2018-11-12T10:39:32-06:00 2017-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2017-01-01 371834045 SANFORD-GOOD SAMARITAN COMMUNITY HEALTH SERVICES LLC SANF 6053623100 4800 W 57TH ST PO BOX 5038 SOUIX FALLS SD 571175038 THOMAS A SYVERSON PRESIDENT 6053623100 2018-11-08 1 KACIE MCEWEN P01599614 6123764500 67.137.57.251 2018-11-08 13:35:56 CS P 912999D8D5E4D9097136BAD3000543774677FD22 3018D2C7A8EF8E88940F980D8F52F9F97466C021 2017 2019-02-21 02:37:17Z X PROSPERA THOMAS A SYVERSON 4800 W 57TH ST PO BOX 5038 SOUIX FALLS SD 571175038 43493051 0 X N/A X LIMITED LIABILTY COMPANY 2016 ND OPERATE, FINANCE AND DEVELOP LONG-TERM CARE, SENIOR LIVING, AND POST-ACUTE FACILITIES IN A MANNER CONSISTENT WITH THE MEMBERS CHARITABLE PURPOSES. 6 6 959 93 115273 -20690 24666 43259104 6987 199861 43490618 4000 0 27748346 0 0 18838984 46591330 -3100712 44498348 27149282 17349066 OPERATE, FINANCE AND DEVELOP LONG-TERM CARE, SENIOR LIVING, AND POST-ACUTE FACILITIES IN A MANNER CONSISTENT WITH THE MEMBERS CHARITABLE PURPOSES. 0 0 39770391 4000 43259104 PROVIDE LONG-TERM CARE, SENIOR LIVING AND POST ACUTE SERVICES FOR OLDER PERSONS AND OTHERS IN NEED. PROVIDED SERVICES FOR 127,188 SKILLED NURSING DAYS, 10,521 ASSISTED LIVING DAYS, AND 30,179 SENIOR HOUSING DAYS. 39770391 1 1 0 0 0 0 0 0 0 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 31 0 959 1 1 1 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 G GRANT TRIBBLE 6053623100 4800 W 57TH ST SIOUX FALLS SD 57108 X THOMAS A SYVERSON PRESIDENT & CHAIRPERSON 0.10 X X 0 0 0 CRAIG LAMBRECHT VICE PRESIDENT & DIRECTOR 0.10 X X 0 0 0 G GRANT TRIBBLE TREASURER & DIRECTOR 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 WEST 57TH STREET SIOUX FALLS SD 57108 MANAGEMENT FEES & SHARED EMPLOYEES 2411409 DAKOTA TRAVEL NURSE INC 1200 COLLINS AVENUE MANDAN ND 58554 POOL STAFF SERVICES 1607040 INFINITY REHAB 25117 SW PARKWAY STE D WILSONVILLE OR 97070 CONTRACT THERAPY SERVICES 1537630 PRIME TIME HEALTHCARE LLC PO BOX 3544 OMAHA NE 681030544 POOL STAFF SERVICES 767562 SANFORD HEALTH PO BOX 5074 SIOUX FALLS SD 571175074 LAB SERVICES 150274 5 24666 24666 HOUSING AND RESIDENT SERVICES 623000 43259104 43259104 43259104 6987 6987 6653 0 6653 6653 6653 11036 0 11036 11036 4961 2433 2528 2528 MEALS 722320 115273 115273 CABLE TV 900099 38050 38050 BARBER & BEAUTY SHOP 623990 11327 11327 14994 14994 179644 43490618 43259104 115273 91575 X 4000 4000 22371758 21231528 1140230 502120 465292 36828 3208730 3045252 163478 1665738 1572744 92994 2692421 2692421 12196 12196 5761210 5367452 393758 27934 27934 154093 7072 147021 32139 32139 4238620 4238620 80328 52845 27483 255702 255702 1017154 1017154 84968 84968 FOOD 1358826 1358826 MEDICAL SUPPLIES 1335457 1335457 DRUGS 757026 757026 BAD DEBT EXPENSE 452034 452034 578876 334277 244599 46591330 39770391 6820939 0 634152 29389 5204283 87689 5928 31534836 999816 0 30535020 8000131 0 1756 0 44498348 5888537 19892352 29389 0 1339004 0 27149282 X 17324400 24666 0 17349066 0 44498348 X -3100712 20449778 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 0 1 X 2060465 2060465 23815857 510521 23305336 1637770 35515 1602255 3921590 453780 3467810 99154 99154 30535020 RELATED PARTY PAYABLE 516807 RESIDENT SECURITY DEPOSITS 17500 ENTRANCE FEE 209889 SPECIAL ASSESSMENT PAYABLE 594808 1339004 X 43471759 0 43471759 18859 18859 43490618 46598231 6901 6901 46591330 0 46591330 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 4B - OTHER ADJUSTMENTS: INTEREST INCOME 1,094. GIFT SHOP EXPENSES -2,433. TEMPORARILY RESTRICTED CONTRIBUTIONS 24,666. VENDING MACHINE EXPENSES -4,468. PART XII, LINE 2D - OTHER ADJUSTMENTS: GIFT SHOP EXPENSES 2,433. VENDING MACHINE EXPENSES 4,468. A MORTON COUNTY NORTH DAKOTA 456002226 2017-08-04 20470000 FUND PURCHASE OF MILLER POINTE IN MANDAN, ND 0 0 0 A 178883 20470000 368253 20101747 2017 0 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 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 HAS BEEN COMPENSATED $2,183,077 FOR MANAGEMENT SERVICES RENDERED IN 2017. 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 REVIEWED AND APPROVED BY 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 BOARD WILL FOLLOW THE STEPS IDENTIFIED IN THE CONFLICT OF INTEREST POLICY. 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 5,220,473. MANAGEMENT AND GENERAL EXPENSES 384,771. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,605,244. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 44,141. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 44,141. MAINTENANCE CONTRACTS: PROGRAM SERVICE EXPENSES 102,838. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 102,838. PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 8,987. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,987. FORM 990, PART XI, LINE 9: EQUITY TRANSFER - THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY 10,224,889. EQUITY TRANSFER - SANFORD LIVING CENTERS 10,224,889.