2019-11-14T12:43:51-06:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 8215 GREENWAY BOULEVARD SUITE 600 MIDDLETON WI 53562 990 2018-01-01 391209707 BETHEL HOME INC BETH 9202354653 225 NORTH EAGLE STREET OSHKOSH WI 54902 THERESA M BERTRAM PRESIDENT & CEO 9202325238 2019-11-07 1 KIMBERLY ANDERSON P00188889 6086628600 2019-11-07 67.137.57.251 2019-11-07 08:07:07 CS P D96076016A1D85786C0DD27C05D232F375DC2AFE 08598E5CD8BEAEC8C407760E8BF8A64CD65A21BD 2018 2020-03-31 21:24:44Z THERESA M BERTRAM 225 NORTH EAGLE STREET OSHKOSH WI 54902 8955070 0 9386 X WWW.MIRAVIDALIVING.COM X 1966 WI TO PROVIDE NURSING CARE FOR AGING PERSONS. 10 10 267 87 0 0 808777 362054 9181346 8488466 3735 8654 85862 95896 10079720 8955070 0 0 0 0 6163847 5893480 0 0 0 3699051 3590010 9862898 9483490 216822 -528420 6804469 6536984 2642585 2953520 4161884 3583464 BETHEL HOME IS PART OF A FAMILY OF HEALTHCARE AND RESIDENTIAL SERVICE ORGANIZATIONS COMMITTED TO PROVIDING QUALITY CARE AND LIFE ENRICHING OPPORTUNITIES TO THE AGING AND THOSE IN NEED IN A CARING, CHRISTIAN ENVIRONMENT. 0 0 8813069 8488466 BETHEL HOME, INC., OPERATES A 128-BED NURSING HOME PROVIDING SKILLED AND INTERMEDIATE NURSING CARE FOR THE AGED AND DISABLED OF OSHKOSH AND THE SURROUNDING AREA. THE HOME ALSO OPERATES A 12-BED DEMENTIA-SPECIFIC COMMUNITY-BASED RESIDENTIAL FACILITY. 8813069 1 1 0 0 0 0 0 0 1 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 21 0 1 267 1 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X X KIM MAKI 9202325238 225 NORTH EAGLE STREET OSHKOSH WI 54902 KAREN JACOBSON CHAIR AS OF JUNE 30, 2018 0.20 1.40 X X 0 0 0 MARY MURKEN VICE CHAIR AS OF JUNE 30, 2018 0.20 1.40 X X 0 0 0 LOIS JAENKE SECRETARY AS OF JUNE 30, 2018 0.20 2.90 X X 0 0 0 MARK BEECHER BOARD MEMBER 0.20 2.90 X 0 0 0 KATHY BERMINGHAM BOARD MEMBER 0.20 1.40 X 0 0 0 JAMIE BONELL BOARD MEMBER 0.20 1.40 X 0 0 0 REV HAN LAVAKE BOARD MEMBER 0.20 1.40 X 0 0 0 GLENN NELSON BOARD MEMBER 0.20 1.40 X 0 0 0 PEG OLSON BOARD MEMBER 0.20 1.40 X 0 0 0 STEW RIECKMAN BOARD MEMBER 0.20 1.40 X 0 0 0 KATHLEEN BELLAIRE CHAIR UNITL JUNE 30, 2018 0.20 1.40 X X 0 0 0 JIM STAPEL SECRETARY UNTIL JUNE 30, 2018 0.20 1.40 X X 0 0 0 DR SUZANNE MARNOCHA BOARD MEMBER 0.20 1.40 X 0 0 0 WAYNE MUELLER BOARD MEMBER 0.20 1.40 X 0 0 0 THERESA BERTRAM PRESIDENT & CEO 4.50 35.50 X 0 376828 0 0 376828 0 0 0 1 0 GREENFIELD REHABILITATION AGENCY 7517 W COLDSPRING RD GREENFIELD WI 53220 THERAPY SERVICES 501690 REINHART FOOD SERVICE LLC 2655 EAST RICHMOND ST SHAWANO WI 54166 FOOD SUPPLIER 334847 CANDEO CREATIVE 146 ALGOMA BLVD SUITE G OSHKOSH WI 54903 CONSULTING/MARKETING 296425 STAT TEMPORARY SERVICES INC 5800 N BAYSHORE DR SUITE A-220 GLENDALE WI 53217 STAFFING AGENCY 244435 WI DEPARTMENT OF HEALTH SERVICES PO BOX 093594 MILWAUKEE WI 53293 HEALTH SERVICES 152320 6 362054 362054 RESIDENT REVENUE 623000 8488466 8488466 8488466 8654 8654 16500 0 16500 16500 16500 MEAL REVENUE 900099 60681 60681 VACCINE REVENUE 900099 8572 8572 OBRA SCREENING 900099 4260 4260 5883 5883 79396 8955070 8488466 0 104550 5077528 4797169 280359 100793 95228 5565 356733 337036 19697 358426 338635 19791 640920 640920 33881 33881 66512 2250 64262 643874 622682 21192 