2019-11-27T17:50:54-06:00 2019-03-31 460403496 CASEY PETERSON LTD 909 ST JOSEPH ST STE 101 RAPID CITY SD 57701 990 2018-04-01 450411825 WEST RIVER HEALTH SERVICES FOUNDATION WEST 7015674561 1000 HIGHWAY 12 HETTINGER ND 58639 NATHAN STADHEIM CFO 7015674561 2019-11-25 1 DEIDRE BUDAHL CPA P01273830 6053481930 2019-11-27 65.153.235.186 2019-11-27 17:43:47 MS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 6674FD86204B922EA835707114D2D463539C6A14 2018 2020-04-17 16:48:07Z MATT SHAHAN 1000 HIGHWAY 12 HETTINGER ND 58639 1998388 0 X WWW.WRHS.COM X 1982 ND SUPPORT WEST RIVER HEALTH SERVICES AND WESTERN HORIZONS LIVING CENTER AS THEY PROVIDE COMPREHENSIVE HEALTH AND WELLNESS SERVICES TO THE REGION BY PROVIDING FUNDRAISING AND DEVELOPMENT SERVICES. 9 8 0 0 0 0 212980 521835 0 0 230678 188662 48166 677843 491824 1388340 120642 1059693 0 0 510 380 0 0 155307 245156 201339 366308 1261412 125516 126928 7070144 4899384 2475426 160231 4594718 4739153 X THE MISSION OF WEST RIVER HEALTH SERVICES FOUNDATION IS TO SUPPORT WEST RIVER HEALTH SERVICES AND WESTERN HORIZONS LIVING CENTER AS THEY PROVIDE COMPREHENSIVE HEALTH AND WELLNESS SERVICES TO THE REGION BY PROVIDING FUNDRAISING AND DEVELOPMENT SERVICES. 0 0 1059693 1059693 0 THE FOUNDATION WAS INCORPORATED IN 1982 TO SERVE AS A SOURCE OF CONTRIBUTED FUNDS FOR WEST RIVER HEALTH SERVICES WITH THE ADDITION OF WESTERN HORIZONS LIVING CENTERS IN SEPTEMBER OF 2007. THE FOUNDATION IS GOVERNED BY A VOLUNTEER BOARD OF DIRECTORS, IS REGISTERED AS A 501(C)(3) U.S. CHARITABLE ORGANIZATION, AND IS LICENSED BY THE STATE OF NORTH DAKOTA. THE FOUNDATION EXISTS TO RAISE FUNDS FOR NEW EQUIPMENT AND TECHNOLOGY; DEVELOP NEW HEALTH-RELATED PROGRAMS AND SERVICES; ENHANCE ASSISTED LIVING AND LONG-TERM CARE SERVICES; SUPPORT COMMUNITY WELLNESS EDUCATION; AND PROVIDE SCHOLARSHIPS AND LOANS FOR NURSING, ALLIED HEALTHCARE PROFESSIONALS, AND PHYSICIANS TO MEET THE CONTINUING CHANGES IN HEALTHCARE REFORM. TO REACH THESE GOALS, AN ENDOWMENT FUND WAS ESTABLISHED. THE ENDOWMENT FUND WILL BE USED AS A PERMANENT FUNDING SOURCE FOR WRHS AND WHLC TO CARRY OUT THEIR VISIONS OF ENSURING QUALITY HEALTH AND LONG-TERM CARE SERVICES TO THE CITIZENS OF THE REGION. 1059693 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 12 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X NATHAN STADHEIM 7015676150 1000 HIGHWAY 12 HETTINGER ND 58639 MATT BARNES CHAIRMAN 1.00 X X 30 0 0 CODY JORGENSON VICE-CHAIRMAN 1.00 X X 50 0 0 LONNIE STIPPICH FORMER SECRETARY/TREASURER 1.00 X X 40 0 0 CONNIE BURWICK REPRESENTATIVE 1.00 X 50 0 0 JENNIFER JOHNSON SECRETARY/TREASURER 1.00 X X 20 0 0 JOHN JOYCE REPRESENTATIVE 