, the governing body of a supported organization?

11a

A family member of a person described on 11a above?

11b

A 35% controlled entity of a person described on line 11a or 11b above? If “Yes” to 11a, 11b, or 11c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the officers, directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in line 2 above, did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer lines 2a and 2b below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described on line 2a, above constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer lines 3a and 3b below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations?If "Yes" or "No", provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990) 2021

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	Section A - Adjusted Net Income		(A) Prior Year	(B) Current Year (optional)
1	Net short-term capital gain	1
2	Recoveries of prior-year distributions	2
3	Other gross income (see instructions)	3
4	Add lines 1 through 3	4
5	Depreciation and depletion	5
6	Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions)	6
7	Other expenses (see instructions)	7
8	Adjusted Net Income (subtract lines 5, 6 and 7 from line 4)	8

	Section B - Minimum Asset Amount		(A) Prior Year	(B) Current Year (optional)
1	Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year):	1
a	Average monthly value of securities	1a
b	Average monthly cash balances	1b
c	Fair market value of other non-exempt-use assets	1c
d	Total (add lines 1a, 1b, and 1c)	1d
e	Discount claimed for blockage or other factors (explain in detail in Part VI):
2	Acquisition indebtedness applicable to non-exempt use assets	2
3	Subtract line 2 from line 1d	3
4	Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions).	4
5	Net value of non-exempt-use assets (subtract line 4 from line 3)	5
6	Multiply line 5 by 0.035	6
7	Recoveries of prior-year distributions	7
8	Minimum Asset Amount (add line 7 to line 6)	8

	Section C - Distributable Amount		Current Year
1	Adjusted net income for prior year (from Section A, line 8, Column A)	1
2	Enter 85% of line 1	2
3	Minimum asset amount for prior year (from Section B, line 8, Column A)	3
4	Enter greater of line 2 or line 3	4
5	Income tax imposed in prior year	5
6	Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions)	6

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990) 2021

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)

Section D - Distributions		Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes	1
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity	2
3 Administrative expenses paid to accomplish exempt purposes of supported organizations	3
4 Amounts paid to acquire exempt-use assets	4
5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI)	5
6 Other distributions (describe in Part VI). See instructions	6
7Total annual distributions. Add lines 1 through 6.	7
8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions	8
9 Distributable amount for 2021 from Section C, line 6	9
10 Line 8 amount divided by Line 9 amount	10

Section E - Distribution Allocations (see instructions)		(i) Excess Distributions	(ii) Underdistributions Pre-2021	(iii) Distributable Amount for 2021
1 Distributable amount for 2021 from Section C, line 6
2 Underdistributions, if any, for years prior to 2021 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2021:
a From 2016.......
b From 2017.......
c From 2018.......
d From 2019.......
e From 2020.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2021 distributable amount
i Carryover from 2016 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.
4Distributions for 2021 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2021 distributable amount
c Remainder. Subtract lines 4a and 4b from line 4.
5 Remaining underdistributions for years prior to 2021, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2021. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2022. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2017.....
b Excess from 2018.....
c Excess from 2019.....
d Excess from 2020.....
e Excess from 2021.....

Schedule A (Form 990) (2021)

Schedule A (Form 990) 2021

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

ELY-BLOOMENSON COMMUNITY HOSPITAL

Employer identification number

41-0808719

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV. See instructions for definition of “political campaign activities."

Political campaign activity expenditures. See instructions .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities. See instructions ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b........... SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990) 2021

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ........................
c	Total lobbying expenditures (add lines 1a and 1b) ............................................................
d	Other exempt purpose expenditures ...............................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ..................................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................................................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ...................................................................................................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2018	(b) 2019	(c) 2020	(d) 2021	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990) 2021

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Yes

1,658

Total. Add lines 1c through 1i ....................................................................................................

1,658

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members ......................................................................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

Carryover from last year ............................................................................................................

Total ...........................................................................................................................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................

Taxable amount of lobbying and political expenditures. See Instructions .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
PART II-B, LINE 1:	THE HOSPITAL PAYS DUES TO CERTAIN ORGANIZATIONS RELATED TO THE INDUSTRY WHICH HAVE LOBBYING EXPENSES. THE AMOUNT LISTED IS THE PERCENTAGE OF THE DUES PAID THAT WERE USED FOR LOBBYING.

Schedule C (Form 990) 2021

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," on 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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

ELY-BLOOMENSON COMMUNITY HOSPITAL

Employer identification number

41-0808719

Part I

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

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate value of contributions to (during year)
3	Aggregate value of 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" on 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 7/25/06, 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, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, handling of violations, 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" on Form 990, Part IV, line 8.

If the organization elected, as permitted under FASB 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 FASB 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)

Revenue included on 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 FASB ASC 958 relating to these items:

Revenue included on 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) 2021

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" on 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


b	If "Yes," explain the arrangement in Part XIII and complete the following table:		Amount
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, for escrow or custodial account liability? ...

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" on Form 990, Part IV, line 10.

		(a) Current year	(b) Prior year	(c) Two years back	(d) Three years back	(e) Four years back

1a	Beginning of year balance ....	77,500	77,500	77,500	77,500	77,500
b	Contributions ...
c	Net investment earnings, gains, and losses	2	462	1,594	1,710	1,588
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....	2	462	1,594	1,710	1,588
g	End of year balance ......	77,500	77,500	77,500	77,500	77,500

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

Board designated or quasi-endowment SchDMd Bullet

0 %

Permanent endowment SchDMd Bullet

100.000 %

Term endowment SchDMd Bullet

0 %

The percentages on 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)

Yes

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

Yes

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

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(a) Cost or other basis (investment)	(b) Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value

1a	Land .....	76,827		76,827
b	Buildings ....	16,373,242	13,514,822	2,858,420
c	Leasehold improvements
d	Equipment ....	9,154,588	6,197,623	2,956,965
e	Other .....	1,661,880	1,300,497	361,383
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				6,253,595

Schedule D (Form 990) 2021

Page 3

Part VII

Investments - Other Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. 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)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

Investments - Program Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

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

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1)INTEREST RECEIVABLE				29
(2)DIRECT FINANCING LEASE				1,236,901
(3)INVESTMENT IN AFFILIATES				709,778
(4)THIRD-PARTY PAYOR SETTLEMENTS				44,000
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........				1,990,708

Part X

Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes

(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)
2. Liability for uncertain tax positions. 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) 2021

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	28,669,896
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains (losses) on investments ....	2a	-885,759
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	42,502
e	Add lines 2a through 2d .....................			2e	-843,257
3	Subtract line 2e from line 1..................			3	29,513,153
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	0
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	29,513,153

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........			1	27,560,216
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	0
3	Subtract line 2e from line 1...................			3	27,560,216
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	-42,502
c	Add lines 4a and 4b.....................			4c	-42,502
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	27,517,714

Part XIII

Supplemental Information

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.

Return Reference	Explanation
PART V, LINE 4:	THE ENDOWMENT FUNDS ARE HELD BY ELY HEALTH AND HOSPITAL FOUNDATION. THE INCOME FROM THE ENDOWMENT FUNDS WILL BE USED FOR GRANTS AND CONTRIBUTIONS.
PART X, LINE 2:	THE HOSPITAL IS A NONPROFIT HOSPITAL AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES. THE FASB ISSUED GUIDANCE ON ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES. MANAGEMENT EVALUATED THE HOSPITAL'S TAX POSITIONS AND CONCLUDED THE HOSPITAL HAS TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENT TO THE FINANCIAL STATEMENTS TO COMPLY WITH THE PROVISIONS OF THE GUIDANCE. GENERALLY, THE HOSPITAL IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL, STATE OR LOCAL TAX AUTHORITIES FOR YEARS BEFORE 2019.
PART XI, LINE 2D - OTHER ADJUSTMENTS:	IMPLICIT PRICE CONCESSIONS 42,502.
PART XII, LINE 4B - OTHER ADJUSTMENTS:	IMPLICIT PRICE CONCESSIONS -42,502.

Schedule D (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

ELY-BLOOMENSON COMMUNITY HOSPITAL

Employer identification number

41-0808719

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .

