2014-02-10T11:25:06-06:00 2013-09-30 476097913 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2012-10-01 470841274 FAIRBURY ASSISTED LIVING FACILITY DBA CEDARWOOD FAIR 4027293351 828 22ND STREET FAIRBURY NE 68352 CHANCE KLASEK 4027293351 2014-02-03 1 JULIE M GERKEN P00400882 4023302660 2012 2015-11-30 17:44:51Z CHANCE KLASEK PO BOX 277 FAIRBURY NE 68352 1500783 0 X WWW.JCHCHEALTHCARE.ORG/CEDARWOOD-AL/ X 2001 NE CEDARWOOD ASSISTED LIVING PROVIDES 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 38 0 0 0 300 150 1443698 1500334 -1864 299 -57059 0 1385075 1500783 0 0 0 0 413826 427783 0 0 0 871385 945348 1285211 1373131 99864 127652 3279734 4322345 2966751 3881710 312983 440635 NONE - SEE PAGE 1 FOR DESCRIPTION OF ACTIVITIES. 0 0 1273810 1500334 CEDARWOOD ASSISTED LIVING FACILITY WAS CONSTRUCTED ADJACENT TO JEFFERSON COMMUNITY HEALTH CENTER (JCHC), A NEBRASKA NONPROFIT 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. 61 RESIDENTS WERE SERVED FROM OCTOBER 2012 THROUGH SEPTEMBER 2013. EIGHT OF THESE RESIDENTS QUALIFIED UNDER THE MEDICAID WAIVER PROGRAM. TOTAL DAYS OF CARE PROVIDED WERE 16,753. 1273810 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 38 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 PO BOX 277 FAIRBURY NE 68352 X X HOMER WARD 1.00 0.00 X X 0 0 0 KENNETH FOSTER 1.00 0.00 X X 0 0 0 CHANCE KLASEK 5.00 0.00 X X 0 0 0 RUSSELL GRONEWOLD 1.00 0.00 X X 0 0 0 RICK STANTON 1.00 0.00 X 0 0 0 SHIRLEY TRAVIS 1.00 0.00 X 0 0 0 CHAD JURGENS 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 410776 1 150 150 RESIDENT REVENUE 623000 749663 749663 MEDICARE/MEDICAID PAYM 623000 738817 738817 RENTAL INCOME 900002 11854 11854 1500334 299 299 1500783 1500334 0 299 X 368776 368776 27083 27083 31924 31924 75174 75174 11478 11478 373006 366696 6310 7444 7444 58682 56148 2534 157848 157848 1713 1713 235814 235814 19697 15872 3825 DUES & SUBSCRIPTIONS 4276 4276 BAD DEBT 216 216 1373131 1273810 99321 0 104511 352145 718811 469121 19525 16262 14966 20244 5590712 2182535 2365104 3408177 56817 56396 3279734 4322345 116737 190504 2795000 3626547 55014 64659 2966751 3881710 X 312983 440635 312983 440635 3279734 4322345 127652 0 X X 0 1 X 1 0 X 2390 300 300 150 3140 1305362 1356907 1399288 1443698 1500334 7005589 1307752 1357207 1399288 1443998 1500484 7008729 0 0 0 7008729 13564 5784 2895 2907 299 25449 13564 5784 2895 2907 299 25449 1321316 1362991 1402183 1446905 1500783 7034178 0.99640 0.99230 0.00360 0.00770 X 60427 60427 5230650 1942770 3287880 216081 172857 43224 83554 66908 16646 3408177 RESIDENT SECURITY DEPOSITS 64659 64659 X 1500783 0 1500783 0 1500783 1373131 0 1373131 0 1373131 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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, 2013, CEDARWOOD HAD NO UNCERTAIN TAX POSITIONS ACCRUED. CEDARWOOD IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR FISCAL YEARS ENDED PRIOR TO SEPTEMBER 30, 2010. A HOSPITAL AUTHORITY NO 1 OF JEFFERSON COUNTY NE 611683496 2012-01-18 2795000 REFI PRIOR BOND ISSUE (01/06/03) 0 0 0 A 260000 2795000 279500 55900 6556 2732544 2004 1 0 1 1 A 0 0 0 0 0 0 0 A 0 1 1 0 0 0 0 0 0 A 0 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 MEDICAL CENTER AND JEFFERSON COMMUNITY HEALTH CENTER, BOTH NEBRASKA NONPROFIT CORPORTIONS. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF THE CORPORATION, BRYAN MEDICAL CENTER, A NEBRASKA NONPROFIT CORPORATION, AND JEFFERSON COMMUNITY HEALTH CENTER, A NEBRASKA NONPROFIT 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 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, THE OFFICER IS REQUIRED TO SIGN THE "CONFLICT OF INTEREST STATEMENT." BY SIGNING THIS STATEMENT, THE TRUSTEE AGREES TO NOT USE HIS OR HER POSITION FOR PERSONAL PROFIT OR TO GAIN PERSONAL ADVANTAGE. THE TRUSTEE IS 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 TRUSTEE IS REQUIRED TO SUBMIT SUCH DISCLOSURE ON A CASE-BY-CASE BASIS. IT IS UNDERSTOOD THAT AFFILIATION WITH AN ORGANIZATION IS CONSIDERED TO EXIST WHEN A 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 TRUSTEE 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 AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. COMPENSATION 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. OTHER FEES FORM 990, PART IX, LINE 11G CONSULTING: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 6,310. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,310. OUTSIDE SERVICE - RESIDENT MEALS: PROGRAM SERVICE EXPENSES 349,858. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 349,858. OTHER: PROGRAM SERVICE EXPENSES 16,838. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 16,838. FORM 990, PART XII, LINE 2C: THERE HAVE BEEN NO CHANGES FROM THE PRIOR YEAR. 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. 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.