1.00 X 10 0 0 MIKE MELLMER REPRESENTATIVE 1.00 X 30 0 0 VANCE TROGSTAD REPRESENTATIVE 1.00 X 40 0 0 LINDA WEAVER FORMER REPRESENTATIVE 1.00 X 40 0 0 STEVE HEDSTROM REPRESENTATIVE 1.00 X 10 0 0 DR MARK KRISTY MEDICAL STAFF LIASON 1.00 X 0 324147 36871 MATT SHAHAN PRESIDENT, CEO 1.00 39.00 X 0 207455 10360 NATHAN STADHEIM CFO 2.00 38.00 X 0 103819 29065 320 635421 76296 0 0 1 0 DR KENT HOERAUF 1000 HIGHWAY 12 HETTINGER ND 58639 DEFERRED COMPENSATION PAYOUT 195108 DR STEVEN KILWEIN 1000 HIGHWAY 12 HETTINGER ND 58639 DEFERRED COMPENSATION PAYOUT 191730 KIMBERLEE ERICKSON PO BOX 1186 HETTINGER ND 58639 DEFERRED COMPENSATION PAYOUT (BENEFICIAR 181327 DR JOHN JOYCE 1000 HIGHWAY 12 HETTINGER ND 58639 DEFERRED COMPENSATION PAYOUT 171771 WEST RIVER REGIONAL MEDICAL CENTER 1000 HIGHWAY 12 HETTINGER ND 58639 MANAGEMENT AND FUNDRAISING SERVICES 110736 7 42267 479568 521835 117126 117126 59343 9951 49392 49392 49392 657060 585524 71536 71536 71536 8668 42267 14573 -5905 -5905 WHLC RECEIVABLE RECOVE 900099 634356 634356 634356 1388340 0 0 866505 1045393 1045393 14300 14300 380 380 8147 8147 32523 32523 33461 33461 88074 88074 19109 19109 5289 2175 3114 847 847 1058 631 427 799 799 1757 1757 ANNUITY EXPENSE 9000 9000 DONOR RECOGNITION EXPEN 1275 1275 1261412 1059693 46412 155307 161001 241728 108480 138475 143 268 659612 18153 642258 641459 6012681 3728350 2274 0 143307 149104 7070144 4899384 4506 1468 21347 21356 2449573 137407 2475426 160231 X 3827318 3918279 422918 354671 344482 466203 4594718 4739153 7070144 4899384 126928 17507 0 X X 0 1 X 1 0 X X 2 WEST RIVER HEALTH SERVICES 450340688 3 1 426529 0 WESTERN HORIZONS LIVING CENTERS 260794602 10 1 618864 0 2 1045393 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 X 1 1 PART IV SECTION A LINE 1 WEST RIVER HEALTH SERVICES IS LISTED BY NAME IN THE ORGANIZATION'S GOVERNING DOCUMENTS. WESTERN HORIZONS LIVING CENTER IS NOT LISTED BY NAME IN THE GOVERNING DOCUMENTS. HOWEVER, THE ORGANIZATION PROVIDES SUPPORT TO ALL OF THE ORGANIZATIONS FOR WHICH IT IS NAMED AS THE MEMBER IN THE SUPPORTED ORGANIZATIONS' GOVERNING DOCUMENTS. IN THIS CASE, BOTH WEST RIVER HEALTH SERVICES AND WESTERN HOIZONS LIVING CENTER LIST THE ORGANIZATION AS THEIR SOLE MEMBER IN EACH OF THEIR RESPECTIVE GOVERNING DOCUMENTS. PART IV SECTION E LINE 3A THE ORGANIZATION IS RESPONSIBLE FOR ELECTING THE DIRECTORS FOR EACH OF ITS SUPPORTED ORGANIZATIONS. PART IV SECTION E LINE 3B THE ORGANIZATION APPROVES AND MAKES AMENDMENTS TO THE SUPPORTED ORGANIZATIONS' GOVERNING DOCUMENT AND POLICIES. