2019-11-12T14:24:58-06:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-01-01 371834045 SANFORD-GOOD SAMARITAN COMMUNITY HEALTH SERVICES LLC SANF 6053623100 4800 W 57TH STREET BOX 5038 SOUIX FALLS SD 571175038 NATHAN SCHEMA PRESIDENT 6053623100 2019-11-11 1 CHRISTOPHER STEINHOFF P01587351 6123764500 2019-11-08 67.137.57.251 2019-11-11 14:49:48 CS P 2CCFC7E30E1C7F7287E1A5F09795F66155F6CA59 06C6282D018575128FE0891D0F3A4E057D2D2323 2018 2020-03-31 21:24:44Z PROSPERA THOMAS A SYVERSON 4800 W 57TH STREET BOX 5038 SOUIX FALLS SD 571175038 49175434 0 X WWW.PROSPERACARES.COM X LLC 2016 ND OPERATE, FINANCE AND DEVELOP LONG-TERM CARE, SENIOR LIVING, AND POST-ACUTE FACILITIES. 6 6 1079 99 117078 -64134 24666 41574 43259104 48864912 6987 8826 199861 257355 43490618 49172667 4000 0 0 0 27748346 29551310 0 0 0 18838984 19666774 46591330 49218084 -3100712 -45417 44498348 50831919 27149282 29105784 17349066 21726135 OPERATE, FINANCE AND DEVELOP LONG-TERM CARE, SENIOR LIVING, AND POST-ACUTE FACILITIES IN A MANNER CONSISTENT WITH THE MEMBERS' CHARITABLE PURPOSES. 0 0 43396708 0 48864912 PROVIDE LONG-TERM CARE, SENIOR LIVING AND POST-ACUTE SERVICES FOR OLDER PERSONS AND OTHERS IN NEED. DURING 2018, PROSPERA PROVIDED SERVICES FOR 140,978 SKILLED NURSING DAYS, 10,588 ASSISTED LIVING DAYS, AND 29,265 SENIOR HOUSING DAYS. 43396708 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 44 0 1079 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 1 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X ERIC VANDEN HULL 6053623100 4800 W 57TH ST SIOUX FALLS SD 57108 X THOMAS A SYVERSON PRESIDENT & CHAIR 0.10 X X 0 0 0 CRAIG LAMBRECHT VICE PRESIDENT 0.10 X X 0 0 0 G GRANT TRIBBLE TREASURER 0.10 X X 0 0 0 KIRK CRISTY DIRECTOR 0.10 X 0 0 0 CLINT GRAYBILL DIRECTOR 0.10 X 0 0 0 BERGEN PETERSON DIRECTOR 0.10 X 0 0 0 MISTY HAM-QUICK SECRETARY 0.10 X 0 0 0 0 0 0 0 0 0 0 THE EVANGELICAL LUTHERAN GOOD SAMARITAN 4800 W 57TH ST SIOUX FALLS SD 57108 MANAGEMENT FEES & SHARED EMPLOYEES 2653577 INFINITY REHAB 25117 SW PARKWAY SUITE D WILSONVILLE OR 97070 THERAPY SERVICES 2357196 DTN STAFFING INC 1200 COLLINS AVENUE MANDAN ND 58554 POOL STAFF SERVICES 1106587 PRIME TIME HEALTHCARE LLC PO BOX 3544 OMAHA NE 681030544 POOL STAFF SERVICES 963612 SANFORD HEALTH PO BOX 5074 SIOUX FALLS SD 571175074 LAB SERVICES 109388 6 41574 41574 HOUSING AND RESIDENT SERVICES 623000 48864912 48864912 48864912 9173 9173 6996 0 6996 6996 6996 347 -347 -347 -347 5587 2420 3167 3167 MEALS 722320 117078 117078 TRANSPORTATION 485000 52965 52965 CABLE TV 900099 49426 49426 27723 27723 247192 49172667 48864912 117078 149103 X 24135874 23189648 946226 553983 524299 29684 3042015 2925577 116438 1819438 1748074 71364 2946335 2946335 60594 60594 5036156 4707769 328387 19842 19842 159875 5569 154306 49666 49666 3823597 3823597 111810 71170 40640 678602 598319 80283 1918723 1691726 226997 103005 90819 12186 