AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY: Form 990, tax year 2011

View the entire original 990 at ProPublica ↗

Organization
AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY (EIN 31-1608696)
Tax period
2011-10-01 to 2012-09-30
Filed
2013-08-14
IRS object ID
201322269349302517
Schema version
2011v1.5
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2013-08-14T12:58:37-05:00Timestamp
Tax Period End Date2012-09-30TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN410746749EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1CLIFTONLARSONALLEN LLPBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1220 SOUTH SIXTH STREET SUITE 300AddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55402ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2011-10-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN311608696EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEYBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlAUGUNameControl
Phone6122385225Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line11007 EAST 14TH STREETAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55404ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameCRAIG KITTELSONName
TitleVP - FINANCE/CFOTitle
Phone6122385225Phone
Date Signed2013-08-13DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameJEFF VRIEZEName
PTINP01273590PTIN
Phone6123764500Phone
FieldValueIRS element (for citing)
Tax Year2011TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonTIM TUCKERNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line11007 EAST 14TH STREETAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55404ZIPCode
FieldValueIRS element (for citing)
Gross Receipts17626633GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web SiteWWW.AUGUSTANACARE.ORGWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1998YearFormation
State Legal DomicileMNStateLegalDomicile
Activity Or Mission DescriptionTO PROVIDE HEALTH CARE, HOUSING AND COMMUNITY SERVICES FOR THE ELDERLY.ActivityOrMissionDescription
Nbr Voting Members Governing Body7NbrVotingMembersGoverningBody
Nbr Independent Voting Members7NbrIndependentVotingMembers
Total Nbr Employees363TotalNbrEmployees
Total Nbr Volunteers90TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year244200ContributionsGrantsPriorYear
Contributions Grants Current Year19934ContributionsGrantsCurrentYear
Program Service Revenue Prior Year22433010ProgramServiceRevenuePriorYear
Program Service Revenue CY17149505ProgramServiceRevenueCY
Investment Income Prior Year117602InvestmentIncomePriorYear
Investment Income Current Year319826InvestmentIncomeCurrentYear
Other Revenue Prior Year195181OtherRevenuePriorYear
Other Revenue Current Year137368OtherRevenueCurrentYear
Total Revenue Prior Year22989993TotalRevenuePriorYear
Total Revenue Current Year17626633TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year620402GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY270386GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year11285842SalariesEtcPriorYear
Salaries Etc Current Year9353366SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year11416577OtherExpensePriorYear
Other Expenses Current Year8484899OtherExpensesCurrentYear
Total Expenses Prior Year23322821TotalExpensesPriorYear
Total Expenses Current Year18108651TotalExpensesCurrentYear
Revenues Less Expenses Prior Year-332828RevenuesLessExpensesPriorYear
Revenues Less Expenses CY-482018RevenuesLessExpensesCY
Total Assets BOY42591294TotalAssetsBOY
Total Assets EOY23148046TotalAssetsEOY
Total Liabilities BOY41180667TotalLiabilitiesBOY
Total Liabilities EOY20469723TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY1410627NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY2678323NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTO SERVE GOD BY FOSTERING FULLNESS OF LIFE FOR OLDER ADULTS AND OTHER PEOPLE IN NEED THROUGH THE PROVISION OF HEALTH CARE, HOUSING AND OTHER SERVICES IN A CHRISTIAN TRADITION.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change1SignificantChange
Expense13968493Expense
Grants20386Grants
Revenue15176635Revenue
DescriptionAUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY IS A LICENSED CARE FACILITY WITH THE CAPACITY TO SERVE 188 PEOPLE AT A TIME. THE FACILITY OFFERS LONG-TERM CARE AND TRANSITIONAL CARE, AND THERAPEUTIC AND REHABILITATION SERVICES. DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2012, THE CARE CENTER SERVED 1,172 PEOPLE.Description

Activity2 Activity2

FieldValueIRS element (for citing)
Expense2185707Expense
Grants250000Grants
Revenue1972870Revenue
DescriptionAUGUSTANA REGENT AT BURNSVILLE IS A 148-UNIT APARTMENT COMMUNITY IN BURNSVILLE, MN PROVIDING RESIDENTS THE OPPORTUNITY TO AGE IN PLACE. AS RESIDENT'S NEEDS CHANGE, THEY CAN MOVE FROM INDEPENDENT TO ASSISTED LIVING, OR TO CARE SUITES OR MEMORY CARE. WHEN A HIGHER LEVEL OF PHYSICAL CARE IS NECESSARY, THE REGENT'S 18 CARE SUITES BRING MORE INTENSIVE NURSING SERVICES 24 HOURS A DAY TO RESIDENTS IN THE PRIVACY OF INDIVIDUAL APARTMENTS. THE REGENT'S MEMORY CARE SUITES BRING A PROFESSIONAL AND FOCUSED APPROACH FOR THOSE WITH MEMORY CHALLENGES WITHIN A SECURE RESIDENTIAL SETTING. ON JANUARY 25, 2012 AUGUSTANA REGENT WAS TRANSFERRED TO AUGUSTANA CARE.Description
FieldValueIRS element (for citing)
Total Program Service Expense16154200TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required0ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities0LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling1CreditCounseling
Term Or Permanent Endowments1TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets1ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote1ReportFin48Footnote
Independent Audit Financial Stmt0IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations1GrantsToOrganizations
Grants To Individuals1GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds1TaxExemptBonds
Invest Tax Exempt Bonds0InvestTaxExemptBonds
Escrow Account0EscrowAccount
On Behalf Of Issuer0OnBehalfOfIssuer
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation1PartialLiquidation
Disregarded Entity1DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transaction Related Entity0TransactionRelatedEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With10960NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees363NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members7NbrVotingGoverningBodyMembers
Number Independent Voting Members7NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties1DelegationOfManagementDuties
Changes To Organizing Docs1ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval1DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body1Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO0CompensationProcessCEO
Compensation Process Other0CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledMNStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