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 405570 123661 23932 14300 3091 535772 345787 50621 25554 14250 2142 405570 284401 50219 27670 15000 1503 345787 271614 23103 1776 11000 1092 284401 223521 41890 13362 5500 1659 271614 0.00000 0.86690 0.13310 0 0 633264 633264 26348 18153 8195 641459 ANNUITY PAYABLE 54963 DUE TO RELATED PARTY 9276 LIFE INSURANCE PAYABLE 70729 ACCRUED PROPERTY TAX 2439 137407 X 1430371 17507 17507 1412864 -24524 -24524 1388340 1285936 24524 24524 1261412 0 1261412 PART V, LINE 4: THE ENDOWMENT FUND WILL BE USED AS A PERMANENT FUNDING SOURCE FOR WRHS AND WHLC TO CARRY OUT THEIR VISION OF ENSURING QUALITY HEALTH AND LONG-TERM CARE SERVICES TO THE CITIZENS OF THE REGION. SPECIFIC GOALS FOR THE ENDOWMENT FUND ARE AS FOLLOWS: TO PROVIDE FUNDS FOR EQUIPMENT; TO ASSIST WITH HEALTH RELATED PROGRAMS AND SERVICES; TO SUPPORT COMMUNITY WELLNESS EDUCATION; TO PROVIDE SCHOLARSHIPS AND LOANS FOR HEALTHCARE PROFESSIONALS; AND TO AID HOSPITAL, CLINICS AND LIVING CENTERS IN THEIR CORPORATE MISSIONS. PART X, LINE 2: THE FOUNDATION IS ORGANIZED AS A NORTH DAKOTA NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE FOUNDATION HAD NO UNCERTAIN TAX POSITIONS THAT QUALIFIED FOR RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE FOUNDATION IS NO LONGER SUBJECT TO FEDERAL AND STATE INOME TAX EXAMINATIONS FOR FISCAL YEARS BEFORE 2015. PART XI, LINE 2D - OTHER ADJUSTMENTS: UNREALIZED GAIN ON INVESTMENTS 17,507. PART XI, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING DIRECT EXPENSE -14,573. RENTAL EXPENSES -9,951. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 9,951. FUNDRAISING DIRECT EXPENSE 14,573. ADULT PROM 44050 35457 8593 7390 175 1203 600 2260 FUN RUN 6885 6810 75 75 2870 50935 42267 8668 7465 175 1203 600 5130 14573 -5905 1 WESTERN HORIZONS LIVING CENTER 1000 HIGHWAY 12 HETTINGER ND 58639 260794602 501(C)(3) 618864 SUPPORT WEST RIVER HEALTH SERVICES 1000 HIGHWAY 12 HETTINGER ND 58639 450340688 501(C)(3) 426529 SUPPORT 2 0 MEDICAL SCHOLARSHIPS 10 14300 PART I, LINE 2: THE GRANTS FROM WEST RIVER HEALTH SERVICES FOUNDATION ARE BEING MADE TO WEST RIVER HEALTH SERVICES AND WESTERN HORIZONS LIVING CENTER, RELATED ORGANIZATIONS. THE CEO, CFO, AND BOARD CHAIR OF WEST RIVER HEALTH SERVICES FOUNDATION MONITOR THE USE OF THE GRANT FUNDS THROUGH THEIR POSITIONS AS CEO, CFO, AND A BOARD MEMBER AT WEST RIVER HEALTH SERVICES AND WESTERN HORIZONS LIVING CENTER. 