2019-04-15T08:58:50-07:00 2018-12-31 990 2018-01-01 381366927 Holland Home HOLL 6162355015 2100 Raybrook St SE Ste 300 Grand Rapids MI 49546 Hermina Breuker CEO 6162355005 2019-04-15 207.242.239.202 2018 2019-02-21 02:37:17Z Hermina Breuker 2100 Raybrook St SE Ste 300 Grand Rapids MI 49546 69047092 0 X www.hollandhome.org X 1892 MI Provide nursing, therapy, and benevolent services for aged residents in skilled nursing, memory care, assisted living and independent living centers. 15 14 1177 628 22576 21576 1602889 2817862 61969332 58520462 1557378 1163247 -72033 -26661 65057566 62474910 0 0 0 0 36646211 45949760 4477 4850 875792 31118857 29064964 67769545 75019574 -2711979 -12544664 234728433 225311958 230071435 217544888 4656998 7767070 X In fulfilling God's calling to serve others, the organization will service aged persons (1) with love and compassion, (2) with a commitment to excellence, and (3) follow Christ's teachings and example in all that the organization does. 0 1 67302441 58543038 Provide nursing and residential care at three facilities located in Grand Rapids, Michigan to an average of approximately 1,512 residents each day in skilled nursing (approximately 152 per day), assisted living (approximately 390 per day) and independent living (approximately 970 per day). Of the approximately 390 residents in assisted living, the organization provides financial assistance to 20% or 75 residents on average which amounts to $1.8 million in benevolence. In skilled nursing, the organization serves an average of 91 residents (60%) on Medicaid and 15 residents (10%) on Medicare. These contractual allowances cost the organization $2.8 million in 2018. The organization provides uncompensated cost of private rooms to most of the 91 residents on Medicaid. 0 0 0 67302441 1 1 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 56 0 1 1177 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 X 15 14 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 MI X David Tiesenga 6162355035 2100 Raybrook St SE Ste 300 Grand Rapids MI 49546 Hermina Breuker President/CEO, Director 50 0 X X 354845 0 27781 Susan Vogel-Vanderson Chairperson, Director 2 0 X X 0 0 0 Mary Ursul Vice-Chairperson, Director 2.00 0 X X 0 0 0 Mark Eriks Secretary, Director 2 0 X X 0 0 0 Gary Malburg Treasurer, Director 2 0.00 X X 0 0 0 Paul Farr Director 2 0 X 0 0 0 Sister Myra Bergman Director 2 0 X 0 0 0 Jean Nagelkirk Director 2 0 X 0 0 0 Sam Watson Director 2 0.00 X 0 0 0 Luis Tomatis Director 2 0 X 0 0 0 James Tuinstra Director 2 0 X 0 0 0 Carl VerBeek Director 2 0 X 0 0 0 David Knibbe Director 2 0 X 0 0 0 Nick Thole Director 2 0 X 0 0 0 Nelson Sanchez Director 2 0 X 0 0 0 David Tiesenga Chief Financial Officer 50 0 X 275304 0 25130 H David Claus Former President Emeritus 20 0 X X 362252 0 235 Dr John Mulder Chief Medical Consultant 50 X 321720 0 16568 Carolyn Flietstra Executive VP, Home and Community Services 50 0 X 168897 0 8804 Troy Vugteveen Executive VP, Operations 50 0 X 164222 0 8527 Jeff Engle Vice President, Information Technology 50 0 X 147193 0 7680 Doug Himmelein Vice President, Human Resources 50 0 X 136404 0 7068 1930837 0 101793 15 1 1 0 Erhardt Construction Co 6060 Fulton St E Ada MI 49301 construction services 6817915 Rasmussen LLC 2914 3 Mile Rd NW Walker MI 49534 roofing contractor services 589974 RehabCare Group PO Box 503534 St Louis MO 63150 rehabilitation services 529818 Authenticity Marketing Group 70 Ionia SW Suite 502 Grand Rapids MI 49503 marketing consulting svcs 247399 Morrison Services 39395 W 12 Mile Rd Farmington Hills MI 48331 dietary services 3504025 18 0 0 239016 0 0 2578846 0 2817862 HFA, AFC and Independent Living 623311 18941695 18941695 0 0 Medicare/Medicaid 