FieldValueIRS element (for citing)
Name PersonCRAIG KITTELSON - AUGUSTANA CARE SENamePerson
Telephone Number6122385225TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11007 EAST 14TH STREETAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55404ZIPCode
FieldValueIRS element (for citing)
Info In Schedule O Part VIIXInfoInScheduleOPartVII

Form990 Part VII Section A Form990PartVIISectionA (12 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorOfficerOfficerReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationKey EmployeeKeyEmployeeHighest Compensated EmployeeHighestCompensatedEmployee
REV DR GARY WILKERSON
CHAIR1.00XX000
MARSHALL MACKAY
VICE CHAIR1.00XX000
CHARLES PARKS JR
SECRETARY1.00XX000
ERIC RICK ELLINGSON
TREASURER1.00XX000
JIM EHLEN
DIRECTOR1.00X000
SCOTT RAMSDALE
DIRECTOR1.00X000
PR ELIZABETH BEISSEL
DIRECTOR1.00X000
TIM TUCKER
PRESIDENT/CEO4.50X031954754491
CRAIG KITTELSON
VP - FINANCE/CFO4.50X025383650711
TIM MIDDENDORF
VP - OPERATIONS/COO4.50X020590638163
KATHERINE KOPP
VP - NEW BUSINESS DEVELOPMENT4.50022178040457X
MICHAEL JOHNSON
VP - HUMAN RESOURCES0.00016264443788X
FieldValueIRS element (for citing)
Total Reportable Comp From Org0TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs1163713TotalReportableCompFrmRltdOrgs
Total Other Compensation227610TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources

Contractor Compensation ContractorCompensation

Name Of Contractor NameOfContractor

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1AUGUSTANA CARE SERVICESBusinessNameLine1

Address Of Contractor AddressOfContractor

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11007 EAST 14TH STREETAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55404ZIPCode
FieldValueIRS element (for citing)
Description Of ServicesMANAGEMENT SERVICESDescriptionOfServices
Compensation776644Compensation
FieldValueIRS element (for citing)
Number Of Contractors GT100 K1NumberOfContractorsGT100K
All Other Contributions19934AllOtherContributions
Total Contributions19934TotalContributions

Program Service Revenue ProgramServiceRevenue (2 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncome
NURSING FACILITIES6230001517663515176635
HOUSING FACILITIES62300019728701972870
FieldValueIRS element (for citing)
Total Program Service Revenue17149505TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column319826TotalRevenueColumn
Exclusion$319,826ExclusionAmount

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real25975Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real0Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real25975Real

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column25975TotalRevenueColumn
Exclusion$25,975ExclusionAmount

Other Revenue Misc OtherRevenueMisc (3 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnExclusionExclusionAmount
MISCELLANEOUS INCOME90009944708$44,708
DIETARY INCOME72221016921$16,921
TELEPHONE INCOME81290016723$16,723

Miscellaneous Revenue MiscellaneousRevenue

FieldValueIRS element (for citing)
Total Revenue Column33041TotalRevenueColumn
Exclusion$33,041ExclusionAmount
FieldValueIRS element (for citing)
Total Other Revenue111393TotalOtherRevenue

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column17626633TotalRevenueColumn
Related Or Exempt Function Income17149505RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$457,194ExclusionAmount

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total250000Total
Program Services250000ProgramServices

Grants To Domestic Individuals GrantsToDomesticIndividuals

FieldValueIRS element (for citing)
Total20386Total
Program Services20386ProgramServices

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total7866747Total
Program Services7447204ProgramServices
Management And General419543ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total107938Total
Program Services96784ProgramServices
Management And General11154ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total804360Total
Program Services709238ProgramServices
Management And General95122ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total574321Total
Program Services546736ProgramServices
Management And General27585ManagementAndGeneral

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total776644Total
Management And General776644ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total27598Total
Management And General27598ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total37198Total
Management And General37198ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total513598Total
Program Services478180ProgramServices
Management And General35418ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total32823Total
Management And General32823ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total269521Total
Program Services148512ProgramServices
Management And General121009ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total430327Total
Program Services430327ProgramServices

Travel Travel

FieldValueIRS element (for citing)
Total22655Total
Program Services8329ProgramServices
Management And General14326ManagementAndGeneral

Conferences Meetings ConferencesMeetings

FieldValueIRS element (for citing)
Total23012Total
Program Services18606ProgramServices
Management And General4406ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total1476170Total
Program Services1476170ProgramServices

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total960532Total
Program Services960532ProgramServices

Insurance Insurance

FieldValueIRS element (for citing)
Total142813Total
Management And General142813ManagementAndGeneral

Other Expenses OtherExpenses (4 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
NURSING SUPPLIES24152042415204
LICENSES, PERMITS, FEES56087155070410167
DIETARY EXPENSES532075532075
BAD DEBT EXPENSE171476171476

All Other Expenses AllOtherExpenses

FieldValueIRS element (for citing)
Total92382Total
Program Services65213ProgramServices
Management And General27169ManagementAndGeneral

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total18108651Total
Program Services16154200ProgramServices
Management And General1954451ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY2254313BOY
EOY1627009EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY2157091BOY
EOY1792711EOY