Yes

If "Yes," was it a written policy? ......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other 12500.0000000000 %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

which of the following was the family income limit for eligibility for discounted care: . . . . . . . .

Yes

200% 250% 300% 350% 400% Other 16000.0000000000 %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .

Did the organization prepare a community benefit report during the tax year? . . . . . . . . .

Yes

If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .	257,446		257,446	0.930 %
b	Medicaid (from Worksheet 3, column a) . . . . .	3,177,828	2,168,162	1,009,666	3.660 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	3,435,274	2,168,162	1,267,112	4.590 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).	74,526		74,526	0.270 %
f	Health professions education (from Worksheet 5) . . .	55,593		55,593	0.200 %
g	Subsidized health services (from Worksheet 6) . . . .
h	Research (from Worksheet 7) .
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .	122,275		122,275	0.440 %
j	Total. Other Benefits . .	252,394		252,394	0.910 %
k	Total. Add lines 7d and 7j .	3,687,668	2,168,162	1,519,506	5.500 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2021

Schedule H (Form 990) 2021

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support	23,805	23,805	0.090 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total	23,805	23,805	0.090 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

8,636,249

Enter Medicare allowable costs of care relating to payments on line 5.....

8,590,134

Subtract line 6 from line 5. This is the surplus (or shortfall)........

46,115

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2021

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)						Other (describe)
1	ELY-BLOOMENSON COMMUNITY HOSPITAL 328 WEST CONAN STREET ELY,MN55731 398394	X	X	X	X	N/A

Schedule H (Form 990) 2021

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)

	ELY-BLOOMENSON COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 21

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): SEE PART V, PAGE 8

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): SEE PART V, PAGE 8

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2021

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	ELY-BLOOMENSON COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 125.000000000000%
and FPG family income limit for eligibility for discounted care of 160.000000000000%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

SEE PART V, PAGE 8

The FAP application form was widely available on a website (list url):

SEE PART V, PAGE 8

A plain language summary of the FAP was widely available on a website (list url):
SEE PART V, PAGE 8

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2021

Page 6

Part VFacility Information (continued)

Billing and Collections

	ELY-BLOOMENSON COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs (if not, describe in Section C)

Made a reasonable effort to orally notify individuals about the FAP and FAP application process (if not, describe in
Section C)

Processed incomplete and complete FAP applications (if not, describe in Section C)

Made presumptive eligibility determinations (if not, describe in Section C)

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2021

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	ELY-BLOOMENSON COMMUNITY HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2021

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
ELY-BLOOMENSON COMMUNITY HOSPITAL	PART V, SECTION B, LINE 5: EBCH PROVIDED RHI WITH A COUNT OF INPATIENT ADMISSIONS BY ZIP CODE FROM THE PREVIOUS YEAR. ZIP CODES WITH THE GREATEST NUMBER OF ADMISSIONS AND UTILIZATION WERE STRATIFIED IN THE INITIAL SAMPLE SELECTION. EACH AREA WOULD BE REPRESENTED IN THE SAMPLING PROPORTIONATELY TO BOTH THE OVERALL SERVED POPULATION AND THE NUMBER OF PAST ADMISSIONS OR UTILIZATION. EIGHT HUNDRED ADDRESSES REPRESENTING THE SAMPLE AREA WERE SELECTED RANDOMLY FROM PRIMENET DATA SOURCE, A MARKETING ORGANIZATION. ALTHOUGH THE SURVEY SAMPLES WERE PROPORTIONATELY SELECTED, ACTUAL SURVEYS RETURNED FROM EACH POPULATION AREA VARIED. THIS MAY RESULT IN SLIGHTLY LESS PROPORTIONAL RESULTS. THE CHNA, A COVER LETTER ON EBCH'S LETTERHEAD, AND A POSTAGE PAID REPLY ENVELOPE WERE MAILED FIRST CLASS TO 800 RANDOMLY SELECTED RESIDENTS IN THE TARGETED REGION (SEVEN ZIP CODES). EBCH ANNOUNCED THE CHNA SURVEY IN A PRESS RELEASE IN THE ELY ECHO AND THE TIMBERJAY NEWSPAPERS THE WEEK OF OCTOBER 25, 2021. THE INFORMATION RAN IN THE TIMBERJAY ON OCTOBER 29, 2021, AND THE ELY ECHO ON OCTOBER 30, 2021. EBCH ALSO PROMOTED THE SURVEY ON SOCIAL MEDIA AND THE LOCAL RADIO STATION WELY.
ELY-BLOOMENSON COMMUNITY HOSPITAL	PART V, SECTION B, LINE 11: THE HOSPITAL IDENTIFIED THE FOLLOWING SIGNIFICANT NEEDS IN ITS MOST RECENTLY CONDUCTED CHNA: 1. ACCESS TO DENTAL SERVICES2. ACCESS TO CHILDCARE3. ACCESS TO SPECIALISTS4. DENTAL CARE5. AVAILABILITY OF SERVICES/ PROVIDERS6. MENTAL HEALTH SERVICESELY-BLOOMENSON COMMUNITY HOSPITAL (EBCH) AND ITS BOARD OF DIRECTORS IDENTIFIED THE FOLLOWING THREE SIGNIFICANT NEEDS. THE HOSPITAL IS ADDRESSING ALL OF THE SIGNIFICANT NEEDS IN SOME CAPACITY: 1.) INCREASE IN ACCESS TO SPECIALTY SERVICES2.) INCREASE IN COMMUNITY AWARENESS AND EDUCATION3.) INCREASE IN ACCESS TO CHILDCARESOME OF THE ONGOING COMMUNITY BENEFIT ACTIVITIES THAT EBCH IS PARTICIPATING IN FOR EACH OF THE SIGNIFICANT NEEDS INCLUDE: 1. WE CONTINUE TO WORK WITH OTHER HEALTHCARE PARTNERS TO INCREASE THE AVAILABILITY OF SERVICES AND PROVIDERS AT EBCH. EBCH HAS THE FOLLOWING SPECIALTIES: PODIATRY, ORTHOPEDICS, GENERAL SURGERY AND GASTROENTEROLOGY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, INFUSIONS, AND CARDIAC REHAB. CURRENTLY EBCH IS EXPLORING ADDING ADDITIONAL SPECIALTIES WITH LIMITED FINANCIAL RESOURCES.2. INCREASE IN ACCESS TO SPECIALTY SERVICES WAS IDENTIFIED BY THE BOARD OF DIRECTORS AND THE CHNA AS A SIGNIFICANT NEED. WE PROVIDE ONGOING PRINT AND RADIO ADS ADVERTISING THESE SPECIALTY SERVICES AND WHAT THEY CAN DO FOR THE COMMUNITY. EBCH HAS INCREASED ITS SOCIAL MEDIA PRESENCE REGARDING HEALTH TOPICS WITHIN THE COMMUNITY THROUGH ITS PARTNERSHIP WITH LEGATO, A MARKETING COMPANY. EBCH ALSO CREATED MARKETING MATERIALS TO GIVE TO LARGE EMPLOYERS IN THE AREA. 3. THE CEO, PATTI BANKS, DURING TAX YEAR 2021, JOINED THE BOARD OF THE ELY AREA COMMUNITY FOUNDATION THAT IS WORKING ON A PROJECT TO PROVIDE AN AFFORDABLE BUILDING SPACE FOR A LOCAL DAY CARE FACILITY. EBCH IS IN THE PLANNING STAGE TO DETERMINE THE BEST WAY TO PROVIDE CHILDCARE SERVICES TO THE COMMUNITY WITH LIMITED FINANCIAL RESOURCES.4. THE CHNA NOTES THAT THERE IS A GAP IN MENTAL HEALTH CARE SERVICES; WE CONTINUE TO PARTNER WITH MANY LOCAL ORGANIZATIONS SUCH AS BEHAVIORAL HEALTH NETWORK AND EPARC TO BRING AWARENESS TO MENTAL HEALTH AND ASSOCIATED SUBSTANCE ABUSE. EBCH IS ALSO PARTICIPATING IN THE MN PATH TO VALUES AND IS PART OF THE MENTAL HEALTH COMMUNITY CARE TEAM. EBCH IS DETERMINING THE BEST WAY TO PROVIDE MENTAL HEALTH SERVICES TO THE COMMUNITY WITH LIMITED FINANCIAL RESOURCES5. THE CHNA NOTES THAT ACCESS TO DENTAL SERVICES IS A SIGNIFICANT NEED IN THE COMMUNITY, EBCH DONATES TO THE ELY FREE CLINIC WHICH PROVIDES DENTAL SERVICES. EBCH IS DETERMINING THE BEST WAY TO PROVIDE DENTAL SERVICES TO THE COMMUNITY WITH LIMITED FINANCIAL RESOURCES.
PART V, LINE 7A, CHNA - HOSPITAL'S WEBSITE	HTTPS://WWW.EBCH.ORG/COMMUNITY-HEALTH/COMMUNITY-HEALTH-NEEDS-ASSESSMENT
PART V, LINE 10, IMPLEMENTATION PLAN WEBSITE	HTTPS://WWW.EBCH.ORG/COMMUNITY-HEALTH/COMMUNITY-HEALTH-NEEDS-ASSESSMENT
PART V, LINE 16A, FAP WEBSITE	HTTPS://EBCH.ORG/SITES/DEFAULT/FILES/2022-04/FINANCIAL%20ASSISTANCE%20POLICY.PDF
PART V, LINE 16B, FAP APPLICATION WEBSITE	HTTPS://EBCH.ORG/SITES/DEFAULT/FILES/2022-01/EBCH%20CHARITY%20CARE%20APPLICATION%20%2012.21.PDF
PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY	HTTPS://EBCH.ORG/SITES/DEFAULT/FILES/2022-01/EBCH%20FAP%20PLAIN%20LANGUAGE%20SUMMARY%2012.21.PDF

