2012-08-27T08:39:31-05:00 2011-12-31 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2011-01-01 261087740 Bethany on 42nd BETH 7012393000 201 South University Drive Fargo ND 58103 Shawn Stuhaug 7012393000 2012-08-20 1 KIM C HUNWARDSEN P00484560 7012398500 2012-08-20 2011 2016-02-24 21:20:13Z Shawn Stuhaug 201 South University Drive Fargo ND 58103 9704626 0 X www.bethanynd.org X 2007 ND Provide long term care services 11 11 0 108 0 0 1992 224894 6900816 9449579 -331 -718 19237 29228 6921714 9702983 0 0 0 0 4331420 5087365 0 0 0 4134334 4689856 8465754 9777221 -1544040 -74238 27750443 26987148 24867407 24366468 2883036 2620680 X To provide living opportunities in a senior community shaped by Christian values. 0 0 8968060 9449579 Bethany on 42nd operates as a charitable organization consistent with the requirements of Internal Revenue Code Section 501(c)(3). Bethany on 42nd provides long term care services including skilled nursing care, transitional care services, assisted living, and independent senior housing. Bethany on 42nd does not discriminate against individuals in the admissions process or in the delivery of care with regard to ability to pay for services. The Organization's cash reserves are generally applied to expansion and replacement of existing facilities and equipment, amortization of mortgages, improvement in resident care, training and education, and community benefit activities. The governing board of Bethany on 42nd is made up of prominent leaders in the Fargo-Moorhead community. Volunteerism - coordinates a volunteer program that included 108 volunteers giving 1,770 hours of service, providing mental stimulation and emotional support to ALH's 118 residents and patients. Volunteers included members of sponsoring churches, experience works program volunteers, and many student volunteers from the community's schools - elementary, middle, high schools and colleges.Assessment and referral services - our staff help to refer individuals needing long term care services to the appropriate agency in the community. Bethany on 42nd's licensed social workers provide guidance with medical assistance applications for residents/families.Community support - Bethany on 42nd provides meeting room space and accommodations for non-profit organizations and community groups. Several of our resident activity programs are open to community members. Facility space is open to use by outside groups for meetings, performances, activities, funeral/memorials services, music recitals, etc. Meals are provided for family members of Bethany on 42nd residents at a reduced cost. Bethany on 42nd organizes employee participation in fundraising activities for United Way and the Alzheimer's Association. There are also representatives from Bethany on 42nd on non-profit boards and civic organizations that work to improve the quality of life in the Fargo-Moorhead area. Bethany's President/CEO is a director on the Lakeland Mental Health non-profit board and the Fargo Dome Finance Committee. He also serves as the Region VI Director on the Board of the North Dakota Long Term Care Association. Bethany's CFO serves on the Board of Hospice of the Red River Valley. The Senior Executive of Medicare/contracted services is on the board of Handi-Wheels, a non-profit organization, and also serves on the board of the North Dakota Nurse Leadership Council. Bethany's Senior Executive of Resident Care is on the Resident Issues Committee of the ND Long Term Care Association; the Partners Investing in Nursing consortium, and the Care Transitions Focus Group, a collaborative project with Sanford Health Systems.The following is specific information relating to Bethany on 42nd's care provided:Bethany on 42nd Skilled/TCU Care - services provided, 65 nursing home beds: 23,629 days of care, and 13 TCU beds: 4,320 days of care. Bethany on 42nd Skilled/TCU operations served approximately 370 individuals in 2011. Total Skilled/TCU employee hours - 243,364. (Total Expenses = 8,615,963)Bethany Gables - senior housing with services, 40 units - 11,890 days of care and 13,555 employee hours (total expenses = 1,161,255) 8968060 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 9 0 1 0 0 0 0 0 0 0 0 0 0 0 X 11 11 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X Jane Kelly 7012393226 201 South University Drive Fargo ND 58103 X Robert McConn 1.00 X X 0 0 0 Mary Johnson Vice Chair Jan-Mar 1.00 X X 0 0 0 Martha Leclerc Treasurer Jan-Mar 1.00 X X 0 0 0 Lloyd Smith Secretary Jan-Mar 1.00 X X 0 0 0 Janice Nelson TrusteeJan-March 1.00 X X 0 0 0 Shannon Charpentier 1.00 X 0 0 0 Neal Eriksmoen 1.00 X 0 0 0 David Glatt 3.00 X 3744 0 0 Robin Pratt 1.00 X 0 0 0 HARRIETTE MCCAUL 1.00 X 0 0 0 Paul Wilson 1.00 X 0 0 0 Jerilynn Brantner-Adams 1.00 X 0 0 0 Shawn Stuhaug 23.00 X 0 199313 7806 Jane Kelly 20.00 X 0 151045 19796 3744 350358 27602 0 0 1 1 RehabCare PO Box 503534 St Louis MO 631503534 Contract Therapy 629760 1 206000 18894 224894 Resident Service Reven 623000 9438344 9438344 Other Income 900099 11235 11235 9449579 925 925 29228 0 29228 29228 29228 1643 -1643 -1643 -1643 9702983 9449579 0 28510 3744 3744 4307112 3936420 370692 39348 29932 9416 424682 389378 35304 312479 285479 27000 22344 22344 757356 757356 706918 502208 204710 440297 440297 27289 22287 5002 1016958 1016958 1197277 1197277 124685 124685 Medical Supplies 368730 368730 Bad Debt Expense 15666 15666 Memberships 10008 10008 Flood Expense 2328 2328 9777221 8968060 809161 0 136008 874259 1173712 916884 73485 84333 67790 77561 25882938 2200380 24747733 23682558 486643 298525 1065072 