Other Notes Loans Receivable Net OtherNotesLoansReceivableNet

FieldValueIRS element (for citing)
BOY880002BOY
EOY1084916EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY122078BOY
EOY67937EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis16277078LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec3365855LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY32984980BOY
EOY12911223EOY

Intangible Assets IntangibleAssets

FieldValueIRS element (for citing)
BOY737638BOY
EOY704661EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY3455192BOY
EOY4959589EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY42591294BOY
EOY23148046EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY1453129BOY
EOY950145EOY

Tax Exempt Bond Liabilities TaxExemptBondLiabilities

FieldValueIRS element (for citing)
BOY20605000BOY
EOY19200000EOY

Escrow Account Liability EscrowAccountLiability

FieldValueIRS element (for citing)
BOY143529BOY
EOY18653EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY18688978BOY
EOY0EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY290031BOY
EOY300925EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY41180667BOY
EOY20469723EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY1400235BOY
EOY2674158EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY7100BOY
EOY2250EOY

Permanently Restricted Net Assets PermanentlyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY3292BOY
EOY1915EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY1410627BOY
EOY2678323EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY42591294BOY
EOY23148046EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses-482018ReconcilationRevenueExpenses
Reconcilation Other Changes1749715ReconcilationOtherChanges
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited
Audit Committee1AuditCommittee
Financial Statement ConsolidatedXFinancialStatementConsolidated
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Publicly Supported Org509a2XPubliclySupportedOrg509a2

Gifts Grants Contrib Received509 GiftsGrantsContribReceived509

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years18786CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years477224CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years34575CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year244200CurrentTaxYearMinus1Year
Current Tax Year19934CurrentTaxYear
Total794719Total

Gross Receipts From Admissions GrossReceiptsFromAdmissions

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years20218677CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years22356265CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years22365488CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year22433010CurrentTaxYearMinus1Year
Current Tax Year17149505CurrentTaxYear
Total104522945Total

Total509 Total509

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years20237463CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years22833489CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years22400063CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year22677210CurrentTaxYearMinus1Year
Current Tax Year17169439CurrentTaxYear
Total105317664Total

Amts Recd From Disqual Persons AmtsRecdFromDisqualPersons

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years1272CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years450CurrentTaxYearMinus2Years
Total1722Total

Amts From Subst Contributors AmtsFromSubstContributors

FieldValueIRS element (for citing)
Total0Total

Support From DQ Ps Etc SupportFromDQPsEtc

FieldValueIRS element (for citing)
Current Tax Year Minus3 Years1272CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years450CurrentTaxYearMinus2Years
Total1722Total
FieldValueIRS element (for citing)
Public Support Total509105315942PublicSupportTotal509

Gross Investment Income509 GrossInvestmentIncome509

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years116972CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years137501CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years148039CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year156961CurrentTaxYearMinus1Year
Current Tax Year319826CurrentTaxYear
Total879299Total

Investment Income And UBTI InvestmentIncomeAndUBTI

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years116972CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years137501CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years148039CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year156961CurrentTaxYearMinus1Year
Current Tax Year319826CurrentTaxYear
Total879299Total

Other Income509 OtherIncome509

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years195004CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years152407CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years156132CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year155822CurrentTaxYearMinus1Year
Current Tax Year111393CurrentTaxYear
Total770758Total

Total Support Total TotalSupportTotal

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years20549439CurrentTaxYearMinus4Years
Current Tax Year Minus3 Years23123397CurrentTaxYearMinus3Years
Current Tax Year Minus2 Years22704234CurrentTaxYearMinus2Years
Current Tax Year Minus1 Year22989993CurrentTaxYearMinus1Year
Current Tax Year17600658CurrentTaxYear
Total106967721Total
FieldValueIRS element (for citing)
Public Support Percentage5090.98460PublicSupportPercentage509
Prior Year Support Percentage0.98510PriorYearSupportPercentage
Investment Income Percentage0.00820InvestmentIncomePercentage
Prior Yr Invest Income Percentage0.00660PriorYrInvestIncomePercentage
Thirty Three Percnt Tests CY509XThirtyThreePercntTestsCY509
General ExplanationSCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME FROM TENANTS TELEPHONE INCOME FROM TENANTS DIETARY INCOME FROM TENANTS HOUSEKEEPING INCOME FROM TENANTS MAINTENANCE INCOME FROM TENANTS GIFT SHOP INCOME FROM TENANTS PENDANT ALARM INCOME FROM TENANTS CABLE TV INCOME FROM TENANTS ANNUITY CONVERSION INCOME VENDING INCOMEGeneralExplanation

Schedule D IRS990ScheduleD

FieldValueIRS element (for citing)
Agent Trustee Etc0AgentTrusteeEtc
Included On FS1IncludedOnFS

Current Year CurrentYear

FieldValueIRS element (for citing)
Beginning Of Year Balance3292BeginningOfYearBalance
Contributions0Contributions
Other Expenditures1377OtherExpenditures
End Of Year Balance1915EndOfYearBalance

Current Year Minus1 Year CurrentYearMinus1Year

FieldValueIRS element (for citing)
Beginning Of Year Balance3052BeginningOfYearBalance
Contributions240Contributions
End Of Year Balance3292EndOfYearBalance

Current Year Minus2 Years CurrentYearMinus2Years

FieldValueIRS element (for citing)
Beginning Of Year Balance2812BeginningOfYearBalance
Contributions240Contributions
Investment Earnings Or Losses166InvestmentEarningsOrLosses
Other Expenditures166OtherExpenditures
End Of Year Balance3052EndOfYearBalance

