2013-08-01T13:35:54-05:00 2012-12-31 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2012-01-01 261087740 Bethany on 42nd BETH 7012393000 201 South University Drive Fargo ND 58103 Shawn Stuhaug 7012393000 2013-07-30 1 LISA CHAFFEE CPA P00193453 7012398500 2013-07-30 2012 2016-02-24 21:20:13Z Shawn Stuhaug 201 South University Drive Fargo ND 58103 9971825 0 X www.bethanynd.org X 2007 ND Provide long term care services 11 11 0 100 0 0 224894 300383 9449579 9645689 -718 -1382 29228 24778 9702983 9969468 0 0 0 0 5087365 5176649 0 0 0 4689856 4782820 9777221 9959469 -74238 9999 26987148 26973808 24366468 24405597 2620680 2568211 X To provide living opportunities in a senior community shaped by Christian values. 0 0 9209561 9645689 Bethany on 42nd operates as a charitable organization consistent with the requirements of Internal Revenue Code Section 501(c)(3). Bethany on 42nd provides long term care services including skilled nursing care, transitional care services, and senior housing with services. Bethany on 42nd does not discriminate against individuals in the admissions process or in the delivery of care with regard to ability to pay for services. The Organization's cash reserves are generally applied to expansion and replacement of existing facilities and equipment, amortization of mortgages, improvement in resident care, training and education, and community benefit activities. The governing board of Bethany on 42nd is made up of prominent leaders in the Fargo-Moorhead community. Volunteerism - coordinates a volunteer program that included 100 volunteers giving 5,750 hours of service, providing mental stimulation and emotional support to Bethany on 42's 118 residents and patients. Volunteers included members of sponsoring churches, experience works program volunteers, and many student volunteers from the community's schools - elementary, middle, high schools and colleges.Assessment and referral services - our staff help to refer individuals needing long term care services to the appropriate agency in the community. Bethany on 42nd's licensed social workers provide guidance with medical assistance applications for residents/families.Community support - Bethany on 42nd provides meeting room space and accommodations for non-profit organizations and community groups. Several of our resident activity programs are open to community members. Facility space is open to use by outside groups for meetings, performances, activities, funeral/memorials services, music recitals, etc. Meals are provided for family members of Bethany on 42nd residents at a reduced cost. Bethany on 42nd organizes employee participation in fundraising activities for United Way and the Alzheimer's Association. There are also representatives from Bethany on 42nd on non-profit boards and civic organizations that work to improve the quality of life in the Fargo-Moorhead area. Bethany's President/CEO serves on HERO's (Health Equipment Recycling Organization) Board of Directors and the Fargo Dome Finance Committee. He also serves as the Region VI Director on the Board of the North Dakota Long Term Care Association. Bethany's CFO serves on the Board of Hospice of the Red River Valley. The Senior Executive of Medicare/Contracted Services serves on the board for the National Association of Directors of Nursing Association (NADONA). He also serves on the Care Transitions Focus Group affiliated with Sanford Health Systems. Bethany's Senior Executive of Support Services is on the Dietetics Advisory Committee for North Dakota State University and the Advisory Board for the Culinary Arts Program at Minnesota State Moorhead. Bethany's Senior Executive of Resident Care serves on the Resident Issues Committee of the ND Long Term Care Association, the Partners Investing in Nursing consortium, and the Care Transitions Focus Group, a collaborative project with Sanford Health Systems. She also serves as Region VI Director for NADONA of ND. Bethany's Director of Social Services serves on the board of the Long Term Care Social Workers of ND.The following is specific information relating to Bethany on 42nd's care provided:Bethany on 42nd Skilled/TCU Care - services provided, 65 nursing home beds: 23,690 days of care, and 13 TCU beds: 4,366 days of care. Total Skilled/TCU employee hours - 250,682. (Total Expenses = 8,813,182)Bethany Gables - senior housing with services, 40 units - 13,567 days of care and 13,874 employee hours (total expenses = 1,142,877)Bethany on 42nd served approximately 454 individuals in 2012. 