2018-05-10T15:42:23-07:00 2017-12-31 990 2017-01-01 381366927 Holland Home HOLL 6162355015 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 Hermina Breuker CEO 6162355005 2018-05-10 207.242.239.202 2017 2021-01-29 14:40:06Z Hermina Breuker 2100 Raybrook St SE Ste 300 Grand Rapids MI 49546 71072262 0 X www.hollandhome.org X 1892 MI Provide nursing, therapy, and benevolent services for aged residents in skilled nursing, dementia nursing, assisted living and independent living centers. 15 14 1360 687 5314 5314 7049198 1602889 62310981 61969332 392636 1557378 144525 -72033 69897340 65057566 0 0 0 0 35567579 36646211 1513 4477 683762 31917794 31118857 67486886 67769545 2410454 -2711979 232447095 234728433 230139904 230071435 2307191 4656998 X In fulfilling God's calling to serve others, the organization will serve 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 61349800 0 61964018 Provide nursing and residential care in three facilities located in the greater Grand Rapids, Michigan area to an average of approximately 1,570 residents each day in skilled nursing (approximately 220 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 approximately 20% or approximately 75 residents per day on average, which amounts to approximately $1.9 million in benevolence annually. In skilled nursing, the organization serves an average of 110 residents (50%) on Medicaid and 33 residents (15%) on Medicare. These services are provided at discounted rates, based upon contractual allowances. These contractual adjustments related to Medicaid & Medicare, reduce the organization's revenues by approximately $3.7 million in 2017. The organization provides uncompensated costs of private rooms to most of the 110 residents on Medicaid. 0 0 0 61349800 1 1 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 51 0 1 1360 1 1 1 0 0 0 0 1 1 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 Suite 300 Grand Rapids MI 49546 Hermina Breuker President/CEO, Director 50 0 X X 340110 0 22593 Susan Vogel-Vanderson Chairperson, Director 2 0 X X 0 0 0 Mary Ursul Vice-Chairperson, Director 2 0 X X 0 0 0 Mark Eriks Secretary, Director 2 0 X X 0 0 0 Gary Malburg Treasurer, Director 2 0 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 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 Sam Watson Director 2 0 X 0 0 0 Nelson Sanchez Director 2 0 X 0 0 0 David Tiesenga Chief Financial Officer 50 0 X 263262 0 25277 H David Claus President Emeritus 20 0 X 375014 0 66098 Dr John Mulder Chief Medical Consultant 50 0 X 321820 0 3449 Carolyn Flietstra Executive VP, Home and Community Services 50 0 X 163495 0 0 Troy Vugteveen Executive VP, Operations 50 0 X 156598 0 615 Jeff Engle VP, Information Technology 50 0 X 138535 0 0 Doug Himmelein VP, Human Resources 50 0 X 127666 0 49 1886500 0 118081 15 0 1 0 Erhardt Construction Co 6060 Fulton St E Ada MI 49301 construction services 7109376 Morrison Services 39395 W 12 Mile Rd Farmington Hills MI 48331 dietary services 3686817 RehabCare Group Inc PO Box 503534 St Louis MO 63150 rehabilitation therapy services 790251 Foster Swift Collins and Smith PC 313 S Washington Square Lansing MI 48933 legal services 272996 Authenticity Marketing Group 70 Ionia SW Suite 502 Grand Rapids MI 49503 marketing consulting services 357150 8 0 0 318469 0 0 1284420 0 1602889 HFA, AFC and Independent Living 623311 20651645 20651645 0 0 Medicare/Medicaid 623311 10026945 10026945 0 0 Skilled Nursing 623311 9993042 9993042 0 0 Amortization of Endowments 623311 6578923 6578923 0 0 Ancillary Revenue 623311 611828 611828 0 0 14106949 14101635 5314 0 61969332 659315 0 0 659315 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6761976 0 5863913 0 898063 0 898063 0 0 898063 78750 318469 150783 -72033 0 -72033 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 65057566 61964018 5314 1485345 0 0 0 0 0 0 0 0 914766 0 914766 0 0 0 0 0 28522162 26173637 1902238 446287 2156668 1836577 288775 31316 2849095 2533252 272648 43195 2203520 1959244 210869 33407 284274 169681 108608 5985 240875 5822 235053 0 141598 0 141598 0 0 0 0 0 4477 4477 64763 0 64763 0 0 0 0 0 935971 895502 40469 0 1560118 1393264 133796 33058 551117 110315 440802 0 0 0 0 0 5077992 4752535 325457 0 219261 163493 45229 10539 0 0 0 0 49585 29606 15546 4433 6086934 6086934 0 0 0 0 0 0 7556896 7117866 439030 0 547797 513899 33898 0 Purchased