Current Year Minus3 Years CurrentYearMinus3Years

FieldValueIRS element (for citing)
Beginning Of Year Balance2432BeginningOfYearBalance
Contributions380Contributions
Investment Earnings Or Losses154InvestmentEarningsOrLosses
Other Expenditures154OtherExpenditures
End Of Year Balance2812EndOfYearBalance
FieldValueIRS element (for citing)
Board Designated EOY Balance0.00000BoardDesignatedEOYBalance
Permanent Endowment EOY Balance1.00000PermanentEndowmentEOYBalance
Term Endowment EOY Balance0.00000TermEndowmentEOYBalance
Endowments Held By Unrelated Orgs0EndowmentsHeldByUnrelatedOrgs
Endowments Held By Related Orgs1EndowmentsHeldByRelatedOrgs
Are Related Orgs Listed Schedule R1AreRelatedOrgsListedScheduleR

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis1423149OtherCostOrOtherBasis
Book Value1423149BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis12099905OtherCostOrOtherBasis
Depreciation2280181Depreciation
Book Value9819724BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis1821530OtherCostOrOtherBasis
Depreciation1085674Depreciation
Book Value735856BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis932494OtherCostOrOtherBasis
Book Value932494BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings12911223TotalOfBookValueLandBuildings

Other Assets OtherAssets (3 entries)

DescriptionDescriptionBook ValueBookValue
ASSETS UNDER BOND AND MORTGAGE INDENTURE AGREEMENTS4939021
BENEFICIAL INTEREST IN NET ASSETS OF THE FOUNDATION1915
RESIDENT TRUST FUNDS18653
FieldValueIRS element (for citing)
Total Book Value Other Assets4959589TotalBookValueOtherAssets

Other Liabilities OtherLiabilities (2 entries)

DescriptionDescriptionAmountAmount
DUE TO AFFILIATES$297,162
ASSET RETIREMENT OBLIGATION$3,763
FieldValueIRS element (for citing)
Total Of Amounts300925TotalOfAmounts

Form990 Schedule D Part XIV Form990ScheduleDPartXIV (3 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
PART IV, LINE 2B:THE ORGANIZATION HOLDS, IN TRUST, FUNDS ADVANCED BY RESIDENTS TO BE USED AT EACH RESIDENT'S DISCRETION. THE FUNDS ARE MAINTAINED IN A SEPARATE INTEREST-BEARING SAVINGS ACCOUNT AND THE ORGANIZATION HAS A FIDUCIARY RESPONSIBILITY FOR THE ADMINISTRATION OF THESE FUNDS. SECURITY DEPOSITS ARE REQUIRED FOR THE ORGANIZATION'S TENANTS AND INCLUDE RESERVED APARTMENTS IF AMOUNTS ARE PAID BEFORE THE TENANT ACTUALLY MOVES IN.
PART V, LINE 4:THE PRINCIPAL WILL BE INVESTED AND KEPT INTACT FOR PERPETUITY TO PROVIDE AN ADDITIONAL SOURCE OF INCOME. THE INCOME GENERATED WILL BE USED TO SUPPORT THE FUND DESIGNATED PROGRAM. THE ORGANIZATION'S ENDOWMENT IS HELD AND ADMINISTERED BY AUGUSTANA CARE FOUNDATION. SEE SCHEDULE R FOR ADDITIONAL DETAILS.DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS:
PART X:AUGUSTANA CARE AND ITS AFFILIATES HAVE BEEN GRANTED EXEMPT STATUS RELATIVE TO FEDERAL AND MINNESOTA CORPORATE INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND APPLICABLE STATE CODES. AUGUSTANA CARE AND ITS AFFILIATES HAVE BEEN CLASSIFIED AS ENTITIES THAT ARE NOT PRIVATE FOUNDATIONS UNDER SECTION 509(A). THE ORGANIZATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. AUGUSTANA CARE AND ITS AFFILIATES' INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE ORGANIZATION REPORTS ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES AND FILES ALL PROPER RETURNS RELATED TO THESE ACTIVITIES. THE TAX RETURNS FOR THE FISCAL YEARS 2009 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, LOCAL, AND STATE AUTHORITIES.DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48:

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Records Maintained1RecordsMaintained

Recipient Table RecipientTable

Recipient Name Business RecipientNameBusiness

FieldValueIRS element (for citing)
Business Name Line1AUGUSTANA CARE FOUNDATIONBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11007 EAST 14TH STREETAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55404ZIPCode
FieldValueIRS element (for citing)
EIN Of Recipient411360678EINOfRecipient
IRC Section501(C)(3)IRCSection
Amount Of Cash Grant250000AmountOfCashGrant
Purpose Of GrantTRANSFER EXCESS CASH TO THE FOUNDATION.PurposeOfGrant
FieldValueIRS element (for citing)
Total Nbr Of501 C3 And Govt Grants1TotalNbrOf501C3AndGovtGrants
Total Nbr Of Other Organizations0TotalNbrOfOtherOrganizations

Form990 Schedule I Part III Form990ScheduleIPartIII

FieldValueIRS element (for citing)
Type Of GrantSCHOLARSHIPSTypeOfGrant
Number Of Recipients13NumberOfRecipients
Amount Of Cash Grant20386AmountOfCashGrant