623000 9572766 9572766 0 0 Skilled Nursing 623000 6521002 6521002 0 0 Amortization of Endowments 623311 7152517 7152517 0 0 Ancillary Revenue 623311 569798 569798 0 0 15762684 15762684 0 0 58520462 540457 0 0 540457 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7063735 0 6440945 0 622790 0 622790 0 0 622790 82000 239016 131237 -49237 0 -49237 0 0 0 0 0 0 0 0 0 0 0 0 Disallowed Employee Fringes For Parking 623311 22576 0 22576 0 22576 62474910 58520462 22576 1114010 0 0 0 0 0 0 0 0 1045547 1045547 0 0 0 0 26325803 24149725 1728014 448064 13214418 11659072 1339028 216318 3285339 2898653 332906 53780 2078653 1833994 210632 34027 316905 171166 145739 121511 121511 134751 134751 0 0 0 0 4850 4850 46627 46627 0 0 0 0 554810 554192 618 0 1368947 1212206 118872 37869 643762 105718 538044 0 0 0 0 0 4242263 3934931 307332 0 212873 171073 30443 11357 0 0 0 0 22764 15753 1221 5790 5956332 5953832 2500 0 0 0 0 0 7989168 7531179 457989 0 527436 494301 33135 0 Purchased Services 4030675 3996275 0 34400 Medical Quality Assurance Fees 1375982 1375982 0 0 Medical Supplies 575377 575377 0 0 Misc 735544 459775 246432 29337 209237 209237 75019574 67302441 6841341 875792 775698 1482854 7557807 8133485 702777 380956 2194149 1847276 0 0 0 0 3501829 3163325 216766 155234 195469 341074 283686716 105624402 172799041 178062314 15903680 7576030 0 0 15394614 14139457 0 0 15486603 10029953 234728433 225311958 9552041 8810378 0 0 37913516 40505113 109105256 107451057 0 0 0 0 0 0 1699295 1492756 71801327 59285584 230071435 217544888 X 3954221 6825623 702777 941447 0 0 4656998 7767070 234728433 225311958 X -12544664 -1358489 0 0 0 17013225 X 0 1 X 1 0 X 3294775 3144724 7046198 1602889 2817862 17906448 58721435 60587159 62310981 61969332 58543038 302131945 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 62016210 63731883 69357179 63572221 61360900 320038393 0 0 0 0 0 0 0 0 0 0 0 0 320038393 323090 469364 408371 659315 540457 2400597 0 0 0 0 0 0 323090 469364 408371 659315 540457 2400597 0 0 0 0 0 0 0 0 0 0 0 0 62339300 64201247 69765550 64231536 61901357 322438990 0.99255 0.9911 0.00745 0.0069 X 0 13985036 13985036 0 250205147 90699197 159505950 0 1021539 368664 652875 0 15931665 13243906 2687759 0 2543329 1312635 1230694 178062314 Interest in Net Assets of Charitable Foundation 14139457 F 14139457 Series 2016 Debt Service Reserve Fund 3573931 Series 2012 Debt Service Reserve Fund 4957631 Assets Held for 457b Plan 588847 Investment in Tandem365 and Others 740485 Split-Dollar Agreement Receivable 169059 10029953 Note Payable to Reliance CCP 2500000 Net Accrued Pension Cost 0 Fair Value of Interest Rate Swap Agreements 4954971 Mortgage Notes and Refundable Entrance Fees 51830613 59285584 60018582 -1358489 0 0 131237 -1227252 61245834 46764 1182312 1229076 62474910 75104047 0 0 0 131237 131237 74972810 46764 0 46764 75019574 Schedule D, Part XI, Line 2d Amount includes expenses related to fundraising events. Schedule D, Part XI, Line 4b Amount includes 250,000 in contribution received from Holland Home Foundation, as well as $932,312 in restricted contributions (pledges) received. Schedule D, Part XII, Line 2d Amount includes expenses related to fundraising events. Christmas Dinner 321016 239016 82000 0 0 34274 64334 8750 23879 0 0 321016 239016 82000 0 0 34274 64334 8750 23879 131237 -49237 X 1 1 X X X X 0 0 0 0 0 0 0 0 0 Hermina Breuker President/CEO, Director 354845 0 0 0 0 0 18500 0 9281 0 382626 0 0 0 David Tiesenga Chief Financial Officer 275304 0 0 0 0 0 18500 0 6630 0 300434 0 0 0 H David Claus Former President Emeritus 109276 0 0 0 0 0 252976 0 235 0 362487 0 0 0 Dr John Mulder Chief Medical Consultant 321720 0 0 0 0 0 16568 0 0 0 338288 0 0 0 Carolyn Flietstra Executive