1053028 27750443 26987148 649298 646455 16000000 15766928 351372 347423 7866737 7605662 24867407 24366468 X 2396393 2322155 486643 298525 2883036 2620680 27750443 26987148 X -74238 -188118 X 0 1 1 X 0 X 3644075 917669 1992 224894 4788630 6900816 9449579 16350395 3644075 917669 6902808 9674473 21139025 0 237586 173925 411511 237586 173925 411511 20727514 19281 30153 49434 19281 30153 49434 3644075 917669 6922089 9704626 21188459 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 768055 768055 21539711 1525646 20014065 2650207 559683 2090524 924965 115051 809914 23682558 Related Party Payable 1373849 Related Entity Note Payable 6231813 7605662 9702983 9777221 -74238 -188118 -188118 -262356 9491211 0 9491211 211772 211772 9702983 9777221 0 9777221 0 9777221 Description of Uncertain Tax Positions Under FIN 48: Part X: Bethany believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. Bethany would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 8 - Other Adjustments: Decrease in Interest in Bethany Homes, Inc -188,118. Part XII, Line 4b - Other Adjustments: Contributions recorded in fund balance for financial statement 211,772. 0 0 0 0 0 0 0 0 0 David Glatt 3744 0 0 0 0 0 0 0 0 0 3744 0 0 0 Shawn Stuhaug 0 160323 0 38990 0 0 0 7491 0 447 0 207251 0 0 Jane Kelly 0 124644 0 26401 0 0 0 6172 0 13730 0 170947 0 0 Supplemental Information Part III Part I, Line 3: The President/CEO is paid by a related organization which has a process in place for establishing compensation using methods identified in question 3. In conjuction with American Lutheran Homes, Inc. a related organization, Bethany on 42nd has an agreement with Sanford Health for Medical Director services provided by David Glatt. Compensation noted in Schedule J Part II is the fee paid to Sanford Health for his services provided to Bethany on 42nd. Cass County North Dakota 456002205 2010-10-01 16000000 Housing and Health Care Facility Revenue Bonds 0 0 0 16000000 137143 15862857 2010 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 Form 990, Part VI, Section A, line 2 The CEO and CFO have a business relationship with all the board members, as the CEO and CFO are employed by another related nonprofit of which the board members serve as well. Form 990, Part VI, Section A, line 6 Bethany Homes, Inc. is the sole member of the Corporation. Form 990, Part VI, Section A, line 7a The Board of Directors is elected at the annual meeting of the Board of Trustees of the Member. The member has the right to fill any vacancies that occur during the year. The Member may also remove any directors with or without cause. Form 990, Part VI, Section A, line 7b The following actions by the Board of Directors require the approval of the Board of Trustees of the Member: - Establishment of annual operating budget - Sale, lease or encumbrance of any corporation real property - Unbudgeted capital expenditures exceeding amounts for which the President/CEO is specifically authorized to approve Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the CFO and CEO and then provided to the Finance Committee for their review and approval. A draft copy of the Form 990 is provided to the board prior to filing. Form 990, Part VI, Section B, line 12c Board officers and directors, as well as officers of the Organization, complete a conflict of interest questionnaire on an annual basis. The Board reviews the conflicts to determine if a conflict exists. The individual with the conflict is required to abstain from voting if the conflict comes up in the board meeting where a decision needs to be made. This is a standing agenda item at each board meeting. Form 990, Part VI, Section B, Line 15: Compensation for the CEO is paid by a related organization. That Organization has a process for determining compensation that includes review by the independent board using comparability data and substantiation of the deliberation and decision. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financial statements are available upon request. FORM 990, PART VII The CEO and CFO are compensated by American Lutheran Homes, Inc. for their services provided to Bethany on 42nd and other related entities. The CEO serves approximately 27 hours per week to other related entities. The CFO services approximately 30 hours per week to other related entities. All board members serve American Lutheran Homes, Inc. and Bethany Homes, Inc. an additional 1 hour per week for each entity. The following individuals serve Bethany Home Health Care, Inc. an additional 1 hour per week: Neal Ericksmoen, Janice Nelson, Shannon Charpentier, Robin Pratt, and Harriette McCaul. David Glatt serves as a board member 1 hour per week. He serves an additional two hours per week as a Medical Director. Compensation shown on Part VII is compensation paid to Sanford Health for his services as Medical Director to Bethany on 42nd. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Decrease in Interest in Bethany Homes, Inc -188,118. Total to Form 990, Part XI, Line 5: -188,118. American Lutheran Homes Inc 201 S University Drive Fargo ND 58103 450274012 long-term care services ND 501(c)(3) 9 Bethany Homes Inc 1 Bethany Home Health Care Inc 201 S University Drive Fargo ND 58103 450433045 promotion of health ND 501(c)(3) 9 Bethany Homes Inc 1 Bethany Homes Inc 201 S University Drive Fargo ND 58103 450394181 fundraising ND 501(c)(3) 9 Bethany Homes Inc 1 0 0 1 0 1 1 0 0 0 0 0 1 0 0 1 0 0 0 American Lutheran Homes Inc E 423120 General Ledger American Lutheran Homes Inc O 7476779 General Ledger Bethany Homes Inc C 206000 Cash Value