Schedule H (Form 990) 2021

Page 9

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2021

Page 10

Part VI

Supplemental Information

Provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Form and Line Reference	Explanation
PART I, LINE 7:	COSTS ARE CALCULATED USING FINANCIAL DATA AND THE COST TO CHARGE RATIO FROM THE AS FILED 9/30/2022 MEDICARE COST REPORT.
PART I, LN 7 COL(F):	IMPLICIT PRICE CONCESSIONS FROM THE FINANCIAL STATEMENTS IS -$42,502.
PART II, COMMUNITY BUILDING ACTIVITIES:	COMMUNITY SUPPORT: OUR HOSPITAL FACILITIES AND THE SAFTEY COMMITTEE MEETS WITH STAFF EVERY MONTH, PROVIDING UPDATES OF FEDERAL AND STATE MANDATES. EACH MANDATE IS ADDRESSED IN REGARDS TO HOW THEY IMPACT OUR COMMUNITY AND THE SURROUNDING SERVICE AREA. OUR DECONTAMINATION TENT IS ERECTED ANNUALLY. STAFF FROM FIRE, POLICE, EMTS AND 1ST RESPONDERS REPRESENTING ELY, TOWER, SOUDAN, BABBITT, ISABELLA AND WINTON ARE INVITED TO PARTICIPATE IN THIS EXERCISE. HOSPITAL STAFF IS ALSO ASKED TO CONTRIBUTE TO THIS EMERGENCY PREPAREDNESS ACTIVITY. IN FY22 EBCH BROUGHT ON A CONSULTANT TO LEAD THE DISCUSSION ON EMERGENCY PREPAREDNESS AND CONDUCT ALICE (ACTIVE SHOOTER) TRAINING. EBCH STAFF ALSO SATTENED THE UNDER ONE ROOF CONFERENCE. HELICOPTER LANDING TRAINING WAS CONDUCTED.
PART III, LINE 2:	THE HOSPITAL GENERALLY ESTIMATES THE AMOUNT OF IMPLICIT PRICE CONCESSIONS FOR THE CURRENT YEAR BY USING THE PRECENTAGE OF REVENUE AS SHOWN AS IMPLICIT PRICE CONCESSIONS IN SUPPLEMENTAL INFORMATION TO THE AUDITED FINANCIAL STATEMENT FROM THE PRIOR YEAR.
PART III, LINE 3:	THE HOSPITAL ESIMATES THE AMOUNT OF IMPLICIT PRICE CONCESSIONS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY BY USING THE PERCENTAGE OF REVENUE SHOWN AS IMPLICIT PRICE CONCESSIONS ON THE HOSPITAL'S OPERATIONS REVIEW REPORT MULTIPLIED BY THE CURRENT YEAR MEDICAID CONTRACTUAL ADJUSTMENT.
PART III, LINE 4:	FROM FOOTNOTE 1 OF THE AUDITED FINANCIAL STATEMENTS: UNDER THE PROVISIONS OF ACCOUNTING STANDARDS UPDATE (ASU) NO. 2014-09, WHICH WAS ADOPTED OCTOBER 1, 2019, WHEN THERE IS AN UNCONDITIONAL RIGHT TO PAYMENT, SUBJECT ONLY TO THE PASSAGE OF TIME, THE RIGHT IS TREATED AS A RECEIVABLE. PATIENT ACCOUNTS RECEIVABLE, INCLUDING BILLED ACCOUNTS AND UNBILLED ACCOUNTS FOR WHICH THE HOSPITAL HAS THE UNCONDITIONAL RIGHT TO PAYMENT, AND ESTIMATED AMOUNTS DUE FROM THIRD-PARTY PAYORS FOR RETROACTIVE ADJUSTMENTS ARE RECEIVABLES IF THE HOSPITAL'S RIGHT TO CONSIDERATION IS UNCONDITIONAL AND ONLY THE PASSAGE OF TIME IS REQUIRED BEFORE PAYMENT OF THAT CONSIDERATION IS DUE. FOR PATIENT ACCOUNTS RECEIVABLE SUBSEQUENT TO THE ADOPTION OF ASU 2014-09, THE ESTIMATED UNCOLLECTIBLE AMOUNTS ARE GENERALLY CONSIDERED IMPLICIT PRICE CONCESSIONS THAT ARE A DIRECT REDUCTION TO PATIENT ACCOUNTS RECEIVABLE RATHER THAN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE HOSPITAL DETERMINES THIS ESTIMATE OF IMPLICIT PRICE CONCESSIONS BASED ON HISTORICAL COLLECTION EXPERIENCE WITH CERTAIN CLASSES OF PATIENTS USING A PORTFOLIO APPROACH AS A PRACTICAL EXPEDIENT TO ACCOUNT FOR PATIENT CONTRACTS AS COLLECTIVE GROUPS RATHER THAN INDIVIDUALLY. THE FINANCIAL STATEMENT EFFECTS OF USING THIS PRACTICAL EXPEDIENT ARE NOT MATERIALLY DIFFERENT FROM AN INDIVIDUAL CONTRACT APPROACH.THE PRIMARY COLLECTIONS RISKS RELATE TO UNINSURED PATIENT ACCOUNTS, INCLUDING PATIENT ACCOUNTS FOR WHICH THE PRIMARY INSURANCE CARRIER HAS PAID THE AMOUNTS COVERED BY THE APPLICABLE AGREEMENT, BUT THE PATIENT RESPONSIBILITY AMOUNT (DEDUCTIBLES AND COPAYMENTS) REMAIN OUTSTANDING. IMPLICIT PRICE CONCESSIONS RELATE PRIMARILY TO AMOUNTS DUE DIRECTLY FROM PATIENTS. ESTIMATED IMPLICIT PRICE CONCESSIONS ARE RECORDED FOR ALL UNINSURED ACCOUNTS, REGARDLESS OF THE AGING OF THOSE ACCOUNTS. ACCOUNTS ARE WRITTEN OFF WHEN ALL REASONABLE INTERNAL AND EXTERNAL COLLECTION EFFORTS HAVE BEEN PERFORMED.
PART III, LINE 8:	THE COSTING METHODOLOGY USED IN DETERMINING THE MEDICARE ALLOWABLE COST REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT AS REFLECTED IN THE AMOUNT REPORTED IN PART III, LINE 6:THE HOSPITAL FOLLOWED MEDICARE'S PRESCRIBED METHODS OF DETERMINING COSTS PAYABLE UNDER TITLE XVIII (MEDICARE) IN COMPLETING ITS ANNUAL MEDICARE COST REPORT (COST REPORT) USING DATA AVAILABLE FROM THE INSTITUTION'S BASIC ACCOUNTS, AS USUALLY MAINTAINED, TO ARRIVE AT EQUITABLE AND PROPER PAYMENT FOR SERVICES. THE COST REPORT WAS COMPLETED USING THE HOSPITAL'S TRIAL BALANCE OF EXPENSES, AS WELL AS OTHER STATISTICAL AND FINANCIAL RECORDS MAINTAINED BY THE HOSPITAL. AS REQUIRED BY MEDICARE REGULATIONS, CERTAIN RECLASSIFICATIONS AND ADJUSTMENTS TO COSTS WERE INCLUDED IN THE COST REPORT TO DETERMINE MEDICARE ALLOWABLE COSTS.AFTER MEDICARE ALLOWABLE COSTS ARE DETERMINED, THE COST REPORT PROVIDES FOR THE STEP DOWN METHOD OF COST FINDING. THIS METHOD PROVIDES FOR ALLOCATING THE COST OF SERVICES RENDERED BY EACH GENERAL SERVICE COST CENTER TO OTHER COST CENTERS, WHICH UTILIZE THE SERVICES. ONCE THE COSTS OF A GENERAL SERVICE COST CENTER HAVE BEEN ALLOCATED, THAT COST CENTER IS CONSIDERED CLOSED. ONCE CLOSED, IT DOES NOT RECEIVE ANY OF THE COSTS SUBSEQUENTLY ALLOCATED FROM THE REMAINING GENERAL SERVICE COST CENTERS. AFTER ALL COSTS OF THE GENERAL SERVICE COST CENTERS HAVE BEEN ALLOCATED TO THE REMAINING COST CENTERS, THE TOTAL COSTS OF THESE REMAINING COST CENTERS ARE FURTHER DISTRIBUTED TO THE DEPARTMENTAL CLASSIFICATION TO WHICH THEY PERTAIN, E.G., HOSPITAL GENERAL INPATIENT ROUTINE, SUBPROVIDER, ANCILLARY, ETC.AFTER THE STEP-DOWN PROCESS, THE COST REPORT PROVIDES FOR THE APPORTIONMENT OF COSTS TO THE MEDICARE PROGRAM BASED ON A NUMBER OF DIFFERENT METHODOLOGIES INCLUDING PER PATIENT DAY, PER VISIT, AND PERCENTAGE OF CHARGES, AS MOST PREVALENT. MEDICARE COSTS AS DETERMINED BY THE COST REPORT METHODOLOGIES DESCRIBED PREVIOUSLY WERE UTILIZED TO COMPLETE THE APPLICABLE MEDICARE ALLOWABLE COSTS OF CARE FOR SCHEDULE H (FORM 990) PART III SECTION B LINE 6.
