2017-08-14T08:33:25-05:00 2016-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2015-10-01 470841274 FAIRBURY ASSISTED LIVING FACILITY FAIR 4027293351 828 22ND STREET FAIRBURY NE 68352 CHANCE KLASEK SECRETARY 4027293351 2017-08-08 1 BARBARA J FAJEN P00400874 4023302660 2015 2021-01-29 14:40:06Z CEDARWOOD CHANCE KLASEK 2200 H STREET PO BOX 277 FAIRBURY NE 68352 1870088 0 X HTTPS://WWW.CEDARWOODAL.ORG/ X 2001 NE CEDARWOOD STRIVES TO PROVIDE THE HIGHEST QUALITY OF HOSPITALITY, SERVICES, ACTIVITIES, SECURITY, COMPANIONSHIP AND FREEDOM TO TENANTS IN A CARING AND LOVING ENVIRONMENT THAT THE TENANTS ARE PROUD TO CALL THEIR HOME. CEDARWOOD'S SERVICES ARE PROVIDED TO THE RESIDENTS OF JEFFERSON COUNTY. 6 6 41 15 0 0 100 675 1830191 1866344 3557 3069 9252 0 1843100 1870088 0 0 0 0 506716 602106 0 0 0 1034006 1101031 1540722 1703137 302378 166951 3611745 3421812 2762258 2406405 849487 1015407 TO PROVIDE THE HIGHEST QUALITY OF HOSPITALITY, SERVICES, ACTIVITIES, SECURITY, COMPANIONSHIP AND FREEDOM TO TENANTS IN A CARING AND LOVING ENVIRONMENT THEY ARE PROUD TO CALL HOME. 0 0 1577558 1866344 CEDARWOOD ASSISTED LIVING FACILITY WAS CONSTRUCTED ADJACENT TO JEFFERSON COMMUNITY HEALTH CENTER, INC. (JCHC), A NEBRASKA NON-PROFIT HOSPITAL EXEMPT FROM INCOME TAXES UNDER I.R.C. 501(C)(3). THE PURPOSE OF THE 50-UNIT FACILITY IS TO MEET AN IDENTIFIABLE COMMUNITY NEED IN THE FAIRBURY AREA, AND TO DEVELOP A MORE COMPREHENSIVE CONTINUUM OF HEALTH CARE THAT COMPLEMENTS THE HEALTH CARE SERVICES ALREADY AVAILABLE ON THE CAMPUS OF JCHC. SIXTY-THREE RESIDENTS WERE SERVED FROM OCTOBER 2015 THROUGH SEPTEMBER 2016. NINE OF THESE RESIDENTS QUALIFIED UNDER THE MEDICAID WAIVER PROGRAM. TOTAL DAYS OF CARE PROVIDED WERE 19,756. 1577558 1 0 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 0 0 41 1 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 0 0 0 0 X CHANCE KLASEK 4027296856 2200 H STREET PO BOX 277 FAIRBURY NE 68352 X X HOMER WARD CHAIRMAN 1.00 0.00 X X 0 0 0 BRYCE BETKE VICE CHAIRMAN 1.00 0.00 X X 0 0 0 CHANCE KLASEK SECRETARY 5.00 0.00 X X 0 0 0 RUSSELL GRONEWOLD TREASURER 1.00 0.00 X X 0 0 0 RICK STANTON BOARD MEMBER 1.00 0.00 X 0 0 0 CAROL FRIESEN BOARD MEMBER 1.00 0.00 X 0 0 0 CHAD JURGENS PRESIDENT/CEO 1.00 0.00 X 0 0 0 0 0 0 0 0 0 0 JEFFERSON COMMUNITY HEALTH CENTER INC 2200 H STREET PO BOX 277 FAIRBURY NE 68352 MANAGEMENT FEES AND OTHER CONTRACTED SER 532388 1 675 675 RESIDENT REVENUE 623000 1665168 1665168 MEDICAID PAYMENTS 623000 195426 195426 RENTAL INCOME 900002 5750 5750 1866344 3069 3069 1870088 1866344 0 3069 504903 504903 55601 55601 41602 41602 93318 93318 10225 10225 24491 9511 14980 6508 6508 97713 94693 3020 37044 37044 4039 4039 1472 1472 85065 85065 267216 267216 18319 14283 4036 RESIDENT MEALS 447068 447068 DUES & SUBSCRIPTIONS 5276 5276 BAD DEBT 3277 3277 1703137 1577558 125579 0 89100 172981 194681 193958 16599 9595 21060 23211 5666695 2958459 2967911 2708236 280204 279029 42190 34802 3611745 3421812 67188 51959 2000000 1725000 565739 507995 129331 121451 2762258 2406405 X 849487 1015407 849487 1015407 3611745 3421812 166951 -1031 0 X X 0 1 X 1 0 X 300 150 501 100 675 1726 1443698 1500334 1529002 1830191 1866344 8169569 1443998 1500484 1529503 1830291 1867019 8171295 0 0 0 8171295 2907 299 27466 12809 3069 46550 2907 299 27466 12809 3069 46550 1446905 1500783 1556969 1843100 1870088 8217845 0.99430 0.99400 0.00570 0.00600 X 60427 60427 5301054 2681060 2619994 221660 200474 21186 83554 76925 6629 2708236 RESIDENT SECURITY DEPOSITS 67296 DUE TO JEFFERSON COMMUNITY HEALTH CENTER 50652 PREPAID RENT 3503 121451 X 1869057 -1031 -1031 1870088 0 1870088 1703137 0 1703137 0 1703137 PART X, LINE 2: CEDARWOOD IS A NOT-FOR-PROFIT ORGANIZATION AS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND HAS RECEIVED A DETERMINATION LETTER