9209561 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 11 0 1 0 0 0 0 0 0 0 0 0 0 0 X 11 11 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 X Jane Kelly 7012393226 201 South University Drive Fargo ND 58103 X Mary Johnson 1.00 3.00 X X 0 0 0 Martha Leclerc 1.00 3.00 X X 0 0 0 Lloyd Smith 1.00 3.00 X X 0 0 0 Janice Nelson 1.00 3.00 X X 0 0 0 David Glatt 2.00 4.00 X X 3744 8256 0 Shannon Charpentier 1.00 3.00 X 0 0 0 Neal Eriksmoen 1.00 3.00 X 0 0 0 Robin Pratt 1.00 3.00 X 0 0 0 Harriette McCaul 1.00 3.00 X 0 0 0 Paul Wilson 1.00 3.00 X 0 0 0 Jerilynn Brantner-Adams 1.00 3.00 X 0 0 0 Jean Bokinskie 1.00 3.00 X 0 0 0 John Hertsgaard 1.00 3.00 X 0 0 0 Roger Olson 1.00 3.00 X 0 0 0 Shawn Stuhaug 23.00 27.00 X 0 216507 9640 Jane Kelly 20.00 30.00 X 0 151811 25357 3744 376574 34997 0 0 1 1 YHR Partners 420 Main Ave Moorhead MN 56560 Design of 42nd Skilled Expansion 336933 RehabCare Group Inc PO Box 503534 St Louis MO 631503534 Contract Therapy 192316 2 203151 97232 300383 Resident Service Rev 623000 9642259 9642259 Other Income 900099 3430 3430 9645689 975 975 24778 0 24778 24778 24778 2357 -2357 -2357 -2357 9969468 9645689 0 23396 3744 3744 4336710 3996343 340367 49834 40709 9125 470851 431009 39842 315510 290688 24822 41004 41004 639915 639915 680514 500860 179654 468832 468832 50553 50553 29563 24399 5164 991824 991824 1216035 1216035 99970 99970 Medical Supplies 362599 362599 Bad Debt Expense 192051 192051 Memberships 9718 9718 242 242 9959469 9209561 749908 0 874259 782879 916884 826825 84333 88845 77561 91995 27208447 3391661 23682558 23816786 298525 236057 1053028 1130421 26987148 26973808 646455 723431 15766928 15483838 3804 18491 347423 420232 7605662 7755801 24366468 24405597 X 2322155 2332154 298525 236057 2620680 2568211 26987148 26973808 X 9999 -62468 X 0 1 X 1 0 X 3644075 917669 1992 224894 300383 5089013 6900816 9449579 9645689 25996084 3644075 917669 6902808 9674473 9946072 31085097 0 237586 173925 89059 500570 237586 173925 89059 500570 30584527 19281 30153 25753 75187 19281 30153 25753 75187 3644075 917669 6922089 9704626 9971825 31160284 0.98150 0.00240 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 897206 897206 21558271 2344934 19213337 2729848 871060 1858788 2023122 175667 1847455 23816786 Related Party Payable 1674530 Related Entity Note Payable 6081271 7755801 X 9757696 0 9757696 211772 211772 9969468 9956064 -3405 -3405 9959469 0 9959469 Part IV, Line 2b: The Organization acts as custodian for the funds of the residents. These funds are included in cash and cash equivalents and a corresponding liability is included in accounts payable-trade in the financial statements. Resident trust funds totaled $3,804 at December 31, 2012. Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: Bethany on 42nd is a North Dakota nonprofit corporations located in Fargo, North Dakota and has been recognized by the Internal Revenue Service as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Organization is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Organization is subject to income tax on net income that is derived from business activities that are unrelated to their exempt purpose. The Organization has deteremined they are not subject to unrelated business income tax and have not filed an Exempt Organization Business Income Tax Return (Form 990-T) with the IRS. Bethany believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. Bethany would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 4b - Other Adjustments: Contributions recorded in fund balance for financial statement 208,367. Sales revenue recorded in expenses for financial statement 3,405. Part XII, Line 2d - Other Adjustments: Sales revenue recorded in expenses for financial statement -3,405. 