PART III, LINE 9B:	AT LEAST 30 DAYS PRIOR TO TAKING ANY EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL TO OBTAIN PAYMENT FOR AN EPISODE OF CARE, EBCH OR ITS AGENT SHALL PROVIDE THE INDIVIDUAL WITH A WRITTEN NOTICE THAT INCLUDES THE FOLLOWING INFORMATION:I. CHARITY CARE FINANCIAL ASSISTANCE PROGRAM (FAP) IS AVAILABLE FOR ELIGIBLE INDIVIDUALS.II. THE EXTRAORDINARY COLLECTION ACTIONS THAT EBCH INTENDS TO INITIATE FOR PAYMENT OF CARE.III. A DEADLINE AFTER WHICH EXTRAORDINARY COLLECTION ACTIONS MAY BE INITIATED.BEFORE SENDING AN ACCOUNT TO A COLLECTION AGENCY, EBCH MAY USE INFORMATION PROVIDED BY AN OUTSIDE AGENCY OR VENDOR TO DETERMINE ELIGIBILITY AND POTENTIAL FINANCIAL ASSISTANCE. THESE AGENCIES MAY USE PUBLICLY AVAILABLE AND PURCHASED TRANSACTION DATA TO ESTIMATE A GUARANTOR'S FINANCIAL PROFILE AND HOUSEHOLD SIZE. EXAMPLES OF SUCH DATA ARE CENSUS DATA, BIRTH CERTIFICATES, MARRIAGE LICENSES, LEGAL NOTICES, BANKRUPTCY FILINGS, AUTOMOBILE REGISTRATIONS, PROPERTY TAX RECORDS, AS WELL AS POINT-OF-SALES TRANSACTIONS DATA THAT RETAILERS AND CREDIT CARD COMPANIES MAKE AVAILABLE FOR PURCHASE TO PRESUMPTIVELY DETERMINE WHETHER THAT INDIVIDUAL MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER EBCH'S FINANCIAL ASSISTANCE POLICY.IF THE INDIVIDUAL IS PRESUMPTIVELY DETERMINED TO BE ELIGIBLE FOR A 100% DISCOUNT (COMPLETE WRITE-OFF) UNDER EBCH'S FINANCIAL ASSISTANCE POLICY, EBCH SHALL INFORM THE INDIVIDUAL OF THAT DECISION AND NO FURTHER ACTIONS WILL BE TAKEN IN RELATION TO MEDICAL SERVICES TO WHICH THIS FINANCIAL ASSISTANCE APPLIES.
PART VI, LINE 2:	NEEDS ASSESSMENT:ELY BLOOMENSON UTILIZES THE BRIDGES TO HEALTH SURVEY FIRST CONDUCTED IN 1995 AND THUS COMPLETED EVERY FIVE YEARS, 2000, 2005, 2010, 2015. 2020. THE SURVEY, A COLLABORATIVE EFFORT AMONG REGIONAL HEALTH ORGANIZATIONS, IS A TRUSTED SOURCE OF POPULATION-BASED HEALTH STATUS INFORMATION USED TO IMPROVE THE HEALTH OF PEOPLE THROUGHOUT NORTHEASTERN MINNESOTA.THE HOSPITAL HELD THREE SESSIONS OF ITS COMMUNITY FORUM IN ELY, BABBITT, AND TOWER IN THE SPRING TO ENCOURAGE THE COMMUNITY TO GET AN UPDATE OF WHAT THEY ARE DOING AT THE HOSPITAL, AND THE HOSPITAL LISTENS TO QUESTIONS AND SUGGESTIONS FOR THE COMMUNITY. THE 2019 SESSIONS TOOK PLACE IN ELY ON 4/24/2019, BABBITT ON 5/23/2019, AND TOWER ON 6/27/2019.IN THE SUMMER OF 2021, EBCH PARTICIPATED IN COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) SERVICES ADMINISTRATED BY RURAL HEALTH INNOVATIONS (RHI), A SUBSIDIARY OF THE NATIONAL RURAL HEALTH RESOURCE CENTER. RHI CONFERRED WITH LEADERS FROM EBCH TO DISCUSS THE OBJECTIVES OF A REGIONAL CHNA. A MAILED SURVEY INSTRUMENT WAS DEVELOPED TO ASSESS THE HEALTH CARE NEEDS AND PREFERENCES IN THE SERVICE AREA. THIS WAS COMPLETED IN NOVEMBER 2021.THE HOSPITAL ALSO RECEIVES QUESTIONS AND SUGGESTIONS FROM THE COMMUNITY THROUGH THE "CONTACT US" PAGE OF THEIR WEBSITE, THE EBCH FACEBOOK PAGE, AND AT VARIOUS SPEAKING ENGAGEMENTS FOR THEIR LOCAL SERVICE CLUBS AND ORGANIZATIONS, SUCH AS THE ROTARY, LIONS, AND KIWANIS.
PART VI, LINE 3:	PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE:THE ELY BLOOMENSON HOSPITAL STAFF ENCOURAGES ANY PATIENT WITH NO INSURANCE TO TALK TO ST. LOUIS COUNTY SOCIAL SERVICES TO FIND OUT ABOUT MEDICAL ASSISTANCE OR MN CARE ELIGIBILITY. ON ALL PATIENT STATEMENTS, THERE ARE DIRECTIONS ON HOW TO ACCESS THE CREDIT AND COLLECTION POLICY AS WELL AS THE FINANCIAL ASSISTANCE POLICY. THE FINANCIAL ASSISTANCE POLICY INFORMS PATIENTS THAT WE HAVE AN INCOME BASED CHARITY CARE POLICY AND THEY CAN CONTACT THE EBCH FINANCIAL COUNCILOR OR BUSINESS OFFICE FOR AN APPLICATION. APPLICATIONS AND POLICIES ARE AVAILABLE ON THE HOPITAL'S WEBSITE AT EBCH.ORG. WHEN AN ACCOUNT IS PAST DUE A SERIES OF COLLECTION LETTERS GO OUT WITH THE MESSAGE THAT THE ELY BLOOMENSON HOSPITAL HAS AN INCOME BASED CHARITY CARE POLICY AND IF ANYONE WOULD LIKE AN APPLICATION OR IF ANYONE HAS A QUESTION ABOUT IT THEY SHOULD CONTACT THE EBCH FINANCIAL COUNCILOR OR THE BUSINESS OFFICE. ALL PATIENTS SHOULD BE AWARE OF THE CHARITY CARE OPTION BEFORE THE ACCOUNT TURNS INTO IMPLICIT PRICE CONCESSION STATUS.
PART VI, LINE 4:	COMMUNITY INFORMATION:ELY, A CITY OF 2.7 SQUARE MILES, AND THE SURROUNDING COMMUNITIES OF WINTON, BABBITT, TOWER AND ISABELLA CONSTITUTES A LARGE RURAL DEMOGRAPHIC REGION IN NORTHEASTERN MINNESOTA BORDERING THE 1.5 MILLION ACRES OF THE BOUNDARY WATERS CANOE AREA WILDERNESS (BWCAW). THE CITY OF DULUTH, 120 MILES SOUTHWEST AND VIRGINIA, 50 MILES WEST, SERVE AS THE NEAREST HEALTH CARE CENTERS. THE HOSPITAL SERVES A YEAR ROUND POPULATION OF APPROXIMATELY 8,600. IN ADDITION, THE COMMUNITY ANNUALLY SERVES OVER 125,000 VISITORS SEEKING A WILDERNESS EXPERIENCE. ACCORDING TO THE 2020 CENSUS, ELY, MN HAD A POPULATION OF 3.34K PEOPLE WITH A MEDIAN AGE OF 52.4 AND A MEDIAN HOUSEHOLD INCOME OF $37,317. BETWEEN 2019 AND 2020 THE POPULATION OF ELY, MN DECLINED FROM 3,390 TO 3,338, A 1.53% DECREASE AND ITS MEDIAN HOUSEHOLD INCOME DECLINED FROM $40,946 TO $37,317, A 8.86% DECREASE.THE 5 LARGEST ETHNIC GROUPS IN ELY, MN ARE WHITE (NON-HISPANIC) (95.1%), TWO+ (HISPANIC) (1.98%), BLACK OR AFRICAN AMERICAN (NON-HISPANIC) (1.11%), AMERICAN INDIAN & ALASKA NATIVE (NON-HISPANIC) (0.989%), AND OTHER (HISPANIC) (0.33%). NONE OF THE HOUSEHOLDS IN ELY, MN REPORTED SPEAKING A NON-ENGLISH LANGUAGE AT HOME AS THEIR PRIMARY SHARED LANGUAGE. THIS DOES NOT CONSIDER THE POTENTIAL MULTI-LINGUAL NATURE OF HOUSEHOLDS, BUT ONLY THE PRIMARY SELF-REPORTED LANGUAGE SPOKEN BY ALL MEMBERS OF THE HOUSEHOLD.99.6% OF THE RESIDENTS IN ELY, MN ARE U.S. CITIZENS. THE LARGEST UNIVERSITIES IN ELY, MN ARE VERMILION COMMUNITY COLLEGE (185 DEGREES AWARDED IN 2020).IN 2020, THE MEDIAN PROPERTY VALUE IN ELY, MN WAS $119,400, AND THE HOMEOWNERSHIP RATE WAS 58.2%.
PART VI, LINE 5:	PROMOTION OF COMMUNITY HEALTH:ELY BLOOMENSON DOES HAVE AN OPEN MEDICIAL STAFF ALLOWING A VARIETY OF PHYSICIANS TO PRACTICE BENEFITING THE COMMUNITY AND CITIZENS OF THE SURROUNDING AREA. THE COMMUNITY HEALTH COUNCIL, BRINGING HEALTH AND WELLNESS TO THE FOREFRONT IN ELY AND SURROUNDING COMMUNITIES THROUGH VARIOUS INITIATIVE AND SERVICES, MEETS AND IS PARTIALLY FUNDED THROUGH THE HOSPITAL. PROVIDES FUNDING FOR ELY, BABBITT, AND TOWER SOUDAN HIGH SCHOOL GRADUATION ACTIVITIES. FUNDING PROVIDED FOR CHILDREN'S PROGRAMS SPONSORED BY THE ELY POLICE, ELY FIRE DEPARTMENTS, AND LOCAL SCHOOLD DISTRCT ISD# 696. THE HOSPITAL RECORDS DAILY RADIO SPOTS PROMOTING HEALTH AND WELLNESS. CONSULTATION SERVICES FOR THE MANY NON PROFIT ORGANIZATIONS SPECIFICALLY HOSPICE/RESPITE AND MENTAL ILLNESS PROGRAMS. TWO BLOOD DRIVES ARE ADMINISTERED ANNUALLY THROUGH ELY BLOOMENSON. ELY BLOOMENSON COMMUNITY HOSPITAL IS THE HEART OF THE CITY.
PART VI, LINE 6:	AFFILIATED HEALTH CARE SYSTEM:N/A
PART VI, LINE 7, REPORTS FILED WITH STATES	MN