THAT THEY ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN CEDARWOOD'S TAX EXEMPT STATUS. IN GENERAL, SUCH STANDARDS REQUIRE CEDARWOOD TO MEET A COMMUNITY BENEFITS STANDARD AND COMPLY WITH VARIOUS LAWS AND REGULATIONS. CEDARWOOD ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. CEDARWOOD RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT SEPTEMBER 30, 2016, CEDARWOOD HAD NO UNCERTAIN TAX POSITIONS ACCRUED. A HOSPITAL AUTHORITY NO 1 OF JEFFERSON COUNTY NE 611683496 2012-01-18 2795000 REFUND PRIOR BOND ISSUE (01/16/03) 0 0 0 A 1070000 2795000 279361 55900 6556 2732544 2004 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 1 1 0 0 0 0 0 1 A 1 PART II, LINE 3: THE TOTAL PROCEEDS DO NOT EQUAL THE SUMMATION OF LINES 4 - 12 DUE TO TRANSFERRED OR REPLACEMENT PROCEEDS IN LINE 4. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS OF THE CORPORATION ARE BRYAN HEALTH AND JEFFERSON COMMUNITY HEALTH CENTER, INC., BOTH NEBRASKA NON-PROFIT CORPORTIONS. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF THE CORPORATION, BRYAN HEALTH, A NEBRASKA NON-PROFIT CORPORATION, AND JEFFERSON COMMUNITY HEALTH CENTER, INC., A NEBRASKA NON-PROFIT CORPORATION, HAVE THE POWER TO APPOINT 3 TRUSTEES EACH, BOTH PERIODICALLY AND AS VACANCIES ARISE. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE 990 WILL BE E-MAILED TO EACH BOARD MEMBER. THE BOARD WILL REVIEW THE FORM 990 AT A REGULARLY SCHEDULED BOARD MEETING, WHICH DOES NOT NECESSARILY OCCUR PRIOR TO THE FILING OF FORM 990. FORM 990 IS REVIEWED BY MR. CHANCE KLASEK, BOARD SECRETARY, PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, OFFICERS AND TRUSTEES ARE REQUIRED TO SIGN THE "CONFLICT OF INTEREST STATEMENT." BY SIGNING THIS STATEMENT, THE OFFICERS AND TRUSTEES AGREE NOT TO USE HIS OR HER POSITION FOR PERSONAL PROFIT OR TO GAIN PERSONAL ADVANTAGE. THE OFFICERS AND TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING TO THE BOARD OF TRUSTEES ANY PERSON TO WHOM HE OR SHE IS CLOSELY RELATED OR ORGANIZATION WITH WHICH HE OR SHE IS AFFILIATED, WHO OR WHICH PRESENTLY TRANSACTS BUSINESS WITH THE CORPORATION OR MIGHT REASONABLY BE EXPECTED TO DO SO IN THE FUTURE. THE OFFICERS AND TRUSTEES ARE REQUIRED TO SUBMIT SUCH DISCLOSURE ON A CASE-BY-CASE BASIS. IT IS UNDERSTOOD THAT AFFILIATION WITH AN ORGANIZATION IS CONSIDERED TO EXIST WHEN AN OFFICER, TRUSTEE OR A MEMBER OF HIS OR HER IMMEDIATE FAMILY OR CLOSE RELATIVE IS AN OFFICER, DIRECTOR, PARTNER, EMPLOYEE OR AGENT OF THE ORGANIZATIONS OR OWNS 5% OF THE VOTING STOCK OR CONTROLLING INTEREST IN THE ORGANIZATION. THE OFFICERS AND TRUSTEES MUST ABSTAIN FROM VOTING ON ANY MOTION REGARDING THE DISCLOSED CONFLICT OF INTEREST. FORM 990, PART VI, SECTION C, LINE 19 FAIRBURY ASSISTED LIVING FACILITY'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII: CHAD JURGENS, PRESIDENT, AND CHANCE KLASEK, SECRETARY, ARE EMPLOYEES OF JEFFERSON COMMUNITY HEALTH CENTER, INC., AN UNRELATED ORGANIZATION THAT PROVIDES MANAGEMENT AND CLERICAL SERVICES FOR THE ORGANIZATION. THEREFORE, THE COMPENSATION IS PAID BY JEFFERSON COMMUNITY HEALTH CENTER, INC. AND IS INCLUDED IN PART IX, LINE 11A AS MANAGEMENT FEES. FORM 990, PART XII, LINE 2C: THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS SELECTS THE INDEPENDENT ACCOUNTANT AND HAS THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. UPON CONCLUSION OF THE AUDIT, THE AUDITING FIRM PRESENTS THE RESULTS AND FINDINGS TO THE FINANCE COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PART VI, SECTION B, LINE 14: THE ORGANIZATION DOES NOT HAVE A WRITTEN POLICY, BUT IT DOES MAINTAIN DOCUMENTS IN ACCORDANCE WITH FEDERAL AND STATE LAWS. FORM 990, PART VI, SECTION B, LINE 15: AS NO OFFICER IS PAID BY THIS ORGANIZATION, NO INDEPENDENT REVIEW OR APPROVAL PROCESS IS CONDUCTED BY THIS ORGANIZATION.