FOOD 1596999 1596999 MEDICAL SUPPLIES 1256761 1256761 DRUGS 760483 760483 BAD DEBT EXPENSE 469602 469602 674724 405898 268826 49218084 43396708 5821376 0 634152 9083691 29389 30960 5204283 4409031 87689 96487 5928 19618 32112062 2920061 30535020 29192001 8000131 8000131 1756 0 44498348 50831919 5888537 8186628 19892352 19453230 29389 30960 1339004 1434966 27149282 29105784 X 17324400 21711415 24666 14720 17349066 21726135 44498348 50831919 X -45417 4422486 X 0 1 X 0 0 X X X 2 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 450228055 10 1 0 0 SANFORD LIVING CENTERS 450416454 3 1 0 0 2 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 SCHEDULE A, PART I, LINE 12G, COLUMN V SANFORD-GOOD SAMARITAN COMMUNITY HEALTH SERVICES, LLC IS AN INTEGRAL PART OF AND PROVIDES SUPPORT TO EACH OF THE ORGANIZATIONS LISTED, HOWEVER, SUCH SERVICES CANNOT EASILY BE QUANTIFIED IN DOLLAR-BASED TERMS. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 2060465 2060465 24011279 1739981 22271298 1772073 162666 1609407 4265837 1017414 3248423 2408 2408 29192001 RELATED PARTY PAYABLE 692113 RESIDENT SECURITY DEPOSITS 28200 ENTRANCE FEE 206905 SPECIAL ASSESSMENT PAYABLE 507748 1434966 X 49166976 39804 39804 49127172 45495 45495 49172667 49225055 6971 6971 49218084 0 49218084 PART IV, LINE 2B: AS SET FORTH BY FEDERAL AND STATE REGULATIONS, SANFORD-GOOD SAMARITAN COMMUNITY HEALTH SERVICES PROVIDES RESIDENT TRUST ACCOUNT (RTA) SERVICES FOR RESIDENTS. THESE RTA FUNDS ARE NOT COMMINGLED WITH THE ORGANZIATION'S FUNDS, ARE ACCESSIBLE FOR RESIDENTS' USE, HAVE DETAILED ACCOUNTING RECORDS MAINTAINED ON AN INDIVIDUAL RESIDENT BASIS, AND FOLLOW BOTH FEDERAL AND STATE REGULATIONS REGARDING THE HANDLING AND DOCUMENTATION OF ACTIVITY. AS RTA FUNDS ARE HELD IN TRUST FOR RESIDENTS, A RESIDENT MAY AUTHORIZE THAT THEIR RTA FUNDS BE RETURNED TO THE RESIDENT OR THEIR DESIGNEE (REPRESENTATIVE PAYEE, FINANCIAL POWER OF ATTORNEY, GUARDIAN, ETC.) AT ANY TIME. ADDITIONALLY, WHEN A RESIDENT IS DISCHARGED FROM A FACILITY, THEIR RTA FUNDS ARE RETURNED TO THE RESIDENT OR THEIR AUTHORIZED DESIGNEE. IF A RESIDENT EXPIRES WITH RTA FUNDS ON HAND, SPECIFIC STATE REGULATIONS ALONG WITH STATE AND/OR FEDERAL AGENCIES GUIDELINES ARE REVIEWED TO ENSURE THESE RTA FUNDS ARE MANAGED APPROPRIATELY. PART X, LINE 2: THE ORGANIZATION IS A NONPROFIT LIMITED LIABILITY CORPORATION AND IS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. PART XI, LINE 2D - OTHER ADJUSTMENTS: GIFT SHOP EXPENSES 2,420. NET ASSETS RELEASED FROM RESTRICTION 32,486. VENDING MACHINE EXPENSES 4,551. LOSS ON DISPOSAL OF ASSETS 347. PART XI, LINE 4B - OTHER ADJUSTMENTS: INTEREST INCOME 4,497. CONTRIBUTIONS WITH DONOR RESTRICTIONS 40,998. PART XII, LINE 2D - OTHER ADJUSTMENTS: GIFT SHOP EXPENSES 2,420. VENDING MACHINE EXPENSES 4,551. A MORTON COUNTY NORTH DAKOTA 456002226 2017-08-04 20470000 FUND PURCHASE OF MILLER POINTE IN