Schedule H (Form 990) 2021

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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" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

ELY-BLOOMENSON COMMUNITY HOSPITAL

Employer identification number

41-0808719

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 on 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 on 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
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on 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 on 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? .............

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

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), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

For persons listed on 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," on line 5a or 5b, describe in Part III.

For persons listed on 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," on line 6a or 6b, describe in Part III.

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

Were any amounts reported on 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" on 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) 2021

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 on 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, 1099-MISC compensation, and/or 1099-NEC			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation in column (B) reported as deferred on 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)
1BROCK URIE PHYSICIAN	(i) (ii)	273,843 ------------- 0	0 ------------- 0	0 ------------- 0	0 ------------- 0	0 ------------- 0	273,843 ------------- 0	0 ------------- 0
2PATTI BANKS CEO	(i) (ii)	239,279 ------------- 0	0 ------------- 0	0 ------------- 0	7,250 ------------- 0	4,396 ------------- 0	250,925 ------------- 0	0 ------------- 0
3SAM RICE PHYSICIAN	(i) (ii)	150,386 ------------- 0	0 ------------- 0	0 ------------- 0	5,027 ------------- 0	34,510 ------------- 0	189,923 ------------- 0	0 ------------- 0
4JOHN SCHINDELE PHARMACIST	(i) (ii)	147,380 ------------- 0	0 ------------- 0	0 ------------- 0	4,690 ------------- 0	33,929 ------------- 0	185,999 ------------- 0	0 ------------- 0
5BETH HARTSHORN PHARMACIST	(i) (ii)	147,910 ------------- 0	0 ------------- 0	0 ------------- 0	4,483 ------------- 0	15,437 ------------- 0	167,830 ------------- 0	0 ------------- 0
6SARAVANA BALARAMAN PHYSICIAN UNTIL 5/28/22	(i) (ii)	136,803 ------------- 0	0 ------------- 0	5,000 ------------- 0	4,167 ------------- 0	11,560 ------------- 0	157,530 ------------- 0	0 ------------- 0
7CURTIS BACH CFO	(i) (ii)	133,383 ------------- 0	0 ------------- 0	1,500 ------------- 0	4,113 ------------- 0	15,141 ------------- 0	154,137 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2021

Page 3

Part III

Supplemental Information

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.

Return Reference	Explanation

Schedule J (Form 990) 2021

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Note: To capture the full content of this document, please select landscape mode (11" x 8.5") when printing.