0 0 0 0 0 0 0 0 0 David Glatt 3744 8256 0 0 0 0 0 0 0 0 3744 8256 0 0 Shawn Stuhaug 0 176348 0 40159 0 0 0 7078 0 2694 0 226279 0 0 Jane Kelly 0 126811 0 25000 0 0 0 6403 0 19060 0 177274 0 0 Supplemental Information Part III Part I, Line 3: The President/CEO is paid by a related organization which has a process in place for establishing compensation using methods identified in question 3. In conjuction with American Lutheran Homes, Inc. a related organization, Bethany on 42nd has an agreement with Sanford Health for Medical Director services provided by David Glatt. Compensation noted in Schedule J Part II is the fee paid to Sanford Health for his services provided to Bethany on 42nd. A Cass County North Dakota 456002205 2010-10-01 16000000 Construct & Equip Retirement Living Campus 0 0 0 B Cass County North Dakota 456002205 2012-08-28 3000000 Construct & Equip 38 Skilled Nursing Bed Addition & Small Kitchen Facility 0 0 0 A 16000000 137143 15862857 2010 0 0 1 1 B 3000000 59755 16317 2923928 0 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 1 0 0 0 0 0 0 1 B 0 1 0 0 1 0 0 0 1 A 0 B 0 Form 990, Part VI, Section A, line 2 The CEO, CFO and Board all have a business relationship with each other, as the CEO and CFO are employed by another related nonprofit of which the board members serve as well. The Board serves all of the related organizations listed on Schedule R. Form 990, Part VI, Section A, line 6 Bethany Homes, Inc. is the sole member of the Corporation. Form 990, Part VI, Section A, line 7a The Board of Directors is elected at the annual meeting of the Board of Trustees of the Member. The Member has the right to fill any vacancies that occur during the year. The Member may also remove any directors with or without cause. Form 990, Part VI, Section A, line 7b The following actions by the Board of Directors require the approval of the Board of Trustees of the Member: - Establishment of annual operating budget - Sale, lease or encumbrance of any corporation real property - Unbudgeted capital expenditures exceeding amounts for which the President/CEO is specifically authorized to approve Form 990, Part VI, Section A, line 8b There are no committees with the broad authority to act on behalf of the governing board. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the CFO and CEO and then provided to the Finance Committee for their review and approval. A draft copy of the Form 990 is provided to the board prior to filing. Form 990, Part VI, Section B, line 12c Board officers and directors, as well as officers of the Organization, complete a conflict of interest questionnaire on an annual basis. The Board reviews the conflicts to determine if a conflict exists. The individual with the conflict is required to abstain from voting if the conflict comes up in the board meeting where a decision needs to be made. This is a standing agenda item at each board meeting. Compensation for the CEO is paid by a related organization. That Organization has a process for determining compensation that includes review by the independent board using comparability data and substantiation of the deliberation and decision. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financial statements are available upon request. FORM 990, PART VII David Glatt serves as a board member 1 hour per week. He serves an additional two total hours per week as a Medical Director for Bethany on 42nd and American Lutheran Homes. Compensation shown on Part VII, Column D is compensation paid to Sanford Health for his services as Medical Director to Bethany on 42nd. Compensation shown on Part VII, Column E is compensation paid to Sanford Health for his services as Medical Director to American Lutheran Homes, Inc. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Decrease in Interest in Bethany Homes, Inc -62,468. American Lutheran Homes Inc 201 S University Drive Fargo ND 58103 450274012 Long-term care services, assisted living, independent living ND 501(c)(3) Line 9 Bethany Homes Inc 1 Bethany Home Health Care 201 S University Drive Fargo ND 58103 450433045 Promotion of health ND 501(c)(3) Line 9 Bethany Homes Inc 1 Bethany Homes Inc 201 S University Drive Fargo ND 58103 450394181 Fundraising ND 501(c)(3) Line 9 N/A 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 American Lutheran Homes Inc P 7803467 General Ledger Bethany Homes Inc C 163143 General Ledger American Lutheran Homes Inc C 129151 General Ledger American Lutheran Homes Inc E General Ledger