2013-01-29T12:44:00-06:00 2012-09-30 410746749 CLIFTONLARSONALLEN LLP PO BOX 217 AUSTIN MN 55912 990 2011-10-01 411263434 KENYON SUNSET HOME DBA KENYON SENIOR LIVING KENY 5077896134 127 GUNDERSON BLVD KENYON MN 55946 DAVID VANDERGON 5077896134 2013-01-07 1 TRENT FAST P00692704 5074347000 2011 2016-02-25 16:41:14Z DAVID VANDERGON 127 GUNDERSON BLVD KENYON MN 55946 3766153 0 9386 X N/A X 1949 MN TO PROVIDE HOUSING AND NURSING SERVICES TO THE ELDERLY IN KENYON, MINNESOTA AND THE SURROUNDING AREA. 9 9 134 78 0 0 27670 36429 3471406 3539675 3677 2687 170863 167292 3673616 3746083 0 0 0 0 2148775 2274576 0 0 0 1556834 1598120 3705609 3872696 -31993 -126613 3902223 4092429 2929329 3246148 972894 846281 WE ARE A CHRISTIAN FAITH BASED NOT FOR PROFIT ORGANIZATION THAT EXTENDS THE MINISTRY OF CARING AND HEALING THROUGH A VARIETY OF QUALITY SERVICES FOR THE ELDERLY, FAMILIES, AND THE AREA COMMUNITIES. 0 0 3276014 3539675 KENYON SUNSET HOME- SINCE 1949, WE HAVE BEEN PROVIDING HOUSING AND NURSING SERVICES THROUGH OPERATION OF A 48-BED LICENSED NURSING FACILITY AND A 19-BED HOUSING WITH SERVICES FACILITY IN KENYON, MINNESOTA. THE HOME HAD 16,183 RESIDENT DAYS DURING 2012. ALSO, SEVENTEEN SERVICES WERE PROVIDED TO THE RESIDENTS OF THE HOUSING WITH SERVICES FACILITY. 3276014 1 1 0 1 0 0 1 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 26 0 134 1 0 0 0 0 0 0 0 0 0 0 X 9 9 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X DAVE VANDERGON 5077896134 127 GUNDERSON BLVD KENYON MN 55946 CAREY HJERMSTAD 1.00 X 0 0 0 PENNY ISAACSON 1.00 X 0 0 0 LARRY LEHMAN 1.00 X 0 0 0 JUDY PAVEK 1.00 X 0 0 0 BARNEY NESSETH 1.00 X 0 0 0 STEVE SVIGGUM 1.00 X 0 0 0 JIM DAVIS 1.00 X 0 0 0 MARLENE SYVERSON 1.00 X 0 0 0 KEVIN ANDERSON 1.00 X 0 0 0 DAVID VANDERGON 40.00 X 79102 0 304 DENISE BUDD 40.00 X 66560 0 3003 145662 0 3307 0 0 0 0 REHABCARE GROUP CONTRACT THERAPY DIVISIO PO BOX 503534 ST LOUIS MO 63105 THERAPIES 177780 DHS MEDICAL CARE SURCHARGE 540 CEDAR ST ST PAUL MN 55101 MEDICAL SURCHARGE 135120 POWER ENGINEERS 105 EAST 4TH STREET NORTHFIELD MN 55057 ARCHITECT 132111 US FOODS NW 6059 PO BOX 1450 MINNEAPOLIS MN 55485 FOOD/SUPPLIES 120763 4 36429 36429 MEDICARE/MEDICAID PAYM 623000 1904758 1904758 RESIDENT REVENUE 623000 1587172 1587172 RENTAL REVENUE 623000 44604 44604 MISCELLANEOUS INCOME 623000 3141 3141 3539675 1614 1614 21143 20070 1073 1073 1073 MISCELLANEOUS INCOME 900099 94250 94250 MEAL REVENUE 623000 66420 66420 DAY CARE REVENUE 623000 6622 6622 167292 3746083 3539675 0 169979 148969 148969 1767291 1699040 68251 5984 3928 2056 214079 155740 58339 138253 99212 39041 92164 54559 37605 2890 2890 14175 14175 409617 317637 91980 20973 20973 187327 154871 32456 130385 130385 2128 2128 28778 25415 3363 117638 117638 166371 166371 48069 2516 45553 FOOD COSTS 167927 167927 MINNESOTA SURCHARGE 135120 135120 REAL ESTATE TAXES 20141 20141 MISCELLANEOUS EXPENSE 13683 13683 40734 23386 17348 3872696 3276014 596682 0 75512 102344 91876 82139 271935 217722 11849 10902 43905 40707 5954441 2497676 3114131 3456765 181749 51417 111266 130433 3902223 4092429 232449 509893 2377679 2390671 319201 345584 2929329 3246148 X 972894 846281 972894 846281 3902223 4092429 -126613 0 X X 0 1 1 X 0 X 57320 23473 54288 25969 35113 196163 3711392 3460096 3419521 3471406 3539675 17602090 3768712 3483569 3473809 3497375 3574788 17798253 57320 23473 23470 28998 35113 168374 1320765 1392852 