Form990 Schedule I Part IV Form990ScheduleIPartIV

FieldValueIRS element (for citing)
IdentifierPROCEDURE FOR MONITORING GRANTS IN THE U.S.:Identifier
Return ReferencePART I, LINE 2:ReturnReference
ExplanationSCHEDULE I, PART I, LINE 2: AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY MAKES INTERCOMPANY TRANSFERS TO RELATED ORGANIZATIONS. AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY AND THE RELATED ORGANIZATIONS ARE UNDER COMMON MANAGEMENT WHO REGULARLY MONITOR THE USE OF FUNDS. RECIPIENTS OF SCHOLARSHIPS RECEIVED FROM THE ORGANIZATION AGREE TO THE FOLLOWING TERMS UPON ACCEPTANCE: (1) THE ORGANIZATION WILL DETERMINE THE AMOUNT OF THE SCHOLARSHIP; (2) TUITION AND ASSOCIATED COSTS WILL BE PAID UP TO A STATED AMOUNT UPON PRESENTATION BY THE RECIPIENT OF A BILLING STATEMENT FROM THE EDUCATIONAL INSTITUTION, AND A DETAILED VERIFICATION OF THE COSTS OF BOOKS; (3) THE RECIPIENT WILL COMPLETE THE TRAINING FOR WHICH A SCHOLARSHIP PAYMENT WAS GRANTED WITH PROOF OF A FINAL GRADE OF C OR BETTER, OR RECIPIENT WILL REIMBURSE THE ORGANIZATION FOR THE COST OF THE COURSE; (4) THE RECIPIENT WILL CONTINUE EMPLOYMENT WITH THE ORGANIZATION WHILE COMPLETING COURSEWORK, WITH BOTH PARTIES MAKING EVERY EFFORT TO ACCOMMODATE ANY NECESSARY CHANGES IN WORK HOURS; AND (5) UPON COMPLETION OF TRAINING FOR WHICH A SCHOLARSHIP PAYMENT IS MADE, THE RECIPIENT WILL WORK FOR THE ORGANIZATION FOR TWO YEARS WITH A MINIMUM OF 2,000 HOURS OR WILL REIMBURSE THE ORGANIZATION A PRO-RATED AMOUNT OF THE SCHOLARSHIP PAYMENT RECEIVED, WHICH WILL BE DEDUCTED FROM THE RECIPIENT'S FINAL PAYCHECK.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan1SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org0CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (5 entries)

Base Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
TIM TUCKER
0247516044415027616031283023208037403800
CRAIG KITTELSON
0187311033897032628023724026987030454700
TIM MIDDENDORF
0165401030123010382016202021961024406900
KATHERINE KOPP
0170993035721015066015305025152026223700
MICHAEL JOHNSON
0124008027093011543016324027464020643200

Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
PART I, LINE 4BTHE FOLLOWING INDIVIDUALS PARTICIPATED IN A 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN PROVIDED BY AUGUSTANA CARE SERVICES, A RELATED ORGANIZATION: TIM TUCKER, PRESIDENT AND CEO - $22,708 CRAIG KITTELSON, VICE PRESIDENT OF FINANCE AND CFO - $15,958 TIM MIDDENDORF, VICE PRESIDENT OF OPERATIONS AND COO - $11,000 KATHERINE KOPP, VICE PRESIDENT OF NEW BUSINESS DEVELOPMENT - $8,000
PART IIIPART I, LINE 3: FOR THE PURPOSE OF DETERMINING COMPENSATION, AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY RELIED ON A RELATED ORGANIZATION, AUGUSTANA CARE SERVICES, TO ESTABLISH THE COMPENSATION OF THE PRESIDENT/CEO. AUGUSTANA CARE SERVICES USED THE FOLLOWING PRACTICES TO ESTABLISH COMPENSATION FOR THE PRESIDENT/CEO: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE.SUPPLEMENTAL INFORMATION

Schedule K IRS990ScheduleK

Form990 Schedule K Part I Form990ScheduleKPartI (3 entries)

Issuer EINIssuerEINCUSIP NumberCUSIPNumberDate IssuedDateIssuedIssue PriceIssuePriceDescription Of PurposeDescriptionOfPurposeDefeasedDefeasedOn Behalf Of IssuerOnBehalfOfIssuerPool FinancingPoolFinancing
APPLE VALLEY ECONOMIC DEVELOPMENT AUTHORITY
41088255903788ABK42006-01-2515675000ACQUIRE & IMPROVE FACILITY000
APPLE VALLEY ECONOMIC DEVELOPMENT AUTHORITY
41088255903788ACR82011-12-222945000FACILITY REMODEL000
APPLE VALLEY ECONOMIC DEVELOPMENT AUTHORITY
41088255903788ACUI2012-01-311000000FACILITY REMODEL000

Form990 Schedule K Part II Form990ScheduleKPartII (3 entries)

Amount RetiredAmountRetiredTotal ProceedsTotalProceedsAmount In Reserve FundAmountInReserveFundIssuance Costs From ProceedsIssuanceCostsFromProceedsCapital ExpendituresCapitalExpendituresYear Of Subst CompletionYearOfSubstCompletionCurrent RefundingCurrentRefundingAdvance RefundingAdvanceRefundingFinal Allocation MadeFinalAllocationMadeAdequate Books And Recds MaintaindAdequateBooksAndRecdsMaintaindCapitalized InterestCapitalizedInterest
4200001567500010905123135001427098820060011
2945000221832589002584356000179912
10000004932017500922777000110403

Form990 Schedule K Part III Form990ScheduleKPartIII (3 entries)