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax-Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part Ⅵ, line 24a. Provide descriptions,
explanations, and any additional information in Part Ⅵ.
SchKMediumBullet

Attach to Form 990.
SchKMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization
ELY-BLOOMENSON COMMUNITY HOSPITAL

Employer identification number
41-0808719

Part Ⅰ

Bond Issues

(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	(g) Defeased		(h) On behalf of issuer		(i) Pool financing
(a) Issuer name		(b) Issuer EIN	(c) CUSIP #	(d) Date issued	(e) Issue price	(f) Description of purpose	Yes	No	Yes	No	Yes	No
A	CITY OF ELY MINNESOTA	41-6005133		03-23-2015	7,680,415	SRS 2015A - REFUNDING OF 10/28/2008 NOTES		X		X		X
B	CITY OF ELY MINNESOTA	41-6005133		03-23-2015	4,287,460	SRS 2015B - REFUNDING OF 10/28/2008 NOTES		X		X		X

Part Ⅱ

Proceeds

	A		B		C		D
	1 Amount of bonds retired ..................	1,835,469		3,101,365
2 Amount of bonds legally defeased ..............
3 Total proceeds of issue ..................	7,680,415		4,287,460
4 Gross proceeds in reserve funds .............
5 Capitalized interest from proceeds .............
6 Proceeds in refunding escrows ...............
7 Issuance costs from proceeds ...............	153,605		85,746
8 Credit enhancement from proceeds .............
9 Working capital expenditures from proceeds .............
10 Capital expenditures from proceeds .............
11 Other spent proceeds .............	7,526,810		4,201,714
12 Other unspent proceeds .............
13 Year of substantial completion .............	2009		2009
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue of tax-exempt bonds (or, if issued prior to 2020, a current refunding issue)? ........	X		X
15 Were the bonds issued as part of an advance refunding issue of taxable bonds (or, if issued prior to 2020, an advance refunding issue)? ........		X		X
16 Has the final allocation of proceeds been made? ..........	X		X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? ..................	X		X

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

Cat. No. 50193E

Schedule K (Form 990) 2021

Page 2

Part Ⅲ

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? .............		X		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? ...............		X		X
3a Are there any management or service contracts that may result in private business use of bond-financed property? .............		X		X
b If "Yes" to line 3a, does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts relating to the financed property?
c Are there any research agreements that may result in private business use of bond-financed property? .............		X		X
d If "Yes" to line 3c, does the organization routinely engage bond counsel or other outside counsel to review any research agreements relating to the financed property?
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government ....	0 %		0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .........	0 %		0 %
6 Total of lines 4 and 5 .............	0 %		0 %
7 Does the bond issue meet the private security or payment test? ...		X		X
8a Has there been a sale or disposition of any of the bond-financed property to a nongovernmental person other than a 501(c)(3) organization since the bonds were issued?.............		X		X
b If "Yes" to line 8a, enter the percentage of bond-financed property sold or disposed of. ..
c If "Yes" to line 8a, was any remedial action taken pursuant to Regulations sections 1.141-12 and 1.145-2? .............
9 Has the organization established written procedures to ensure that all nonqualified bonds of the issue are remediated in accordance with the requirements under Regulations sections 1.141-12 and 1.145-2? ........	X		X

Part Ⅳ

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has the issuer filed Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate? ...		X		X
2 If "No" to line 1, did the following apply? ....
a Rebate not due yet? .......		X		X
b Exception to rebate? ........		X		X
c No rebate due? .........	X		X
If "Yes" to line 2c, provide in Part Ⅵ the date the rebate computation was performed ......
3 Is the bond issue a variable rate issue? .....		X		X

Schedule K (Form 990) 2021

Page 3

Part Ⅳ

Arbitrage (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
4a Has the organization or the governmental issuer entered into a qualified hedge with respect to the bond issue?		X		X
b Name of provider ..........
c Term of hedge .........
d Was the hedge superintegrated? ......
e Was the hedge terminated? ........
5a Were gross proceeds invested in a guaranteed investment contract (GIC)?		X		X
b Name of provider ..........
c Term of GIC .........
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? ........
6 Were any gross proceeds invested beyond an available temporary period?		X		X
7 Has the organization established written procedures to monitor the requirements of section 148? ...	X		X

Part Ⅴ

Procedures To Undertake Corrective Action

---------------------------------------------------------------------------------------------------------------	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
Has the organization established written procedures to ensure that violations of federal tax requirements are timely identified and corrected through the voluntary closing agreement program if self-remediation is not available under applicable regulations?	X		X

Part Ⅵ

Supplemental Information. Provide additional information for responses to questions on Schedule K. (See instructions).

Return Reference

Explanation

PART IV, LINE 3

FOR NOTE A THE INTEREST RATE IS FIXED EXCEPT THAT ON THE SIXTY-FOURTH AND ONE HUNDRED TWENTY-EIGHTH PAYMENT DATES THE INTEREST RATE HEREON SHALL BE ADJUSTED TO A PER ANNUM INTEREST RATE EQUAL TO .67 TIMES THE SUM OF THE 5 YEAR LIBOR/SWAP RATE AND 2.65%, PROVIDED THAT THE ACTUAL INCREASE IN THE ANNUAL RATE HEREON ON ANY ADJUSTMENT DATE, MAY NOT EXCEED 1.5% AND THE ANNUAL RATE HEREON CAN NEVER BE LESS THAN 2.91%. FOR NOTE B THE INTEREST RATE IS FIXED EXCEPT THAT ON THE SIXTY-FOURTH PAYMENT DATE THE INTEREST RATE HEREON SHALL BE ADJUSTED TO A PER ANNUM INTEREST RATE EQUAL TO .67 TIMES THE SUM OF THE 5 YEAR LIBOR/SWAP RATE AND 2.65%, PROVIDED THAT THE ACTUAL INCREASE IN THE ANNUAL RATE HEREON ON ANY ADJUSTMENT DATE, MAY NOT EXCEED 1.5% AND THE ANNUAL RATE HEREON CAN NEVER BE LESS THAN 2.78%.

Schedule K (Form 990) 2021

Additional Data

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SCHEDULE O
(Form 990)

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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization

