2017-05-15T13:36:36-07:00 2016-12-31 990 2016-01-01 381366927 Holland Home HOLL 6162355015 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 Hermina Breuker CEO 6162355005 2017-05-08 50.200.18.74 2016 2021-01-29 14:40:06Z Hermina Breuker 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 76776428 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. 14 13 1456 510 1102 1102 3144724 7049198 60587159 62310981 187746 392636 233091 144525 64152720 69897340 0 0 0 0 32314718 35567579 2486 1513 716373 30953868 31917794 63271072 67486886 881648 2410454 229618100 232447095 235760458 230139904 -6142358 2307191 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 0 60371165 0 62309879 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 $2.1 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 $6.3 million in 2016. The organization provides uncompensated costs of private rooms to most of the 110 residents on Medicaid. 0 0 0 60371165 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 1 0 0 0 0 1 1 1 0 0 1 46 0 1 1456 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 X 14 13 0 0 0 0 1 0 1 1 1 0 0 0 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 295582 0 18170 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 Bruce Neckers 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 David Tiesenga Chief Financial Officer 50 0 X 254839 0 21251 H David Claus President Emeritus 32 0 X 364345 0 22506 Dr John Mulder Chief Medical Consultant 50 0 X 309896 0 1125 Carolyn Flietstra Executive VP, Home and Community Services 50 0 X 161735 0 3831 Troy Vugteveen Executive VP, Operations 50 0 X 141487 0 3517 Jeff Engle VP, Information Technology 50 0 X 132190 0 3341 Doug Himmelein VP, Human Resources 50 0 X 117037 0 1233 1777111 0 74974 14 0 1 0 Morrison Services 39395 W 12 Mile Rd Farmington Hills MI 48331 dietary services 3794232 Erhardt Construction Co 6060 Fulton Street East Ada MI 49301 construction services 2035926 RehabCare Group Inc PO Box 503534 St Louis MO 63150 rehabilitation therapy services 957964 Foster Swift Collins and Smith PC 313 S Washington Square Lansing MI 48933 legal services 396129 Authenticity Marketing Group 70 Ionia SW Suite 502 Grand Rapids MI 49503 marketing consulting services 256494 10 0 0 37825 0 0 7011373 4700000 7049198 HFA, AFC and Independent Living 623311 21140508 21140508 0 0 Medicare / Medicaid 623311 10445531 10445531 0 0 Skilled Nursing 623311 11273536 11273536 0 0 Amortization of Endowments 623311 6872488 6872488 0 0 Ancillary Revenue 623311 724991 724991 0 0 11853927 11852825 1102 0 62310981 408371 0 0 408371 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6761976 0 6777711 0 -15735 0 -15735 0 0 -15735 245902 37825 101377 144525 0 144525 0 0 0 0 0 0 0 0 0 0 0 0 0 69897340 62309879 1102 537161 0 0 0 0 0 0 914766 0 914766 0 0 0 0 0 27647000 25368810 1808164 470026 1838756 1534888 275430 28438 3065976 2723227 292294 50455 2101081 1866199 200306 34576 324240 168925 152315 3000 208151 2970 205181 0 96599 0 96599 0 0 0 0 0 1513 1513 58820 0 58820 0 0 0 0 0 1008592 982312 26280 0 1520800 1334005 162045 24750 678921 104963 573958 0 0 0 0 0 4685234 4335871 349363 0 262374 183210 67274 11890 0 0 0 0 60361 31637 22298 6426 6231484 6231484 0 0 0 0 0 0 7246691 6849086 397605 0 514164 480414 33750 0 Purchased Services 4770355 4716674 425 53256 Medicaid Quality Assurance Fees 1693843 1693843 0 0 Medical Supplies 900666 900666 0 0 Bad Debt 195439 195439 0 0 1461060 666542 762475 32043 67486886 60371165 6399348 716373 1084074 1823191 8563016 7718944 5523045 1060000 2915292 2871932 0 0 0 0 4757607 3452478 280625 281790 375184 210670 262489115 93327739 166228362 169161376 23591318 15380856 0 0 12215146 13003377 0 0 4084431 17482481 229618100 232447095 30203201 8365935 0 0 37462767 37168721 105197081 110644116 0 0 0 0 0 0 3430000 1895066 59467409 72066066 235760458 230139904 X -11665403 1247191 5523045 1060000 0 0 -6142358 2307191 229618100 232447095 X 2410454 689727 0 0 0 5349368 X 0 1 X 1 0 X 2567214 2648707 3294775 3144724 7046198 18701618 55784173 57098359 58721435 60587159 62310981 294502107 58351387 59747066 62016210 63731883 69357179 313203725 313203725 495718 1009991 323090 469364 408371 2706534 495718 1009991 323090 469364 408371 2706534 58847105 60757057 62339300 64201247 69765550 315910259 0.99143 0.9908 0.00857 0.0092 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 13985037 13985037 0 215928787 79983358 135945429 0 1080376 327979 752397 0 17220668 10119155 7101513 0 14274247 2897247 11377000 169161376 Interest in Net Assets of Charitable Foundation 13003377 F 13003377 Series 2016 Debt Service Reserve Fund 3511561 Series 2012 Debt Service Reserve Fund 4809227 Series 2016 Designed Project Fund 8060469 Assets Held for 457b Plan 675893 Invesment in Tandem365 and Others 275057 Split-Dollar Agreement Receivable 150274 17482481 Note Payable to Reliance CCP 1500000 Net Accrued Pension Cost 12061877 Fair Value of Interest Rate Swap Agreements 7758533 Mortgage Notes and Refundable Entrance Fees 50745656 72066066 62810985 689727 0 0 0 689727 62121258 0 7776082 7776082 69897340 66904443 0 0 0 0 0 66904443 0 582443 582443 67486886 Schedule D, Part XI, Line 4b Amount includes in revenues, not included in audited revenues include: $408,371 in investment income; ($15,735) in realized loss on sale of investments; ($101,377) in costs related to fundraising events; and $6,795,096 in receipt of