Owning Bond Financed PropertyOwningBondFinancedPropertyAny Lease ArrangementsAnyLeaseArrangementsMngment Cntrct Bond Financd PrprtyMngmentCntrctBondFinancdPrprtyAny Research AgreementsAnyResearchAgreementsPost Issuance Compliance ProcdrsPostIssuanceComplianceProcdrs
00001
00001
00001

Form990 Schedule K Part IV Form990ScheduleKPartIV (3 entries)

Form8038 T FiledForm8038TFiledVariable Rate IssueVariableRateIssueHedge Identified In Books And RecdsHedgeIdentifiedInBooksAndRecdsGross Proceeds Invested In GICGrossProceedsInvestedInGICGross Proceeds InvestedGrossProceedsInvestedException To RebateExceptionToRebate
110000
110000
110000

Form990 Schedule K Part VI Form990ScheduleKPartVI

FieldValueIRS element (for citing)
IdentifierSCHEDULE K, PART VIdentifier
Return ReferencePROCEDURES TO UNDERTAKE CORRECTIVE ACTIONReturnReference
ExplanationAUGUSTANA HEALTH CARE CENTER OF APPLY VALLEY DOES NOT HAVE A WRITTEN POLICY IN PLACE AS OF FISCAL YEAR ENDED SEPTEMBER 30, 2012 BUT IS WORKING TO HAVE ONE IN PLACE BY FISCAL YEAR ENDING SEPTEMBER 30, 2013.Explanation

Schedule N IRS990ScheduleN

Disposition Table DispositionTable (6 entries)

Description Of AssetDescriptionOfAssetDate Of DistributionDateOfDistributionFMV Of AssetFMVOfAssetMethod Of FMV DeterminationMethodOfFMVDeterminationEINEINAddress Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeIRC SectionIRCSection
AUGUSTANA CARE
CASH AND CASH EQUIVALENTS2012-01-25221049BOOK VALUE AS OF TRANSFER DATE4117287531007 EAST 14TH STREETMINNEAPOLISMN55404501(C)(3)
AUGUSTANA CARE
ACCOUNTS RECEIVABLES2012-01-25166636BOOK VALUE AS OF TRANSFER DATE4117287531007 EAST 14TH STREETMINNEAPOLISMN55404501(C)(3)
AUGUSTANA CARE
OTHER ASSETS2012-01-25235439BOOK VALUE AS OF TRANSFER DATE4117287531007 EAST 14TH STREETMINNEAPOLISMN55404501(C)(3)
AUGUSTANA CARE
PROPERTY AND EQUIPMENT2012-01-2520523778BOOK VALUE AS OF TRANSFER DATE4117287531007 EAST 14TH STREETMINNEAPOLISMN55404501(C)(3)
AUGUSTANA CARE
ASSETS UNDER BOND AND MORTGAGE AGREEMENTS2012-01-251446132BOOK VALUE AS OF TRANSFER DATE4117287531007 EAST 14TH STREETMINNEAPOLISMN55404501(C)(3)
AUGUSTANA CARE
UNAMORTIZED FINANCING COSTS2012-01-251177957BOOK VALUE AS OF TRANSFER DATE4117287531007 EAST 14TH STREETMINNEAPOLISMN55404501(C)(3)
FieldValueIRS element (for citing)
Director Of Successor20DirectorOfSuccessor2
Employee Of Successor20EmployeeOfSuccessor2
Owner Of Successor20OwnerOfSuccessor2
Receive Compensation20ReceiveCompensation2

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (12 entries)