ELY-BLOOMENSON COMMUNITY HOSPITAL

Employer identification number

41-0808719

Return Reference	Explanation
FORM 990, PART VI, SECTION A, LINE 6	THE ELY HEATH AND HOSPITAL FOUNDATION IS THE SOLE MEMBER OF THE ELY-BLOOMENSON COMMUNITY HOSPITAL. THE ELY HEALTH AND HOSPITAL FOUNDATION HAS OVER 700 MEMBERS; ANY RESIDENT OF THE AREA SERVED BY THE HOSPITAL MAY BECOME A MEMBER WITH A PAYMENT OF $100.
FORM 990, PART VI, SECTION A, LINE 7A	ELY HEALTH AND HOSPITAL FOUNDATION (SOLE MEMBER OF EBCH) ELECTS ALL BOARD MEMBERS OF THE HOSPITAL.
FORM 990, PART VI, SECTION A, LINE 7B	THERE ARE CERTAIN ISSUES THAT MUST BE APPROVED BY ALL MEMBERS, SUCH AS BY-LAW CHANGES AND TRANSFER OF SUBSTANTIAL AMOUNTS OF ASSETS. ALL MEMBERS HAVE VOTING RIGHTS.
FORM 990, PART VI, SECTION B, LINE 11B	THE 990 IS REVIEWED BY THE CEO AND PRESENTED TO THE BOARD MEMBERS AT A BOARD MEETING PRIOR TO ITS FILING.
FORM 990, PART VI, SECTION B, LINE 12C	DEFINITION OF CONFLICT: A CONFLICT OF INTEREST SHALL EXIST AT ANY TIME THAT A CONTRACT OR OTHER TRANSACTION EXISTS OR IS PROPOSED BETWEEN ELY-BLOOMENSON COMMUNITY HOSPITAL AND ONE OF ITS DIRECTORS OR BETWEEN ONE OF ITS DIRECTORS AND A RELATED ORGANIZATION, OR BETWEEN ELY-BLOOMENSON COMMUNITY AND AN ORGANIZATION IN OR OF WHICH A DIRECTOR OF ELY-BLOOMENSON COMMUNITY HOSPITAL IS ALSO A DIRECTOR, OFFICER OR LEGAL REPRESENTATIVE OR HAS MATERIAL FINANCIAL INTERESTS. A DIRECTOR OF ELY-BLOOMENSON COMMUNITY HOSPITAL HAS A MATERIAL FINANCIAL INTEREST IN AN ORGANIZATION WHICH THE DIRECTOR OR THE SPOUSE, PARENTS, CHILDREN AND SPOUSES OF CHILDREN, BROTHER AND SISTER AND SPOUSES OF BROTHERS AND SISTERS OF THE DIRECTOR, HAVE A MATERIAL FINANCIAL INTEREST. DECLARATION OF CONFLICT OF INTEREST: EACH DIRECTOR OF ELY-BLOOMENSON COMMUNITY HOSPITAL IS EXPECTED TO DECLARE A CONFLICT OF INTEREST AS SOON AS THE DIRECTOR IS AWARE OF SUCH CONFLICT. ONCE A CONFLICT OF INTEREST HAS BEEN DECLARED THE BOARD OF DIRECTORS SHALL FOLLOW THE PROCEDURE OUTLINED IN THE PROCEDURE PARAGRAPH OF THIS POLICY. DETERMINATION OF CONFLICT OF INTEREST: ANY OFFICER OR MEMBER OF THE BOARD OF DIRECTORS OF ELY-BLOOMENSON COMMUNITY HOSPITAL WHO BELIEVES THAT A BOARD MEMBER HAS A CONFLICT OF INTEREST SHALL STATE TO THE BOARD OF DIRECTORS THE BASIS FOR SUCH BELIEF. IF THE PERSON BELIEVED TO HAVE THE CONFLICT OF INTEREST DOES NOT AGREE THAT SUCH A CONFLICT EXISTS, SUCH PERSON SHALL BE GIVEN AN OPPORTUNITY TO RESPOND. IF IT IS NOT AGREED THAT A CONFLICT DOES EXIST THEN THE BOARD OF DIRECTORS SHALL VOTE TO DETERMINE WHETHER OR NOT SUCH CONFLICT EXISTS. ANY DIRECTOR WHO IS ENTITLED TO VOTE MAY REQUEST THAT THE VOTE BE BY CLOSED BALLOT AND UPON SUCH REQUEST THE CHAIRPERSON SHALL DECLARE THE VOTE BY CLOSED BALLOT. A SIMPLE MAJORITY OF THE MEMBERS PRESENT AND VOTING SHALL BE SUFFICIENT TO ESTABLISH THAT A CONFLICT OF INTEREST DOES EXIST. PROCEDURE UPON DETERMINATION OF CONFLICT: ONCE A CONFLICT OF INTEREST HAS BEEN DECLARED OR DETERMINED BY THE BOARD, THE INTERESTED PERSON OR PERSONS SHALL BE EXCUSED FROM THE MEETING UNTIL SUCH TIME AS A VOTE HAS BEEN TAKEN BY THE BOARD IN REGARD TO THE ISSUE IN WHICH THE INTERESTED MEMBER HAS A CONFLICT. ONCE A CONFLICT OF INTEREST HAS BEEN DECLARED OR DETERMINED, THE INTERESTED MEMBER SHALL NOT PARTICIPATE IN ANY DISCUSSION IN REGARD TO THE SUBJECT MATTER AND MAY ONLY RESPOND TO QUESTIONS DIRECTED TO HIM/HER BY ANY ONE OR MORE THE DIRECTORS. THE INTERESTED DIRECTOR SHALL NOT BE COUNTED IN THE QUORUM AND SHALL ABSTAIN FROM VOTING. THE STATEMENT REGARDING THE CONFLICT OF INTEREST MUST BE ENTERED INTO THE MINUTES. ONCE A DIRECTOR OR OFFICER HAS DECLARED OR BEEN DETERMINED TO HAVE A CONFLICT OF INTEREST, SUCH CONFLICT SHALL BE DEEMED TO CONTINUE UNTIL THE FINAL VOTE HAS BEEN TAKEN BY THE BOARD OF DIRECTORS IN REGARD TO THE SUBJECT MATTER IN WHICH SUCH DIRECTOR HAS A CONFLICT.
FORM 990, PART VI, SECTION B, LINE 15	THERE IS A BOARD LEVEL COMPENSATION COMMITTEE, MADE UP OF INDEPENDENT DIRECTORS, THAT MEETS ANNUALLY AND REVIEWS AND COMPARES THE COMPENSATION OF THE CEO, CFO, COO, CHRO & CNO WITH VARIOUS COMPENSATION STUDIES OF HOSPITALS OUR SIZE, SUCH AS THE MINNESOTA HOSPITAL ASSOCIATION ANNUAL SURVEY. THIS COMMITTEE IS APPRAISED OF 990 DISCLOSURE REQUIREMENTS. THE CEO MAKES RECOMMENDATIONS TO THE COMMITTEE REGARDING THE COMPENSATION OF THE CFO AND CNO BASED ON VARIOUS COMPENSATION STUDIES. THE COMPENSATION COMMITTEE THEN MAKES RECOMMENDATIONS TO THE FULL BOARD IN CLOSED SESSION AND MINUTES ARE KEPT OF SAID MEETING. THE MINUTES AND ALL MATERIALS RELATED TO THE COMPENSATION DECISIONS ARE KEPT ON FILE WITH THE HOSPITAL'S ATTORNEY'S OFFICE. OTHER POSITIONS RELY ON THE HEALTHCARE HUMAN RESOURCES ASSOCIATION OF MINNESOTA (HHRAM) SURVEY AND ANNUAL BUDGET REQUESTS.
FORM 990, PART VI, SECTION C, LINE 19	THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC. ANNUAL FINANCIAL REPORTS ARE PROVIDED TO ALL SHAREHOLDERS WHO ATTEND THE ANNUAL MEETING OR UPON REQUEST. OTHER DOCUMENTS WILL BE PROVIDED TO MEMBERS UPON REQUEST. THE ANNUAL FINANCIAL REPORT WILL BE GIVEN TO THE GENERAL PUBLIC IF REQUESTED DURING THE SAME PERIOD OF DISCLOSURE AS SET FORTH IN SECTION 6104(D).
FORM 990, PART IX, LINE 11G	OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 4,133,889. MANAGEMENT AND GENERAL EXPENSES 228,643. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,362,532.

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

Cat. No. 51056K

Schedule O (Form 990) 2021

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" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public Inspection

Name of the organization

ELY-BLOOMENSON COMMUNITY HOSPITAL

Employer identification number

41-0808719

Part I

Identification of Disregarded Entities. Complete if the organization answered "Yes" on 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" on 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)ELY HEALTH & HOSPITAL FOUNDATION 328 W CONAN STREET ELY,MN55731 41-2001411	TO PROVIDE SUPPORT TO ELY-BLOOMENSON COMMUNITY HOSPITAL FOR HEALTHCARE	MN	501(C)(3)	LINE 12B, II	N/A		No
(2)ELY HEALTH & HOSPITAL FUND 328 W CONAN STREET ELY,MN55731 46-1836177	TO PROVIDE SUPPORT TO ELY-BLOOMENSON COMMUNITY HOSPITAL FOR HEALTHCARE	MN	501(C)(3)	LINE 12B, II	ELY HEALTH & HOSPITAL FOUNDATION		No

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

Cat. No. 50135Y

Schedule R (Form 990) 2021

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on 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	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI 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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on 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	(h) Percentage ownership	Yes	No

Schedule R (Form 990) 2021

Page 3

Part V

Transactions With Related Organizations. Complete if the organization answered "Yes" on 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) ............................

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

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) ......................

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) .................

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

Yes

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

Yes

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

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

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 related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved

Schedule R (Form 990) 2021

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on 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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(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 V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No	(k) Percentage ownership

Schedule R (Form 990) 2021

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R. See instructions.