VP, Home and Community Services 168897 0 0 0 0 0 8804 0 0 0 177701 0 0 0 Troy Vugteveen Executive VP, Operations 164222 0 0 0 0 0 8527 0 0 0 172749 0 0 0 Schedule J, Part I, Line 1a The organization provides reimbursement of health club dues to the Chief Financial Officer. A Econ Dev Corp of the City of Kentwood 381844797 491740DF0 2012-06-29 50090801 see Part VI 0 0 0 B Michigan Strategic Fund 521417332 000000000 2014-12-11 23590000 Refund prior issue (12/18/2009) 0 0 0 C Econ Dev Corp of the City of Kentwood 381844797 491740EW2 2016-10-31 32187291 Refund prior issue (8/31/2006) 0 0 0 D Michigan Strategic Fund 521417332 594698PM8 2016-10-31 9483642 Renovate facility 0 0 0 A 830000 0 50422325 4897259 0 0 1001816 0 0 0 45435529 0 2005 1 0 1 1 B 3166667 0 23590000 0 0 0 0 0 0 0 23590000 0 2005 1 0 1 1 C 1390000 0 3201824 2594177 434 0 651160 0 0 0 28956053 2005 1 0 1 1 D 0 0 9488293 881150 0 0 182258 0 0 8424884 0 0 0 0 0 1 A 0 0 0 0 0 0 0 1 0 0 B 0 0 0 0 0 0 0 1 0 0 C 0 0 0 0 0 0 0 1 0 0 D 0 0 0 0 0 0 0 1 0 0 A 0 0 1 1 0 0 1 Wachovia 27.8000000 1 0 0 B 0 0 1 1 1 0 0 0 0 C 0 1 1 0 0 0 0 0 0 D 0 1 0 0 0 0 0 0 0 A 0 B 0 C 0 D 0 Schedule K, Part I, Column f-06/29/2012 50,090,801 Econ Dev Corp of the City of Kentwood Refund prior bonds (8/2/00, 8/31/06, 10/3/02) Schedule K, Part II, Line 3-06/29/2012 50,090,801 Econ Dev Corp of the City of Kentwood The total proceeds do not equal the summation of lines 4-12 due to transferred or replacement proceeds in line 4. Schedule K, Part II, Line 3-10/31/2016 32,187,291 Econ Dev Corp of the City of Kentwood The total proceeds do not agree to the issue price in Part I, column (e) due to investment earnings / market value fluctuations. Schedule K, Part IV, Line 2c-06/29/2012 50,090,801 Econ Dev Corp of the City of Kentwood Date the Rebate Computation was Performed: 5/31/2017. Schedule K, Part IV, Line 2c-12/11/2014 23,590,000 Michigan Strategic Fund Date the Rebate Computation was Performed: 6/11/2015 Sister Myra Bergman Director 676002 pharmacy, physician & lab svcs 0 Mark Eriks Secretary, Director 234170 food supplies 0 Form 990, Part III, Line 3 In September 2017, the organization ceased admissions to its Fulton Manor campus. In February 2018, all skilled nursing care services ceased, as all remaining nursing patients were transitioned to other organization-operated facilities or outside facilities. Additionally, in November 2018, all remaining home for the aged residents were transitioned to other organization-operated facilities. As of December 31, 2018, there remain no clinical operations occurring within the organization's Fulton Manor campus. Form 990, Part VI, Section A, Line 6 Pursuant to its Articles of Incorporation, as amended, the corporation is organized on a membership basis. Form 990, Part VI, Section A, Line 7b Pursuant to its Bylaws, as amended, the corporation is a subsidiary of Christian Living Services (CLS) and not withstanding any other provision in their Bylaws to the contrary, the approval of Christian Living Services as the member of this corporation is required to: (1) change the purpose, philsophy, core values or mission of the corporation, (2) amend the Articles of Incorporation or Bylaws of the corporation, (3) make any changes to the structure of operations of the corporation which would affect its status as a nonprofit entity, exempt from taxation under Section 501(c)(3) of the Internal Revenue Code, (4) dissolve or liquidate the corporation, (5) merge or consolidate with another entity, (6) remove a Director of the corporation, (7) create or acquire a new subsidiary entity or enter into a joint venture or partnership, (8) purchase, acquire, or lease any real property or sell, lease, exchange, give