2014-11-04T09:14:41-06:00 2013-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2013-01-01 391209707 BETHEL HOME INC BETH 9202354653 225 NORTH EAGLE STREET OSHKOSH WI 54902 THERESA M BERTRAM PRESIDENT & CEO 9202325238 2014-10-16 1 CORY RUTLEDGE P01329381 6123764500 2013 2015-11-30 17:44:51Z THERESA M BERTRAM 225 NORTH EAGLE STREET OSHKOSH WI 54902 10942395 0 9386 X WWW.LUTHERANHOMES.COM X 1966 WI TO PROVIDE NURSING CARE FOR AGING PERSONS. 14 14 266 83 0 0 83147 258336 10698668 10484131 10095 9815 585943 190113 11377853 10942395 2637998 4500 0 0 7313350 7137021 0 0 0 4607909 4109353 14559257 11250874 -3181404 -308479 7101000 6600655 2089500 1897634 5011500 4703021 BETHEL HOME IS PART OF A FAMILY OF HEALTHCARE AND RESIDENTIAL SERVICE ORGANIZATIONS COMMITTED TO PROVIDING QUALITY CARE AND LIFE ENRICHING OPPORTUNITIES TO THE AGING AND THOSE IN NEED IN A CARING, CHRISTIAN ENVIRONMENT. 0 0 9646997 4500 10484131 BETHEL HOME, INC., OPERATES A 150-BED NURSING HOME PROVIDING SKILLED AND INTERMEDIATE NURSING CARE FOR THE AGED AND DISABLED OF OSHKOSH AND THE SURROUNDING AREA. THE HOME ALSO OPERATES A 12-BED DEMENTIA-SPECIFIC COMMUNITY-BASED RESIDENTIAL FACILITY. 9646997 1 1 0 0 0 0 0 0 1 0 1 0 0 1 1 1 0 1 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 1 0 0 0 1 22 0 266 1 0 0 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 X KIM MAKI 9202325238 225 NORTH EAGLE STREET OSHKOSH WI 54902 LOIS JAENKE CHAIR 0.20 1.40 X X 0 0 0 JIM STAPEL VICE CHAIR 0.20 1.40 X X 0 0 0 DR JAN EDELSTEIN SECRETARY 0.20 1.40 X X 0 0 0 MARK BEECHER BOARD MEMBER 0.20 1.40 X 0 0 0 KATHLEEN BELLAIRE BOARD MEMBER 0.20 1.40 X 0 0 0 THOMAS DUNHAM BOARD MEMBER 0.20 1.40 X 0 0 0 KAREN FREDRICK BOARD MEMBER 0.20 1.40 X 0 0 0 DR ROGER HEROLD BOARD MEMBER 0.20 1.40 X 0 0 0 REV RICK HOPKINS BOARD MEMBER 0.20 1.40 X 0 0 0 REV KAREN JEWELL BOARD MEMBER 0.20 1.40 X 0 0 0 GEORGE KONTOS BOARD MEMBER 0.20 1.40 X 0 0 0 JANE KUHN BOARD MEMBER 0.20 1.40 X 0 0 0 DR SUZANNE MARNOCHA BOARD MEMBER 0.20 1.40 X 0 0 0 WAYNE MUELLER BOARD MEMBER 0.20 1.40 X 0 0 0 THERESA BERTRAM PRESIDENT & CEO 4.50 36.00 X 0 190313 7014 JULIE VANDENBERG CORPORATE SECRETARY 4.50 36.00 X 0 70061 6051 GERARD BODALSKI VP HEALTHCARE SERVICES 40.00 0.00 X 115000 0 10249 115000 260374 23314 1 0 1 0 VALLEY-BAY THERAPY 3305 N BALLARD RD APPLETON WI 54911 THERAPY SERVICES 611600 LUTHERAN HOMES OF OSHKOSH INC 225 NORTH EAGLE STREET OSHKOSH WI 54902 MANAGEMENT SERVICES 565152 SYSCO FOODS ONE SYSCO DRIVE JACKSON WI 53037 FOOD SERVICES 360506 WISCONSIN DEPARTMENT OF HEALTH 1 WEST WILSON STREET MADISON WI 53702 HEALTH SERVICES 306000 OTIS ELEVATOR 2247 PROGRESS WAY KAUKAUNA WI 54130 ELEVATOR CONTRACT 143193 5 29358 228978 258336 RESIDENT REVENUE 623000 10484131 10484131 10484131 3341 3341 12000 0 12000 12000 12000 6474 0 6474 6474 6474 CPE 900099 100550 100550 MEAL REVENUE 900099 62428 62428 MISCELLANEOUS REVENUE 900099 11785 11785 3350 3350 178113 10942395 10484131 0 199928 4500 4500 5908094 5603272 304822 146858 139281 7577 655719 621888 33831 426350 404353 21997 565152 565152 6755 6755 80219 2021 78198 680645 678968 1677 9313 9313 988204 946326 41878 31657 31657 424787 422596 2191 14465 12454 2011 16400 16400 499897 499897 149129 149129 BED ASSESSMENT 306000 306000 BAD DEBT 155000 155000 EMPLOYEE EDUCATION 89361 