0 0 0 0 0 0 0 0 0 DR MARK KRISTY MEDICAL STAFF LIASON 0 324147 0 0 0 0 0 8250 0 28621 0 361018 0 0 MATT SHAHAN PRESIDENT, CEO 0 197455 0 10000 0 0 0 6303 0 4057 0 217815 0 0 PART I, LINE 3 THE ORGANIZATION'S CEO IS COMPENSATED BY WEST RIVER HEALTH SERVICES (A RELATED PARTY). THE WEST RIVER HEALTH SERVICES BOARD OF DIRECTORS DETERMINES THE CEO'S COMPENSATION VIA COMPENSATION COMMITTEE, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CAN ACT FOR AND ON BEHALF OF THE FULL BOARD. IT IS COMPRISED OF THE CEO, FUND DEVELOPMENT DIRECTOR, CHAIR, VICE CHAIR, SECRETARY/TREASURER, PAST CHAIR, MEDICAL STAFF REPRESENTATIVE, ONE MEMBER OF THE HOSPITAL BOARD, AND ONE MEMBER OF THE WHLC BOARD. FORM 990, PART VI, SECTION A, LINE 6 THERE IS ONLY ONE CLASS OF MEMBERS. MEMBERS ARE ANY INDIVIDUALS THAT HAVE CONTRIBUTED THE SUM OF ONE DOLLAR AND ARE RESIDENTS OF THE PRIMARY CARE SERVICE AREA OF THE FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER HAS ONE VOTE AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 11B THE CEO AND CFO WILL REVIEW THE FORM 990 PRIOR TO THE COMPLETED FORM 990 BEING DISTRIBUTED ELECTRONICALLY TO THE BOARD MEMBERS FOR THEIR REVIEW AND COMMENTS. THE FORM 990 IS ALSO REVIEWED AND DISCUSSED AT A BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS ARE REQUIRED TO ANNUALLY DISCLOSE ANY POTENTIAL CONFLICTS. POTENTIAL CONFLCITS ARE REVIEWED BY THE CEO. INDIVIDUALS WITH CONFLICTS ABSTAIN FROM VOTING, AND THIS ACTION IS NOTED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION PAID TO THE CEO & CFO IS PAID AND DETERMINED BY A RELATED ORGANIZATION, WEST RIVER HEALTH SERVICES (WRHS). THE COMPENSATION PROCEDURES USED BY WRHS ARE AS FOLLOWS: CEO: EACH BOARD AND MEDICAL STAFF MEMBER ANNUALLY COMPLETES AN EVALUATION FORM ON THE CEO'S PERFORMANCE; THE CHAIRMAN OF THE EXECUTIVE COMMITTEE TABULATES THE RESULTS AND REVIEWS WITH THE MEMBERS OF THE EXECUTIVE COMMITTEE.; RESULTS ARE PRESENTED TO THE FULL BOARD OF DIRECTORS WHO HAVE FINAL AUTHORITY IN DETERMINING COMPENSATION. COMPARABILITY DATA FROM THE STATE HOSPITAL ASSOCIATION, AS WELL AS OTHER COMPARATIVE INDUSTRY INFORMATION, IS USED IN DETERMINING COMPENSATION. CFO: THE CEO REVIEWS THE CFO PERFORMANCE AND USES COMPARABILITY DATA IN DETERMINING COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XII, LINE 2C: THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. WEST RIVER HEALTH SERVICES 1000 HIGHWAY 12 HETTINGER ND 58639 450340688 HOSPITAL ND 501(C)(3) LINE 3 WEST RIVER HEALTH SERVICES FOUNDATION 1 WESTERN HORIZONS LIVING CENTERS 1104 HIGHWAY 12 HETTINGER ND 58639 260794602 LONG-TERM CARE/ASSISTED LIVING SERVICES ND 501(C)(3) LINE 10 WEST RIVER HEALTH SERVICES FOUNDATION 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 WESTERN HORIZONS LIVING CENTERS B 618864 CASH PAID WEST RIVER HEALTH SERVICES B 426529 CASH PAID WEST RIVER HEALTH SERVICES E 9276 LOAN AGREEMENT WEST RIVER HEALTH SERVICES P 115541 CASH PAID WEST RIVER HEALTH SERVICES Q 650 CASH PAID