as security, mortgage, or dispose of any personal property owned, held or leased by the corporation, (9) purchase, lease (as lessor or lessee), sell or otherwise dispose of any personal property that would be a capital asset of the corporation under generally accepted accounting principles, (10) borrow or enter into a guarantee, (11) adopt a budget, schedule of fees, marketing plan or long-range plan for the corporation, (12) enter into a material contract such as an employee lease arrangement or a contract to subcontract the provision for food service, facilities, maintenance or janitorial services, or (13) change accountants or attorneys. Form 990, Part VI, Section B, Line 11b The Form 990 and appropriate Schedules are prepared by the organization. A draft of the Form is reported to the organization's Finance Committee, which is given opportunity to review the form, prior to its submission to the Internal Revenue Service. Upon confirmation of review, the form is subsequently submitted and filed with the Internal Revenue Service. Form 990, Part VI, Section B, Line 12c On an annual basis, each director, principal officer, and member of a committee with board delegated powers must complete a statement that (1) they have received a copy of the Conflict of Interest Policy, (2) they have read and understand the policy, (3) they have agreed to comply with the policy, and (4) understand that the organization is charitable and in order to maintain its federal tax exemption Form 990, Part VI, Section B, Line 15 The organization purchases compensation surveys and establishes the executive compensation around the fiftieth percentile (with some flexibility) of prevailing market rates for similar positions, market trends, and the financial resources of the organization. The organization is committed to balancing fiscal stewardship with a desire to competitively compensate its personnel. Executive compensation is reviewed within the compensation committee of the Board of Directors. Form 990, Part VI, Section C, Line 19 The organization does not generally make its governing documents or Conflict of Interest Policy available to the public; however, such documents would be subject to public inspection if so requested. A summary of the annual audited financial statements is made available each year within a quarterly publication of Holland Home called "New Horizons." This publication is made available to residents and key stakeholders. Form 990, Part XI, Line 9 Other changes in net assets includes reductions of: unrealized loss of $1,255,157 on change in interest in net assets of Foundation; $371,821 in receipts on outstanding pledges receivable. Other changes in net assets includes additions of: $50,000 in new pledges receivable; unrealized gain of $1,177,737 on the change in fair value of interest rate swap agreements; $5,000,000 from transfers received from affiliates; and $12,412,466 in pension-related changes other than net periodic benefit cost (due to the termination and liquidation of the defined benefit pension plan in September 2018). Christian Living Services 2100 Raybrook St SE Suite 200 Grand Rapids MI 49546 261126816 Admin Services MI 501(c)(3) 12b N/A 0 Faith Hospice 2100 Raybrook St SE Grand Rapids MI 49546 383062893 Hospice Care MI 501(c)(3) 12b Christian Living Services 0 Reliance Community Care Partners 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 382295909 Community Services MI 501(c)(3) 10 Christian Living Services 0 Helpers of Holland Home 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 271062997 In-Home Services MI 501(c)(3) 12b Christian Living Services 0 Atrio Home Health 2100 Raybrook St SE Grand Rapids MI 49546 382660300 