Services 4407781 4367160 42 40579 Medical Quality Assurance Fees 1508770 1508770 0 0 Medical Supplies 801529 801529 0 0 Bad Debt 269978 269978 0 0 813618 660736 122396 30486 67769545 61349800 5735983 683762 1823191 775698 7718944 7557807 1060000 702777 2871932 2194149 0 0 0 0 3452478 3501829 281790 216766 210670 195469 273300492 100501451 169161376 172799041 15380856 15903680 0 0 13003377 15394614 0 0 17482481 15486603 232447095 234728433 8365935 9552041 0 0 37168721 37913516 110644116 109105256 0 0 0 0 0 0 1895066 1699295 72066066 71801327 230139904 230071435 X 1247191 3954221 1060000 702777 0 0 2307191 4656998 232447095 234728433 X -2711979 744404 0 0 0 4317382 X 0 1 X 1 0 X 2648707 3294775 3144724 7046198 1602889 17737293 57098359 58721435 60587159 62310981 61969332 300687266 59747066 62016210 63731883 69357179 63572221 318424559 318424559 1009991 323090 469364 408371 659315 2870131 1009991 323090 469364 408371 659315 2870131 60757057 62339300 64201247 69765550 64231536 321294690 0.99107 0.99143 0.00893 0.00857 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 13985036 13985036 0 223583123 85772739 137810384 0 1080376 379159 701217 0 18083079 11077408 7005671 0 16568878 3272145 13296733 172799041 Beneficial Interest in Net Assets of Holland Home Foundation 15394614 F 15394614 Series 2016 Debt Service Reserve Fund 3605059 Series 2012 Debt Service Reserve Fund 4820330 Series 2016 Designated Project Fund 5809254 Assets Held for 457b Plan 847298 Investment in Tandem365 and Others 245001 Split-Dollar Agreement Receivable 159661 15486603 Note Payable to Reliance CCP 2500000 Net Accrued Pension Cost 11888218 Fair Value of Interest Rate Swap Agreements 6132708 Mortgage Notes and Refundable Entrance Fees 51280401 71801327 65540676 744404 0 0 150783 895187 64645489 0 412077 412077 65057566 67920328 0 0 0 150783 150783 67769545 0 0 0 67769545 Schedule D, Part XI, Line 2d Amount represents costs incurred related to fundraising events, which is included in revenues for purposes of the Form 990. Schedule D, Part XI, Line 4b Amount includes contribution of $310,000 received from Holland Home Foundation and $102,777 in restricted contributions (pledges) received. Schedule D, Part XII, Line 2d Amount of expenses related to fundraising event expenses have been excluded from expenses for purposes of the Form 990. Christmas Dinner 397219 318469 78750 0 0 25730 73315 29625 22113 0 0 397219 318469 78750 0 0 25730 73315 29625 22113 150783 -72033 X 1 1 X X X 0 0 0 0 0 0 0 0 0 Hermina Breuker President/CEO, Director 340110 0 0 0 0 0 12903 0 9690 0 362703 0 0 0 David Tiesenga Chief Financial Officer 263262 0 0 0 0 0 19167 0 6110 0 288539 0 0 0 H David Claus President Emeritus 375014 0 0 0 0 0 59039 0 7059 0 441112 0 0 0 Dr John Mulder Chief Medical Consultant 321820 0 0 0 0 0 3449 0 0 0 325269 0 0 0 Carolyn Flietstra Executive VP, Home and Community Services 163495 0 0 0 0 0 0 0 0 0 163495 0 0 0 Troy Vugteveen Executive VP, Operations 156598 0 0 0 0 0 615 0 0 0 157213 0 0 0 Schedule J, Part I, Line 1a The Chief Financial Officer is reimbursed on a monthly basis for health club dues that are paid for personally. 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 665000 0 50345395 4820330 0 0 1001816 0 0 0 45435529 0 1 0 1 1 B 2338750 0 23590000 0 0 0 0 0 0 0 23590000 0 1 0 1 1 C 665000 0 32197291 2579644 434 0 651160 0 0 0 28956053 0 1 0 1 1 D 0 0 9483642 876500 0 0 182258 0 0 2615630 0 5809254 1 0 1 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 1 1 0 0 0 1 Wachovia 27.8 1 0 0 B 0 1 1 0 0 0 0 0 0 C 0 1 1 0 0 0 0 0 0 D 0 1 1 0 0 0 0 0 0 A 0 B 0 C 0 Schedule K, Part I, Column f-06/29/2012 50,090,801 Econ Dev Corp of the City of Kentwood Refund prior bonds (8/2/2000, 8/31/2006, 10/3/2002) 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 agree to the issue price in Part I, Column E, due to investment earnings / market value fluctuations. 