89361 REPAIRS & MAINTENANCE 26263 26263 66106 37528 28578 11250874 9646997 1603877 0 23837 28310 930635 1016882 820538 749647 74863 52330 52795 25043 14952537 11819600 3403533 3132937 112950 113801 92699 92699 2580 265 1586570 1388741 7101000 6600655 1032327 1100377 23667 620000 315000 78779 87951 55093 245000 245000 89727 94213 2089500 1897634 X 4918801 4610322 92699 92699 5011500 4703021 7101000 6600655 -308479 0 X 0 1 X 1 0 X 155988 182434 72431 83147 258366 752366 14386347 13263600 10988783 10698668 10484131 59821529 14542335 13446034 11061214 10781815 10742497 60573895 0 0 0 60573895 90835 49160 29326 20895 15341 205557 90835 49160 29326 20895 15341 205557 155963 187543 184298 573943 178113 1279860 14789133 13682737 11274838 11376653 10935951 62059312 0.97610 0.97660 0.00330 0.00520 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: TRAINING REVENUE MEAL REVENUE MISCELLANEOUS INCOME TRANSPORTATION INCOME OTHER INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 26261 26261 8302063 6458381 1843682 435091 367467 67624 6115424 4993752 1121672 73698 73698 3132937 DUE FROM AFFILIATES 1294854 RESIDENTS' CUSTODIAL ACCOUNTS 93887 1388741 ASSET RETIREMENT OBLIGATIONS 94213 94213 X PART IV, LINE 2B: RESIDENTS' CUSTODIAL ACCOUNTS CONSIST OF AMOUNTS ON DEPOSIT WITH BETHEL HOME BY RESIDENTS FOR SAFEKEEPING. THESE FUNDS CAN BE WITHDRAWN AT ANY TIME BY RESIDENTS. PART X, LINE 2: THE ORGANIZATION IS EXEMPT FROM INCOME TAXES PURSUANT TO SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ENTITY IS NOT A PRIVATE FOUNDATION, AND CONTRIBUTIONS TO THE ORGANIZATION QUALIFY AS CHARITABLE TAX DEDUCTIONS BY THE CONTRIBUTOR. THE ORGANIZATION FOLLOWS THE ACCOUNTING STANDARDS FOR CONTINGENCIES IN EVALUATING UNCERTAIN TAX POSITIONS. THE ORGANIZATION FILES INFORMATIONAL RETURNS AS A TAX-EXEMPT ORGANIZATION. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE INFORMATIONAL RETURNS FOR THE YEARS 2009 TO 2012 ARE OPEN TO EXAMINATION BY THOSE AUTHORITIES. 0 0 0 0 0 0 0 0 0 THERESA BERTRAM PRESIDENT & CEO 0 187500 0 0 0 2813 0 3036 0 3978 0 197327 0 0 PART I, LINE 3 THE COMPENSATION OF THE PRESIDENT & CEO IS DETERMINED BY THE ORGANIZATION'S SOLE MEMBER, LUTHERAN HOMES OF OSHKOSH, INC. THE FOLLOWING METHODS WERE USED BY LUTHERAN HOMES OF OSHKOSH, INC. TO ESTABLISH THE PRESIDENT & CEO'S COMPENSATION: 1. COMPENSATION SURVEY OR STUDY 2. APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS OF THE BOARD OF DIRECTORS PLUS TWO OTHER MEMBERS OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL BE RESPONSIBLE FOR THE AGENDA FOR THE BOARD AND VOTING MEMBERSHIP MEETINGS. THIS COMMITTEE SHALL KEEP ITSELF INFORMED OF THE ENTIRE OPERATION OF THE CORPORATION AND ITS SUBSIDIARY CORPORATIONS, AND SHALL EXECUTE SUCH ACTIONS AS MAY BE ASSIGNED TO IT BY THE BOARD. THE COMMITTEE SHALL ALSO CONCERN ITSELF WITH MATTERS NOT ASSIGNED TO OTHER COMMITTEES. FORM 990, PART VI, SECTION A, LINE 6 LUTHERAN HOMES OF OSHKOSH, INC., IS THE SOLE MEMBER OF BETHEL HOME, INC. FORM 990, PART VI, SECTION A, LINE 7A THE DIRECTORS OF BETHEL HOME, INC. ARE ELECTED BY THE BOARD OF DIRECTORS OF THE SOLE MEMBER, LUTHERAN HOMES OF OSHKOSH, INC. FORM 990, PART VI, SECTION A, LINE 7B MAJOR STANDARD OPERATING PROCEDURES, MAJOR POLICIES, AND PROGRAMS OF BETHEL HOME, INC. ARE SUBMITTED TO THE BOARD OF