Home Health Care MI 501(c)(3) 12b Christian Living Services 0 Trillium Institute 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 471295260 Education Services MI 501(c)(3) 12b Christian Living Services 0 Rehab Dimensions 2100 Raybrook St SE Grand Rapids MI 49546 383337881 Rehabilitation Services MI 501(c)(3) Christian Living Services 0 Atrio Home Health Lakeshore 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 814839696 Home Health Care MI 501(c)(3) 12b Atrio Home Care 0 Atrio Home Care 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 813166606 In-Home Services MI 501(c)(3) 10 Christian Living Services 0 Holland Home Foundation 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 382663466 Mission Fundraising MI 501(c)(3) 7 Holland Home 1 Care Resources 1471 Grace St SE Grand Rapids MI 49506 300166828 PACE Services MI 501(c)(3) 12b N/A 0 Raybrook Limited Partners 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 Property Ownership MI Holland Home Related 100 100 0 0 0 1 Facility Management Services 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 Health Management MI Holland Home Unrelated 100 100 0 0 0 1 EHCO Group LLC (dba Tandem365) 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 Health Management MI N/A Related 20 20 0 0 0 0.2 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 1 Holland Home Foundation c 250000 grant Reliance Community Care Partners l 955146 set fee based on services Atrio Home Health l 333948 set fee based on services Atrio Home Care l 139152 set fee based on services Atrio Home Health Lakeshore l 89580 set fee based on services Care Resources l 1077858 set fee based on services Atrio Home Care p 14822 reimbursement Atrio Home Care q 84784 reimbursement Atrio Home Health Lakeshore q 149092 reimbursement Reliance Community Care Partners n 230684 facility rent Reliance Community Care Partners q 723797 reimbursement Reliance Community Care Partners s 4000000 transfer of cash reserves for pension plan liquidation Care Resources q 5289726 reimbursement EHCO Group LLC (dba Tandem365) q 2402965 reimbursement Facility Management Services q 34542 reimbursement Faith Hospice l 2541403 set fee based on services Faith Hospice n 90710 facility rent Faith Hospice p 28270 reimbursement Faith Hospice q 1925366 reimbursement Faith Hospice s 1623563 transfer of cash reserves for pay down of note payable to Holland Home and assistance with pension plan liquidation funding Trillium Institute l 45000 set fee based on services Trillium Institute q 280240 reimbursement Atrio Home Health n 55648 facility rent Atrio Home Health p 36120 reimbursement Atrio Home Health q 209252 reimbursement Schedule R, Part I Facility Management Services of Holland Home, LLC is not an exempt organization; however, it is a wholly owned subsidiary of Holland Home, generating unrelated business income for the benefit of Holland Home. Holland Home files a Form 990-T on an annual basis, reporting any unrelated business income related to Facility Management Services of Holland Home. Facility Management Services substantively ceased operations in 2018. EHCO Group, LLC (dba Tandem365) is not an exempt organization. Holland Home, a wholly-owned subsidiary of Christian Living Services, maintains a 20% membership interest. The organization is a collaborative partnership between five organizations focused on managing health care costs of a specific pool of individuals, based upon contracting with health insurers and health care providers. Raybrook Partners was dissolved in 2018 and previously held ownership of the 2100 Raybrook corporate offices of Holland Home. The property was transferred to Holland Home in 2018 and the partnership subsequently dissolved.