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 equal the summary of lines 4 - 12 due to transferred or replacement proceeds in line 4. Schedule K, Part IV, Line 2c-12/11/2014 23,590,000 Michigan Strategic Fund Date the rebate computation was performed: 6/11/2015. Note regarding the 6/11/2016 rebate computation: since the bond proceeds have been spent, a spending exception was met, and the debt service fund was operated on a bona fide basis, no further rebate calculations are necessary. Sister Myra Bergman Director 531971 pharmacy, physician & lab services 0 Mark Eriks Secretary, Director 266566 food supplies 0 Form 990, Part III, Line 3 In September 2017, as a result of strategic master planning efforts, Holland Home announced the cessation of admissions to skilled nursing and assisted living at Fulton Manor. Fulton Manor intends to reduce its skilled nursing census over the course of the remainder of 2017 and the first six months of 2018, with the objective of ceasing skilled nursing services by mid-2018. Additionally, Fulton Manor intends to transition existing assisted living residents, over the course of the next three years, to available assisted living units located on Holland Home's other campuses. 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 the Bylaws to the contrary, the approval of Christian Living Services as the member of the corporation is required to: (1) change the purpose, philosophy, 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 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 it must engage in activities which accomplish one or more of its tax-exempt purposes. 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 Change in interest in net assets of Holland Home Foundation: $2,391,237; Change in fair value of interest rate swap agreements: $1,625,825; Pension-related changes other then net periodic benefit cost: $351,618; Transfer from (to) affiliates: ($51,298) Christian Living Services 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 261126816 Admin Services MI 501(c)(3) 12b N/A 0 Faith Hospice 2100 Raybrook St SE Suite 300 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 Suite 300 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 Suite 300 Grand Rapids MI 49546 383337881 Rehabilitation Services MI 501(c)(3) 12b Christian Living Services 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 Atrio Home Health Lakeshore 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 814839696 Home Health Care MI 501(c)(3) 12b 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 Excluded 0 1 1 Facility Management Services of Holland Home LLC 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 Grounds Maintenance MI Holland Home Unrelated 0 1 1 ECHO Group LLC dba Tandem365 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 Health Management MI N/A Related 0 1 0.2 0 0 1 0 1 0 0 0 0 0 0 1 1 1 0 1 1 1 1 Holland Home Foundation c 310000 grant Reliance Community Care Partners e 1000000 additional cash advance Atrio Home Health l 450651 set fee based on service Atrio Home Care l 103995 set fee based on service Atrio Home Health Lakeshore l 66429 set fee based on service Reliance Community Care Partners l 891295 set fee based on service Care Resources l 1717136 set fee based on service Faith Hospice l 3333843 set fee based on service Trillium Institute l 45000 set fee based on service Helpers of Holland Home l 5888 set fee based on service Reliance Community Care Partners n 220930 facility rent Faith Hospice n 86934 facility rent Atrio Home Health n 41055 facility rent Atrio Home Care p 2561 reimbursement for expenses Atrio Home Care q 87283 reimbursement for expenses Atrio Home Health Lakeshore q 233003 reimbursement for expenses Care Resources q 4384354 reimbursement for expenses ECHO Group LLC dba Tandem365 q 1938586 reimbursement for expenses Facility Management Services of Holland Home LLC q 128805 reimbursement for expenses Faith Hospice q 1317557 reimbursement for expenses Trillium Institute q 320008 reimbursement for expenses Rehab Dimensions q 35688 reimbursement for expenses Helpers of Holland Home q 55161 reimbursement for expenses Atrio Home Health q 628822 reimbursement for expenses Faith Hospice r 10767 transfer of contributions Faith Hospice s 539050 payment on note payable Care Resources r 405 transfer of contributions Schedule R, Part I Raybrook Limited Partners became a related entity on December 31, 2016. The complete membership interest in the partnership was contributed to Holland Home. Raybrook Limited Partners holds the ownership of the corporate office (2100 Raybrook St SE). 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. ECHO Group, LLC (dba Tandem365) is not an exempt organization. Holland Home 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.