contributions (both receipt of pledges receivable and releases from restriction), all net of unrealized gains on investments of $689,727. Schedule D, Part XII, Line 4b Amount includes $680,530 included in expenses related to loss on refinancing as well as reclassification of certain fundraising expenses, reclassified to revenues for Form 990 reporting purposes. Christmas Dinner 283727 37825 245902 0 1679 10012 52974 8000 28712 0 0 283727 37825 245902 0 1679 10012 52974 8000 28712 101377 144525 X 0 1 X X X 0 0 0 0 0 0 0 0 0 Hermina Breuker President/CEO, Director 295582 0 0 0 0 0 10918 0 7252 0 313752 0 0 0 David Tiesenga Chief Financial Officer 254839 0 0 0 0 0 15583 0 5668 0 276090 0 0 0 H David Claus President Emeritus 364345 0 0 0 0 0 16500 0 6006 0 386851 0 0 0 Dr John Mulder Chief Medical Consultant 309896 0 0 0 0 0 1125 0 0 0 311021 0 0 0 Carolyn Flietstra Executive VP, Home and Community Services 161735 0 0 0 0 0 3831 0 0 0 165566 0 0 0 Schedule J, Part I, Line 1a The CFO is reimbursement on a monthly basis for health club dues that are paid for personally. Schedule J, Part I, Line 1b The CFO is reimbursement 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 515000 0 50278251 4753186 0 0 1001816 0 0 0 45435529 0 2005 1 0 1 1 B 1545834 0 23590000 0 0 0 0 0 0 0 23590000 0 2005 1 0 1 1 C 0 0 32187291 2579644 0 0 651160 0 0 0 28956053 434 2005 1 0 1 1 D 0 0 9483642 876500 0 0 182258 0 0 364415 0 8060469 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 1 1 0 0 0 1 Wachovia 27.8 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 (8/2/2000, 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 6/11/2015 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. Carl VerBeek Director 110715 legal services 0 Mark Eriks Secretary, Director 254904 food supplies 0 Sister Myra Bergman Director 593759 pharmacy, physician and lab services 0 X 2 4700000 FMV 0 0 0 Schedule M, Part I The organization received, as contribution, the entire membership interest in Raybrook Limited Partners, as of December 31, 2016. The organization recorded total contributions in 2016 of $4,700,000 related to the assessed value of the single asset held by Raybrook Limited Partners, the corporate office of the organization located at 2100 Raybrook St SE Suite 300, Grand Rapids, Michigan. The asset was appraised within 30 days of receipt of the contribution. 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, philosophy, core values or mission of the corporation, (2) amend the Articles of Incorporation or Bylaws of the corporation, (3) make any change to the structure of operation 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 guaranty, (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. The completion of the Form is reported to the organization's Finance Committee, which is given opportunity to review the form subsequent to its submission to the Internal Revenue Service. If there is believed to be a subsequent material modification from a previously submitted Form 990, the Committee would be notified of such a change. 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 primarily 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 Amount of other adjustments includes the following: transfers from affiliates: $9,362,096; pension-related changes other than net periodic benefit cost: ($414,990); change in fair value of interest rate swap agreements: $303,327; change in interest in net assets of the Foundation: $788,231; change in value of pledges receivable: ($4,689,296) 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 Home Health Care Agency of Holland Home 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 100 100 0 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 100 100 0 0 1 1 ECHO Group LLC dba Tandem365 2100 Raybrook St SE Suite 300 Grand Rapids MI 49546 Health Management MI N/A Related 20 20 0 0 1 0.2 1 0 1 1 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 Rehab Dimensions l 101136 set fee for management services Rehab Dimensions q 69708 reimbursement for expenses Home Health Care Agency of Holland Home l 737693 set fee for management services Home Health Care Agency of Holland Home p 490065 reimbursement for expenses Home Health Care Agency of Holland Home m 30576 services based upon set fee Rehab Dimensions s 554879 amount of receivable forgiveness Home Health Care Agency of Holland Home s 7220270 amount of receivable forgiveness Holland Home Foundation c 250000 analysis of benevolent need Trillium Institute l 45000 fixed monthly management fee Trillium Institute q 344773 reimbursement for expenses Trillium Institute r 500000 funding investment Reliance Community Care Partners l 949279 set fee for management services Reliance Community Care Partners e 1500000 amount of cash advanced Helpers of Holland Home l 56583 set management fee Helpers of Holland Home q 208138 reimbursement for expenses Helpers of Holland Home r 732047 amount of forgiveness Faith Hospice l 2182751 set fee for management services Faith Hospice s 414000 repayment of note payable Faith Hospice q 1409862 reimbursement for expenses Faith Hospice l 856026 amount paid for room and board Care Resources l 2756167 payment for room and board services Care Resources q 3733802 reimbursement for expenses ECHO Group LLC dba Tandem365 q 1480261 reimbursement for expenses Facility Management Services of Holland Home LLC q 150018 reimbursement for expenses