MANDAN, ND 0 0 0 A 634055 20470000 368253 20101747 2017 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 1 0 0 0 0 0 0 0 A 0 FORM 990, PART VI, SECTION A, LINE 3 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (THE SOCIETY) HAS BEEN DELEGATED CONTROL OVER THE MANAGEMENT OF THE ORGANIZATION. THE SOCIETY WAS COMPENSATED $2,467,444 FOR MANAGEMENT SERVICES RENDERED IN 2018. FORM 990, PART VI, SECTION A, LINE 6 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY AND SANFORD LIVING CENTERS ARE THE MEMBERS OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER CAN ELECT THREE MEMBERS TO THE GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS PROVIDED TO THE BOARD PRIOR TO ITS FILING. THE ORGANIZATION'S OFFICERS AND MANAGEMENT WERE AN INTEGRAL PART OF THE PREPARATION OF THE FORM 990. THEREFORE, THEY HAD AN ON-GOING REVIEW OF THE INFORMATION AS IT WAS PREPARED FOR THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C MEMBERS AND OFFICERS ARE COVERED UNDER THE ORGANIZATION'S CONFLICT OF INTEREST POLICY. THEY ARE REQUIRED AT LEAST ANNUALLY TO DISCLOSE POTENTIAL CONFLICTS OF INTEREST TO THE ORGANIZATION'S SECRETARY. ANY CONFLICT IS BROUGHT TO THE BOARD FOR REVIEW AND VOTE TO DETERMINE IF AN ACTUAL CONFLICT EXISTS. IF A CONFLICT DOES IN FACT EXIST, THE INTERESTED PERSON MAY PRESENT RELEVANT FACTS TO THE BOARD, BUT IS THEN REQUIRED TO LEAVE THE MEETING FOR FURTHER DISCUSSION AND VOTES ON THE MATTER. THE CHAIR MAY APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION. THE DISINTERESTED BOARD MEMBERS THEN VOTE ON WHETHER TO ENTER THE TRANSACTION. IF THE BOARD HAS REASON TO BELIEVE AN INDIVIDUAL HAS FAILED TO DISCLOSE A CONFLICT OF INTEREST, THE INDIVIDUAL IS GIVEN THE CHANCE TO EXPLAIN, AFTER WHICH THE DISINTERESTED BOARD MEMBERS DETERMINE WHETHER A VIOLATION OCCURRED. IF A VIOLATION OCCURS, THE BOARD WILL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. FORM 990, PART VI, SECTION B, LINE 15A THE EXECUTIVE DIRECTOR FOR THE ORGANIZATION IS COMPENSATED BY ONE OF THE MEMBERS, THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY. A COMPENSATION STUDY WAS USED TO DETERMINE THE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIALS STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 4,547,759. MANAGEMENT AND GENERAL EXPENSES 292,043. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,839,802. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 60,235. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 60,235. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 99,775. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 99,775. PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 36,344. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 36,344. FORM 990, PART XI, LINE 9: EQUITY TRANSFER - THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 2,222,486. EQUITY TRANSFER - SANFORD LIVING CENTERS 2,200,000.