IdentifierIdentifierReturn ReferenceReturnReferenceExplanationExplanation
ORGANIZATION MISSION STATEMENTOVERALL MISSION OF AUGUSTANA ENTITIESAUGUSTANA CARE, AND ITS SUBSIDIARIES', MISSION IS TO FOSTER FULLNESS OF LIFE FOR OLDER ADULTS AND OTHERS IN NEED THROUGH THE PROVISION OF HEALTHCARE, HOUSING AND OTHER SERVICES. BECAUSE ELDERS ARE VITAL TO OUR COMMUNITIES, WE PROVIDE SERVICES TO HELP THEM CONTINUE LIVING LIFE TO THE FULLEST, GIVING US ALL THE BENEFIT OF THEIR WISDOM AND EXPERIENCE. WE OFFER A FULL SPECTRUM OF SERVICES FOR OLDER ADULTS AND SERVE MORE THAN 6,000 PEOPLE EACH YEAR IN COMMUNITIES IN MINNESOTA AND COLORADO. OUR HEALTH CARE FACILITIES PROVIDE TRANSITIONAL CARE, LONG-TERM CARE, DEMENTIA CARE, AND REHABILITATION SERVICES TO MORE THAN 3,500 PEOPLE EACH YEAR. AUGUSTANA CARE ALSO OWNS AND MANAGES A VARIETY OF LIVING COMMUNITIES SERVING OLDER ADULTS WITH COMFORTABLE LIVING AND CARE OPTIONS, INCLUDING APARTMENTS FOR INDEPENDENT LIVING, HOUSING WITH SERVICES, AND ASSISTED LIVING AND MEMORY CARE. ADDITIONALLY, WE OFFER A RANGE OF COMMUNITY-BASED SUPPORT SERVICES SUCH AS ADULT DAY PROGRAMS TO ENHANCE THE QUALITY OF LIFE FOR OLDER ADULTS WHO CONTINUE TO LIVE IN THEIR OWN HOMES, AS WELL AS MANAGEMENT CONSULTING SERVICES TO OTHER ORGANIZATIONS THAT SERVE OLDER ADULTS.
CHANGES IN PROGRAM SERVICESFORM 990, PART III, LINE 3TRANSFERED ASSETS FROM AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY TO AUGUSTANA CARE CORPORATION AS OF 1/25/2012.
FORM 990, PART VI, SECTION A, LINE 3AUGUSTANA CARE SERVICES PROVIDES MANAGEMENT SERVICES FOR AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY. AUGUSTANA CARE SERVICES PROVIDES FINANCIAL ACCOUNTING, OPERATIONAL OVERSIGHT, HUMAN RESOURCES, INFORMATION TECHNOLOGY, CLINICAL NURSING CONSULTATION, CORPORATE COMPLIANCE, COORDINATED ADVERTISING AND MARKETING, STAFFING FOR FUND DEVELOPMENT, AND NEW BUSINESS DEVELOPMENT.
FORM 990, PART VI, SECTION A, LINE 4AUGUSTANA REGENT AT BURNSVILLE, LLC'S SOLE MEMBER CHANGED FROM AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY TO AUGUSTANA CARE. THIS CHANGE OF MEMBERSHIP WAS EFFECTIVE JANUARY 25, 2012.
FORM 990, PART VI, SECTION A, LINE 6THE SOLE MEMBER OF THE ORGANIZATION IS AUGUSTANA CARE.
FORM 990, PART VI, SECTION A, LINE 7ATHE ORGANIZATION'S BOARD OF DIRECTORS ARE APPOINTED BY A MAJORITY VOTE FROM THE BOARD OF DIRECTORS OF THE SOLE MEMBER, AUGUSTANA CARE.
FORM 990, PART VI, SECTION A, LINE 7BTHE FOLLOWING ACTIONS REQUIRE AFFIRMATIVE APPROVAL FROM THE SOLE MEMBER OF THE ORGANIZATION, AUGUSTANA CARE: (A) AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS OF THIS CORPORATION; (B) CAPITAL BUDGETS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, AND ALL MAJOR EXPENDITURES BEFORE FUNDS ARE EXPENDED THEREFORE; (C) OPERATING BUDGETS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, BEFORE AUTHORIZED EXPENDITURES MAY BE MADE THEREFROM; (D) STRATEGIC PLANS OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSIHPS, AND OTHER LEGAL ENTITIES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION; (E) THE INCURRING OF ANY LONG TERM DEBT OF THIS CORPORATION AND ALL CORPORATIONS, PARTNERSHIPS, AND OTHER LEGAL ENTITES DIRECTLY OR INDIRECTLY CONTROLLED BY THIS CORPORATION, OTHER THAN INTRA-SYSTEM OR REFINANCING DEBT; (F) HUMAN RESOURCES AND BENEFITS POLICIES OF THIS CORPORATION; (G) MAJOR RISK CONTRACTING AGREEMENTS, WHICH FOR THESE PURPOSES MEANS ANY CONTRACT WHICH DEALS WITH CAPITATION OR SIMILAR RISK BEARING CONCEPT; (H) MERGER, CONSOLIDATION, OR TOTAL OR PARTIAL DISSOLUTION INVOLVING THIS CORPORATION; (I) GOVERNANCE AND ACTION OF THE TYPE SET FORTH IN SUBPARAGRAPH (A) AND SUBPARAGRAPHS (F) THROUGH (H) ABOVE AS PROPOSED BY THE BOARD OF DIRECTORS OF ANY CORPORATION, PARTNERSHIP, OR OTHER LEGAL ENTITES DIRECTLY CONTROLLED BY THIS CORPORATION AS A MEMBER, SHAREHOLDER OR OTHERWISE, TO THE EXTENT THAT THE GOVERNING DOCUMENTS OF SUCH CORPORATION, PARTNERSHIP, OR OTHER LEGAL ENTITIES GIVE THIS CORPORATION OR THE BOARD A RIGHT OF APPROVAL OVER SUCH GOVERNANCE ACTION.
FORM 990, PART VI, SECTION B, LINE 11THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND REVIEWED IN DETAIL BY THE ORGANIZATION'S VP - FINANCE/CFO. THE FORM 990 WAS THEN PRESENTED TO THE FULL BOARD BY THE VP - FINANCE/CFO PRIOR TO BEING FILED WITH THE IRS.
FORM 990, PART VI, SECTION B, LINE 12CTHE ORGANIZATION'S CONFLICT OF INTEREST POLICY COVERS ALL BOARD MEMBERS AND KEY EMPLOYEES. ALL COVERED INDIVIDUALS ARE REQUIRED TO COMPLETE AN ANNUAL CONFLICT OF INTEREST STATEMENT. ALL COVERED INDIVIDUALS ARE REQUIRED TO DISCLOSE ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST TO THE APPROPRIATE LEVEL OF MANAGEMENT OR TO THE BOARD OF DIRECTORS AS OUTLINED IN THE POLICY BASED ON THE INDIVIDUAL'S POSITION WITHIN THE ORGANIZATION. CONFLICTS ARE DETERMINED AT THE APPROPRIATE LEVEL OF MANAGEMENT OR BY THE BOARD OF DIRECTORS. INDIVIDUALS WITH ACTUAL OR POTENTIAL CONFLICTS WILL ABSTAIN FROM DISCUSSING OR VOTING ON ANY MATTERS RELATING TO THE CONFLICT. ALL PROCEEDINGS RELATING TO ACTUAL OR POTENTIAL CONFLICTS WILL BE NOTED IN THE MEETING MINUTES.
FORM 990, PART VI, SECTION C, LINE 19THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
EXPLANATION FOR HOURS WORKEDFORM 990, PART VII, LINE 1ATIM TUCKER, CRAIG KITTELSON, TIM MIDDENDORF, AND KATHERINE KOPP EACH EARVE AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY AND ITS RELATED ORGANIZATIONS. EACH INDIVIDUAL SPENDS APPROXIMATELY 4.5 HOURS PER WEEK WORKING FOR EACH OF THE RELATED ORGANIZATIONS, FOR A TOTAL OF 45 HOURS PER WEEK. REV. DR. GARY WILKERSON, CHARLES PARKS, JR., MARSHALL MACKAY, ERIC (RICK) ELLINGSON, JIM EHLEN, SCOTT RAMSDALE, AND PR. ELIZABETH BEISSEL EACH SERVE ON THE BOARD OF AUGUSTANA HEALTHCARE CENTER OF APPLE VALLEY AND ITS RELATED ORGANIZATIONS, WITH THE EXCEPTION OF AUGUSTANA CARE FOUNDATION. EACH INDIVIDUAL SPENDS APPROXIMATELY 1 HOUR PER WEEK WORKING FOR EACH OF THE RELATED ORGANIZATIONS, FOR A TOTAL OF 8 HOURS.
CHANGES IN NET ASSETS OR FUND BALANCES:FORM 990, PART XI, LINE 5:NET UNREALIZED LOSSES ON INVESTMENTS: -617. TRANSFER OF REGENT, LLC TO AUGUSTANA CARE 1,750,332. TOTAL TO FORM 990, PART XI, LINE 5: 1,749,715.