1323617 1234064 1228742 6500040 1378085 1416325 1347087 1263062 1263855 6668414 11129839 8666 6746 5851 5378 2930 29571 8666 6746 5851 5378 2930 29571 170863 167292 338155 3777378 3490315 3479660 3673616 3745010 18165979 0.61270 0.63170 0.00160 0.00180 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 0 0 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: SPENT TIME WALKING AROUND CAPITAL WITH LEGISLATURES. ALSO EMAILED LEGISLATURES ON VARIOUS TOPICS. X 1 1.00 1 0 0 1 0 0.00 0 1 65505 65505 4653115 1803168 2849947 864169 694508 169661 371652 371652 3456765 RESIDENT DEPOSITS & TRUST FUNDS PAY 17841 ASSET RETIREMENT OBLIGATION 242908 DUE TO FOUNDATION 84835 345584 DESCRIPTION OF HOW ORGANIZATION REPORTS CONSERVATION EASEMENTS: PART II, LINE 9: FACILITY IS ADJACENT TO THE GUNDERSON HOUSE WHICH IS ON THE NATIONAL HISTORIC REGISTRY, AND COVENENTS APPLY TO RECENT PROPERTY DEVELOPMENTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: BOTH KENYON SENIOR LIVING AND THE FOUNDATION HAVE BEEN GRANTED EXEMPT STATUS RELATIVE TO FEDERAL AND STATE INCOME TAXES UNDER SECTION 501(C)3 OF THE INTERNAL REVENUE CODE. KENYON SENIOR LIVING AND THE FOUNDATION FOLLOW THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. NO LIABILITY HAS BEEN RECOGNIZED BY THE ORGANIZATION OR FOUNDATION AS A RESULT OF THIS STANDARD. KENYON SENIOR LIVING AND FOUNDATION FILE AS TAX-EXEMPT ORGANIZATIONS. SHOULD THAT STATUS BE CHALLENGED IN THE FUTURE, ALL YEARS SINCE INCEPTION COULD BE SUBJECT TO REVIEW BY THE IRS. THE 2009, 2010, AND 2011 TAX YEARS OF KENYON SENIOR LIVING AND THE FOUNDATION ARE OPEN FOR EXAMINATION BY THE IRS. FORM 990, PART VI, SECTION A, LINE 2 CAREY HJERMSTAD AND DAVID HJERMSTAD - FAMILY RELATIONSHIP FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO BEING FILED WITH THE IRS, A COPY OF THE IRS FORM 990 AND RELATED SCHEDULES ARE REVIEWED BY THE ADMINISTRATOR, INCLUDING A CONFIRMATION OF THE ACCURACY OF EVERY ANSWER AND OVERSIGHT OF APPROPRIATE CHANGES. TWO MEMBERS OF THE BOARD OF DIRECTORS ALSO REVIEW AND APPROVE FORM 990 PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ADMINISTRATION WILL BE RESPONSIBLE TO COMMUNICATE THIS POLICY TO EACH OFFICER, DIRECTOR, AND TRUSTEE SERVING KSH OR ANY OF ITS SUBSIDIARIES AND OTHERS AS THEY ARE NEWLY APPOINTED TO SUCH RULES. IF THERE IS A PERSON WITH A CONFLICT OR POTENTIAL CONFLICT, THEY SHALL REFRAIN FROM VOTING OR OTHERWISE ATTEMPT TO EXERT ANY INFLUENCE OF KSH. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS DETERMINE AND REVIEW THE CEO. THE CEO, WITH THE HELP FROM THE BOARD DETERMINE'S AND REVIEWS THE OTHER KEY EMPLOYEES. THE LAST REVIEWS WERE IN 2012. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATIONS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XII, LINE 2C: THE ORGANIZATIONS CONSOLIDATED FINANCIAL STATEMENTS ARE AUDITED ANNUALLY BY AN INDEPENDENT ACCOUNTANT, RECEIVING AN UNQUALIFIED OPINION AS OF AND FOR THE YEARS ENDED SEPTEMBER 30, 2012 AND 2011. THE ORGANIZATIONS BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS CONSOLIDATED FINANCIAL STATEMENTS AND THE SELECTION OF ITS INDEPENDENT ACCOUNTANT. KENYON SUNSET HOME FOUNDATION 127 GUNDERSON BLVD KENYON MN 55946 411694615 SUPPORTING ORGANIZATION MN 501(C)(3) LINE 11, TYPE II KENYON SUNSET HOME 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 ALL TRANSACTIONS WERE UNDER 50000 THEREFORE NOT REQUIRED TO BE DISCLOSED