2017-02-09T19:05:31-06:00 2016-03-31 460403496 CASEY PETERSON LTD 909 ST JOSEPH ST SUITE 101 RAPID CITY SD 57701 990 2015-04-01 450411825 WEST RIVER HEALTH SERVICES FOUNDATION WEST 7015674561 1000 HIGHWAY 12 HETTINGER ND 58639 Nathan Stadheim CFO 7015674561 2017-02-09 1 DEIDRE BUDAHL CPA P01273830 6053481930 2017-02-09 2015 2021-01-29 14:40:06Z JIM K LONG 1000 HIGHWAY 12 HETTINGER ND 58639 1330886 0 X WWW.WRHS.COM X 1982 ND SUPPORT WEST RIVER HEALTH SERVICES BY PROVIDING FUNDRAISING AND DEVELOPMENT SERVICES. 11 11 0 0 0 0 302347 514659 0 0 161330 140189 53691 67131 517368 721979 77371 583438 0 0 0 1012 0 0 164965 159520 815144 236891 1399594 280477 -677615 7618520 6681381 2399519 2246789 5219001 4434592 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 583438 583438 53673 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 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 VISION OF ENSURING QUALITY HEALTH AND LONG-TERM CARE SERVICES TO THE CITIZENS OF THE REGION. 583438 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 4 0 1 0 0 0 0 0 0 0 0 0 0 0 X 11 11 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 DENNIS RUSTAN CHAIRMAN 1.00 X X 150 0 0 Dr John Joyce MEDICAL STAFF LIASON 1.00 X 0 0 0 LOIS EGGEBO Secretary/Treasurer 2.00 X X 70 0 0 CHUCK CHRISTMAN Vice Chair 2.00 X X 70 0 0 LINDA WEAVER wrHSF REPRESENTATIVE 1.00 X 90 0 0 ROGER GOODFELLOW WRHSF REPRESENTATIVE 1.00 X 40 0 0 JOHN SCHERBENSKE WRHSF REPRESENTATIVE 1.00 X 40 0 0 CRAIG SILKMAN WRHSF REPRESENTATIVE 1.00 X 60 0 0 MATT BARNES WRHSF REPRESENTATIVE 1.00 X 40 0 0 MIKE MELLMER WRHSF REPRESENTATIVE 1.00 X 20 0 0 MARK RESNER WRHSF REPRESENTATIVE 1.00 X 0 0 0 Jim Long CEO/PRESIDENT 1.00 39.00 X 0 163529 21400 Nathan Stadheim CFO 2.00 38.00 X 0 91189 18263 580 254718 39663 0 0 1 0 West River Regional Medical Center 1000 Highway 12 Hettinger ND 58639 management services 295896 1 514659 514659 111536 111536 61588 7915 53673 53673 53673 622793 594140 28653 28653 28653 20310 6852 13458 13458 721979 53673 0 153647 572438 572438 11000 11000 1012 1012 7397 7397 21379 21379 33999 33999 111374 9057 102317 12990 12990 7104 2480 4624 1577 1577 7683 7640 43 800 800 1426 1426 Provision for Bad debt- 600000 600000 ANNUITY EXPENSE 9000 9000 DONOR RECOGNITION 415 415 1399594 583438 651191 164965 95586 38911 95087 197678 2386 137 130 659612 15755 644657 643857 5806430 5492544 144881 83774 829493 224350 7618520 6681381 160 11589 9785 22184 2389574 2213016 2399519 2246789 X 4390407 3658051 769989 696556 58605 79985 5219001 4434592 7618520 6681381 X -677615 -106790 -4 X X 0 1 X 1 0 X X 2 WEST RIVER HEALTH SERVICES 450340688 3 1 536683 0 WESTERN HORIZONS LIVING CENTERS 260794602 9 1 29302 0 2 565985 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 ORGANIZATION 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 271614 23103 1776 11000 1092 284401 223521 41890 13362 5500 1659 271614 624990 18533 12778 7000 424965 815 223521 658226 109701 17359 33309 124475 2512 624990 1813821 274718 8150 1400000 38463 658226 1.00000 0.00000 0 0 633264 633264 26348 15755 10593 643857 DEFERRED COMPENSATION 2078986 ANNUITY PAYABLE 63399 DUE TO RELATED PARTY 7002 LIFE INSURANCE PAYABLE 63629 2213016 X 626627 -106790 -106790 733417 -11438 -11438 721979 1411032 11438 11438 1399594 0 1399594 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 DAKTOA 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 2012. Part XI, Line 4b - Other Adjustments: rent expense -7,915. Fundraising Direct Expense -3,523. Part XII, Line 2d - Other Adjustments: rent expense 7,915. Fundraising Direct Expense 3,523. Fun Run 20310 20310 6852 20310 20310 6852 6852 13458 1 WEST RIVER HEALTH SERVICES 1000 HIGHWAY 12 HETTINGER ND 58639 450340688 501(C)(3) 536683 SUPPORT Western Horizons Living Center 1000 HIGHWAY 12 hETTINGER ND 58639 260794602 501(C)(3) 29302 support MEDICAL SCHOLARSHIPS 15 11000 Part I, Line 2: THE GRANT FROM WEST RIVER HEALTH SERVICES FOUNDATION IS BEING MADE TO WEST RIVER HEALTH SERVICES, A RELATED ORGANIZATION. 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. 0 0 0 0 0 0 0 0 0 Jim Long CEO/PRESIDENT 0 163529 0 0 0 0 0 6000 0 15400 0 184929 0 0 Part I, Line 3 THE CEO COMPENSATION IS PAID AND DETERMINED BY A RELATED ORGANIZATION, WEST RIVER HEALTH SERVICES. THE COMPENSATION IS DETERMINED THROUGH THE USE OF: A COMPENSATION COMMITTEE CONSISTING OF THE EXECUTIVE 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 11 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 XI, line 9: Rounding -4. Form 990, Part XII, Line 2c: THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE OVERSIGHT OF THE AUDIT. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS. 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 9 WEST RIVER HEALTH SERVICES FOUNDATION 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 western horizons living centers B 29302 cash paid west river health services B 536683 cash paid west river health services P 128522 cash paid west river health services D 8055 loan agreement western horizons living centers D 634356 loan agreement west river health services E 38844 loan agreement