DIRECTORS OF THE SOLE MEMBER, LUTHERAN HOMES OF OSHKOSH, INC., FOR APPROVAL AND IMPLEMENTATION. AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS REQUIRE THE APPROVAL OF THE BOARD OF DIRECTORS OF THE SOLE MEMBER, LUTHERAN HOMES OF OSHKOSH, INC. FORM 990, PART VI, SECTION B, LINE 11 BEFORE IT WAS FILED, THE FORM 990 WAS REVIEWED BY THE CEO, THEN DISTRIBUTED TO EACH MEMBER OF THE BOARD OF DIRECTORS FOR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, THE CORPORATE SECRETARY DISTRIBUTES A CONFLICT OF INTEREST FORM TO EACH MEMBER OF THE BOARD OF DIRECTORS AND VARIOUS COMMITTEE MEMBERS NOT ON THE BOARD THAT REQUIRES EACH TO IDENTIFY POTENTIAL CONFLICTS OR OTHER RELATED PARTY INTERESTS. THE REPORTS ARE REVIEWED BY THE SECRETARY AND CEO AND ANY CONFLICTS ARE BROUGHT TO THE BOARD'S ATTENTION. A MEMBER OF THE BOARD WHO HAS A CONFLICT OF INTEREST MAY NOT VOTE ON ANY SUCH ISSUE BEFORE THE BOARD. ANY QUESTION OF WHETHER THERE IS A CONFLICT IS RESOLVED BY THE BOARD OF DIRECTORS. IF THE BOARD OF DIRECTORS DETERMINES THAT A DIRECTOR HAS COMMITTED A SUBSTANTIAL VIOLATION OF THE CONFLICT OF INTEREST POLICY, THE INDIVIDUAL IS REMOVED FROM THE OFFICE OF DIRECTOR. IN ADDITION, ALL MANAGEMENT AND SUPERVISORY EMPLOYEES ARE INFORMED OF THE ORGANIZATION'S POLICY REGARDING RELATED PARTY TRANSACTIONS AND CONFLICTS OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15A CEO COMPENSATION IS DETERMINED BY A COMMITTEE OF THE BOARD OF DIRECTORS. THE COMMITTEE CONSIDERS COMPARABLE DATA AND ECONOMIC CONDITIONS. THE DELIBERATIONS ARE RECORDED. OTHER OFFICER AND SENIOR MANAGEMENT SALARIES ARE DETERMINED BY THE CEO, WITHOUT CONFLICT, IN CONJUNCTION WITH THE HUMAN RESOURCES MANAGER AND ARE BASED ON COMPARABLE DATA, PERFORMANCE MEASURES, AND OTHER ECONOMIC CONDITIONS. THIS PROCESS LAST OCCURRED IN 2012 FOR THE CEO AND FOR ALL OTHER OFFICERS AND SENIOR MANAGEMENT. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 990 IS AVAILABLE UPON REQUEST AND IS ALSO AVAILABLE AT WWW.GUIDESTAR.ORG. THE ORGANIZATION'S FORM 1023 IS ALSO AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. LUTHERAN HOMES OF OSHKOSH INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 391032234 MANAGEMENT SERVICES WI 501(C)(3) LINE 9 N/A 0 CARMEL RESIDENCE INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 391448325 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 GABRIEL'S VILLA INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 391857036 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA APARTMENTS INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 237148097 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA SOUTH INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 391238670 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 SIMEANNA III INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 391270056 SENIOR HOUSING WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 BETHEL FOUNDATION OF OSHKOSH INC 225 NORTH EAGLE STREET OSHKOSH WI 59402 010938793 FUNDRAISING WI 501(C)(3) LINE 11A, I LUTHERAN HOMES OF OSHKOSH INC 0 EDEN REHABILITATION SUITES AND GREENHOUSE HOMES INC 3151 EDEN COURT OSHKOSH WI 54902 900506872 SKILLED NURSING FACILITY WI 501(C)(3) LINE 9 LUTHERAN HOMES OF OSHKOSH INC 0 0 0 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 0 0