Return Reference	Explanation

Schedule R (Form 990) 2021

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: ELY-BLOOMENSON COMMUNITY HOSPITAL IS COMMITTED TO CARING FOR AND ENHANCING THE HEALTH AND WELL BEING OF THE COMMUNITY IT SERVES.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	9
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 2021 (Part V, line 2a) ......	5	135
6	Total number of volunteers (estimate if necessary) .............	6	11
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	5,487,296
b	Net unrelated business taxable income from Form 990-T, Part I, line 11 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	5,159,699	783,103
9	Program service revenue (Part VIII, line 2g) .........	26,269,856	28,498,592
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	30,310	124,984
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	61,213	106,474
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	31,521,078	29,513,153
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
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)	9,315,610	10,566,183
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)....	15,928,981	16,951,531
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	25,244,591	27,517,714
19	Revenue less expenses. Subtract line 18 from line 12.......	6,276,487	1,995,439
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	25,820,577	26,208,958
21	Total liabilities (Part X, line 26).............	10,512,191	9,790,892
22	Net assets or fund balances. Subtract line 21 from line 20.....	15,308,386	16,418,066

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 23,559,287 including grants of $ ) (Revenue $ 23,097,500 )
	HOSPITAL SERVICES PROVIDED FOR THE ELY COMMUNITY AND SURROUNDING AREA. ELY-BLOOMENSON COMMUNITY HOSPITAL (EBCH), RECOGNIZED BY THE FEDERAL & STATE OF MINNESOTA GOVERNMENTS AS A CRITICAL ACCESS HOSPITAL, IS THE ONLY LOCAL HEALTHCARE CENTER SERVING ELY AND SURROUNDING COMMUNITIES BORDERING THE VAST ACREAGE OF BOUNDARY WATERS CANOE AREA WILDERNESS. UNDER ORIGINAL FEDERAL RULES EBCH WOULD HAVE BEEN ONLY ONE OUT OF SEVEN HOSPITALS IN MINNESOTA THAT WOULD HAVE QUALIFIED FOR CRITICAL ACCESS HOSPITAL STATUS. THE HOSPITAL BOASTS: IN AND OUTPATIENT HOSPITAL NURSING SERVICE, IN-HOUSE LABORATORY, AN ON-SITE RETAIL PHARMACY, PHYSICAL AND OCCUPATIONAL THERAPY, CHEMOTHERAPY, A FULLY-STAFFED 24-7 RADIOLOGY DEPARTMENT, A PROFESSIONAL ANESTHESIA TEAM, SWING BED CARE FOR PATIENTS WHO NO LONGER REQUIRE ACUTE CARE HOSPITALIZATION, AND A 24-7 EMERGENCY ROOM. DURING THE FY2022 EBCH PERFORMED 483 SURGICAL PROCEDURES, 64,848 LABORATORY TESTS, 7,022 RADIOLOGICAL EXAMS, AND 3,403 EMERGENCY ROOM VISITS. IN ADDITION, 239 PEOPLE WERE ADMITTED FOR INPATIENT CARE. 1064 DAYS OF CARE WERE PROVIDED, 8,388 OUTPATIENTS WERE SEEN, AND 16,245 MODALITIES WERE PERFORMED IN OT AND PT.

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 expenses23,559,287

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	1,235,484	0	144,703

(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/1099-NEC)	(E) Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and title
(18) SARAVANA BALARAMAN........................................................................ PHYSICIAN UNTIL 5/28/22	40.00 .......................0.00	X	141,803	0	15,727

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d
e	Government grants (contributions)		1e	781,261

f	All other contributions, gifts, grants, and similar amounts not included above		1f	1,842

g	Noncash contributions included in lines 1a - 1f:$		1g

h Total. Add lines 1a-1f.......		783,103

		Business Code
2a	PATIENT SERVICE	621400	22,779,277	22,779,277
b	RETAIL PHARMACY	446110	5,484,949		5,484,949
c	EQUITY IN EARNINGS OF AFFILIATES	900099	234,366	234,366
d
e
f	All other program service revenue.
g	Total. Add lines 2a–2f .....		28,498,592

3 Investment income (including dividends, interest, and othersimilar amounts) ......			125,653			125,653
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		28,449	6a
b	Less: rental expenses		8,179	6b
c	Rental income or (loss)		20,270	6c
d	Net rental income or (loss).......			20,270			20,270
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory		9,950	7a
b	Less: cost or other basis and sales expenses		10,619	7b
c	Gain or (loss)		-669	7c
d	Net gain or (loss).........			-669			-669
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ....
			8a
b	Less: direct expenses ...		8b
c	Net income or (loss) from fundraising events..
9a	Gross income from gaming activities. See Part IV, line 19 ...
			9a
b	Less: direct expenses ...		9b
c	Net income or (loss) from gaming activities..
10a	Gross sales of inventory, less returns and allowances ..
			10a
b	Less: cost of goods sold ..		10b
c	Net income or (loss) from sales of inventory..
Business Code			Miscellaneous Revenue
11a	OTHER OPERATING		621400	83,857	83,857
b	RETAIL PHARMACY MISCELLANEOUS		446110	2,347		2,347
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			86,204
12	Total revenue. See instructions.....			29,513,153	23,097,500	5,487,296	145,254

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 ....
2	Grants and other assistance to domestic individuals. See Part IV, line 22 ...........
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............
4	Benefits paid to or for members .......
5	Compensation of current officers, directors, trustees, and key employees ...........	413,070		413,070
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .........
7	Other salaries and wages........	8,047,239	6,959,260	1,087,979
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	211,221	187,178	24,043
9	Other employee benefits .......	1,305,111	1,165,577	139,534
10	Payroll taxes ...........	589,542	489,068	100,474
11	Fees for services (non-employees):
a	Management ......
b	Legal .........	72,883		72,883
c	Accounting ...........	283,533		283,533
d	Lobbying ...........	1,658		1,658
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	4,362,532	4,133,889	228,643
12	Advertising and promotion ....	70,435	3,180	67,255
13	Office expenses .......	1,099,416	884,841	214,575
14	Information technology ......	791,861	483,627	308,234
15	Royalties ..
16	Occupancy ...........	268,710	268,710
17	Travel ............	60,310	24,544	35,766
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....
20	Interest ...........	236,324		236,324
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	1,095,477	994,279	101,198
23	Insurance ...	107,127		107,127
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	DRUGS	6,308,026	6,308,026
b	REPAIRS & MAINTENANCE	574,124	544,803	29,321
c	MEDICAL EQUIPMENT LEASE	365,360	365,360
d	LAUNDRY & HOUSEKEEPING	352,569	352,569
e	All other expenses	901,186	394,376	506,810
25	Total functional expenses. Add lines 1 through 24e	27,517,714	23,559,287	3,958,427	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).

1	Cash–non-interest-bearing ........			5,225,841	1	9,405,423
2	Savings and temporary cash investments .........				2
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			5,953,990	4	3,428,871
5	Loans and other receivables from any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
					5
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
					6
7	Notes and loans receivable, net ...........				7
8	Inventories for sale or use ............			958,977	8	1,081,110
9	Prepaid expenses and deferred charges ......			97,976	9	209,594
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	27,266,537
b	Less: accumulated depreciation	10b	21,012,942	6,902,050	10c	6,253,595
11	Investments—publicly traded securities .			4,625,083	11	3,839,657
12	Investments—other securities. See Part IV, line 11 .....				12
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			2,056,660	15	1,990,708
16	Total assets. Add lines 1 through 15 (must equal line 33)...			25,820,577	16	26,208,958

17	Accounts payable and accrued expenses .....	2,685,232	17	2,656,566
18	Grants payable ...		18
19	Deferred revenue .........	122,798	19	150,086
20	Tax-exempt bond liabilities .........	7,665,976	20	6,962,204
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
22	Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
			22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ..	38,185	24	22,036
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		25
26	Total liabilities. Add lines 17 through 25..	10,512,191	26	9,790,892

	Organizations that follow FASB ASC 958, check here and complete lines 27, 28, 32, and 33.
27	Net assets without donor restrictions ..........	15,308,386	27	16,418,066
28	Net assets with donor restrictions ...........		28
	Organizations that do not follow FASB ASC 958, check here and complete lines 29 through 33.
29	Capital stock or trust principal, or current funds .....		29
30	Paid-in or capital surplus, or land, building or equipment fund ...		30
31	Retained earnings, endowment, accumulated income, or other funds		31
32	Total net assets or fund balances ...........	15,308,386	32	16,418,066
33	Total liabilities and net assets/fund balances ........	25,820,577	33	26,208,958