Schedule R IRS990ScheduleR

Form990 Schedule R Part I Form990ScheduleRPartI

Name Of Disregarded Entity NameOfDisregardedEntity

FieldValueIRS element (for citing)
Business Name Line1AUGUSTANA REGENT AT BURNSVILLE LLCBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line114500 REGENT LANEAddressLine1
CityBURNSVILLECity
StateMNState
ZIP Code55306ZIPCode
FieldValueIRS element (for citing)
EIN208915982EIN
Primary ActivitiesASSISTED LIVING FACILITYPrimaryActivities
Legal Domicile StateMNLegalDomicileState
Total Income2015356TotalIncome
EOY Assets23770991EOYAssets

Direct Controlling Entity Name DirectControllingEntityName

FieldValueIRS element (for citing)
Business Name Line1HCCAV & AUGUSTANA CAREBusinessNameLine1

Form990 Schedule R Part II Form990ScheduleRPartII (9 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusBusiness Name Line1DirectControllingEntityName/BusinessNameLine1Controlled OrgControlledOrgDirect Controlling Entity NADirectControllingEntityNA
APPLE VALLEY VILLA APARTMENTS
1007 EAST 14TH STREETMINNEAPOLISMN55404311608691HEALTH CARE FACILITIES/SERVICESMN501(C)(3)9AUGUSTANA CARE0
AUGUSTANA APARTMENTS OF HASTINGS
1007 EAST 14TH STREETMINNEAPOLISMN55404311608701HEALTH CARE FACILITIES/SERVICESMN501(C)(3)9AUGUSTANA CARE0
AUGUSTANA CARE
1007 EAST 14TH STREETMINNEAPOLISMN55404411728753HEALTH CARE FACILITIES/SERVICESMN501(C)(3)70N/A
AUGUSTANA CARE FOUNDATION
1007 EAST 14TH STREETMINNEAPOLISMN55404411360678CHARITABLE FOUNDATIONMN501(C)(3)11 - TYPE 1AUGUSTANA CARE0
AUGUSTANA CARE SERVICES
1007 EAST 14TH STREETMINNEAPOLISMN55404411806946MANAGEMENT SERVICESMN501(C)(3)11 - TYPE 1AUGUSTANA CARE0
AUGUSTANA CHAPEL VIEW HOMES INC
1007 EAST 14TH STREETMINNEAPOLISMN55404410693953HEALTH CARE FACILITIES/SERVICESMN501(C)(3)9AUGUSTANA CARE0
AUGUSTANA COMMUNITY PARTNERS
1007 EAST 14TH STREETMINNEAPOLISMN55404411783680HOME HEALTH CARE SERVICESMN501(C)(3)9AUGUSTANA CARE0
AUGUSTANA HOME OF HASTINGS
1007 EAST 14TH STREETMINNEAPOLISMN55404311572624HEALTH CARE FACILITIES/SERVICESMN501(C)(3)9AUGUSTANA CARE0
OPEN CIRCLE ADULT DAY CENTER
1007 EAST 14TH STREETMINNEAPOLISMN55404411424801HEALTH CARE FACILITIES/SERVICESMN501(C)(3)9AUGUSTANA CARE0

Form990 Schedule R Part IV Form990ScheduleRPartIV

Name Of Related Org NameOfRelatedOrg

FieldValueIRS element (for citing)
Business Name Line1AUGUSTANA SENIOR DEVELOPMENT INCBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line11007 EAST 14TH STREETAddressLine1
CityMINNEAPOLISCity
StateMNState
ZIP Code55404ZIPCode
FieldValueIRS element (for citing)
EIN481293891EIN
Primary ActivityCONSULTINGPrimaryActivity
Legal Domicile StateMNLegalDomicileState
Direct Controlling Entity NAN/ADirectControllingEntityNA
Type Of EntityCTypeOfEntity
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org1GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org0GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org1LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs1RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs0RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs0PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs1PerformOfServicesByOtherOrgs
Sharing Of Facilities1SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org1ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org1ReimbursementPaidByOtherOrg
Other Transfer To Other Org1OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

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