71406 71406 804054 735130 68924 65433 65433 389760 386752 3008 7092 6624 468 347033 347033 132530 132530 BED ASSESSMENT 261120 261120 MISCELLANEOUS 42887 42872 15 EQUIPMENT AND REPAIRS 36462 36462 EMPLOYEE EDUCATION 18166 17751 415 28880 12875 16005 9483490 8813069 670421 0 2012 2012 1283955 1252589 721412 655644 33426 25242 23583 31706 16488732 13514222 2857986 2974510 227362 0 1654733 1595281 6804469 6536984 955243 1209608 81451 72935 1605891 1670977 2642585 2953520 X 4161884 3583464 4161884 3583464 6804469 6536984 X -528420 -50000 X 0 1 X 1 0 X 386924 137638 77692 808777 362054 1773085 10022581 10576232 9345251 9181346 8488466 47613876 10409505 10713870 9422943 9990123 8850520 49386961 0 0 0 49386961 14779 20152 20707 23453 25154 104245 14779 20152 20707 23453 25154 104245 110462 76615 93445 66144 79396 426062 10534746 10810637 9537095 10079720 8955070 49917268 0.98940 0.98810 0.00210 0.00180 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 26261 26261 8561729 7342684 1219045 526776 431706 95070 7291787 5739832 1551955 82179 82179 2974510 DUE FROM AFFILIATES 1490910 RESIDENTS' CUSTODIAL ACCOUNTS 104371 1595281 ASSET RETIREMENT OBLIGATIONS 117780 DUE/TO FROM AFFILIATES 1553197 1670977 X PART IV, LINE 2B: RESIDENTS' CUSTODIAL ACCOUNTS CONSIST OF AMOUNTS ON DEPOSIT WITH BETHEL HOME BY RESIDENTS FOR SAFEKEEPING. THESE FUNDS CAN BE WITHDRAWN AT ANY TIME BY RESIDENTS. PART X, LINE 2: THE ORGANIZATION FOLLOWS THE PROVISIONS OF THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE APPLICATION OF THE INCOME TAX STANDARD HAD NO IMPACT ON THE ORGANIZATION'S CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATOIN FILES INFORMATIONAL RETURNS AS A TAX-EXEMPT ORGANIZATION. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. 0 0 0 0 0 0 0 0 0 THERESA BERTRAM PRESIDENT & CEO 0 314828 0 62000 0 0 0 0 0 0 0 376828 0 0 PART I, LINE 3 THE COMPENSATION OF THE PRESIDENT & CEO IS DETERMINED BY THE ORGANIZATION'S SOLE MEMBER, MIRAVIDA LIVING, INC. THE FOLLOWING METHODS WERE USED BY MIRAVIDA LIVING, INC. TO ESTABLISH THE PRESIDENT & CEO'S COMPENSATION: 1. COMPENSATION SURVEY OR STUDY 2. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD OF DIRECTORS PLUS TWO OTHER MEMBERS OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL BE RESPONSIBLE FOR THE AGENDA FOR THE BOARD AND VOTING MEMBERSHIP MEETINGS. THIS COMMITTEE SHALL KEEP ITSELF INFORMED OF THE ENTIRE OPERATION OF THE CORPORATION AND ITS SUBSIDIARY CORPORATIONS, AND SHALL EXECUTE SUCH ACTIONS AS MAY BE ASSIGNED TO IT BY THE BOARD. THE COMMITTEE SHALL ALSO CONCERN ITSELF WITH MATTERS NOT ASSIGNED TO OTHER COMMITTEES. FORM 990, PART VI, SECTION A, LINE 6 MIRAVIDA LIVING, INC., IS THE SOLE MEMBER OF BETHEL HOME, INC. FORM 990, PART VI, SECTION A, LINE 7A THE DIRECTORS OF BETHEL HOME, INC. ARE ELECTED BY THE BOARD OF DIRECTORS OF THE SOLE MEMBER, MIRAVIDA LIVING, INC. FORM 990, PART VI, SECTION A, LINE 7B MAJOR STANDARD OPERATING PROCEDURES, MAJOR POLICIES, AND PROGRAMS OF BETHEL HOME, INC. ARE SUBMITTED TO THE BOARD OF DIRECTORS OF THE SOLE MEMBER, MIRAVIDA LIVING, INC., FOR APPROVAL AND IMPLEMENTATION. AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS REQUIRE THE APPROVAL OF THE BOARD OF DIRECTORS OF THE SOLE MEMBER, MIRAVIDA LIVING, INC. FORM 990, PART VI, SECTION B, LINE 11B BEFORE IT WAS FILED, THE FORM 990 WAS REVIEWED BY THE CEO, THEN DISTRIBUTED TO EACH MEMBER OF THE BOARD OF DIRECTORS FOR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, THE CORPORATE SECRETARY DISTRIBUTES A CONFLICT OF INTEREST FORM TO EACH MEMBER OF THE BOARD OF DIRECTORS AND VARIOUS COMMITTEE MEMBERS NOT ON THE BOARD THAT REQUIRES EACH TO IDENTIFY POTENTIAL CONFLICTS OR OTHER RELATED PARTY INTERESTS. THE REPORTS ARE REVIEWED BY THE SECRETARY AND CEO AND ANY CONFLICTS ARE BROUGHT TO THE BOARD'S ATTENTION. A MEMBER OF THE BOARD WHO HAS A CONFLICT OF INTEREST MAY NOT VOTE ON ANY SUCH ISSUE BEFORE THE BOARD. ANY QUESTION OF WHETHER THERE IS A CONFLICT IS RESOLVED BY THE BOARD OF DIRECTORS. IF THE BOARD OF DIRECTORS DETERMINES THAT A DIRECTOR HAS COMMITTED A SUBSTANTIAL VIOLATION OF THE CONFLICT OF INTEREST POLICY, THE INDIVIDUAL IS REMOVED FROM THE OFFICE OF DIRECTOR. IN ADDITION, ALL MANAGEMENT AND SUPERVISORY EMPLOYEES ARE INFORMED OF THE ORGANIZATION'S POLICY REGARDING RELATED PARTY TRANSACTIONS AND CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 CEO COMPENSATION IS DETERMINED BY A COMMITTEE OF THE BOARD OF DIRECTORS. THE COMMITTEE CONSIDERS COMPARABLE DATA AND ECONOMIC CONDITIONS. THE DELIBERATIONS ARE RECORDED. COMPENSATION AND BENEFITS FOR OTHER OFFICERS AND KEY EMPLOYEES ARE REVIEWED ANNUALLY BY THE CEO. COMPARABLE INDUSTRY STANDARDS ARE CONSIDERED INCLUDING COMPENSATION AND BENEFIT INFORMATION PROVIDED BY LEADINGAGE WISCONSIN. DELIBERATIONS INCLUDE A REVIEW OF OBJECTIVES AND ACTUAL DELIVERABLES. PROCESS IS DOCUMENTED/MAINTAINED ELECTRONICALLY. THESE PROCESSES LAST OCCURRED IN 2018. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 990 IS AVAILABLE UPON REQUEST AND IS ALSO AVAILABLE AT WWW.GUIDESTAR.ORG. THE ORGANIZATION'S FORM 1023 IS ALSO AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: INTERCOMPANY NET ASSET TRANSFER -50,000. MIRAVIDA LIVING INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 391032234 MANAGEMENT SERVICES WI 501(C)(3) LINE 10 N/A 0 CARMEL RESIDENCE INC 220 NORTH WESTFIELD STREET OSHKOSH WI 59402 391448325 SENIOR HOUSING WI 501(C)(3) LINE 10 MIRAVIDA LIVING INC 0 GABRIEL'S VILLA INC 215 NORTH WESTFIELD STREET OSHKOSH WI 59402 391857036 SENIOR HOUSING WI 501(C)(3) LINE 10 MIRAVIDA LIVING INC 0 SIMEANNA APARTMENTS INC 155 NORTH EAGLE STREET OSHKOSH WI 59402 237148097 SENIOR HOUSING WI 501(C)(3) LINE 10 MIRAVIDA LIVING INC 0 SIMEANNA SOUTH INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 391238670 SENIOR HOUSING WI 501(C)(3) LINE 10 MIRAVIDA LIVING INC 0 SIMEANNA III INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 391270056 SENIOR HOUSING WI 501(C)(3) LINE 10 MIRAVIDA LIVING INC 0 MIRAVIDA LIVING FOUNDATION INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 010938793 FUNDRAISING WI 501(C)(3) LINE 12A, I MIRAVIDA LIVING INC 0 EDEN REHABILITATION SUITES AND GREENHOUSE HOMES INC 3151 EDEN COURT OSHKOSH WI 54904 900506872 SKILLED NURSING FACILITY WI 501(C)(3) LINE 10 MIRAVIDA LIVING INC 0 0 0 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 0 0