2011-06-13T09:23:58-05:00 2010-09-30 SEIM JOHNSON LLP 18081 BURT STREET SUITE 200 OMAHA NE 680224722 990 2009-10-01 470841274 FAIRBURY ASSISTED LIVING FACILITY DBA CEDARWOOD FAIR 4027293351 828 22ND STREET FAIRBURY NE 68352 CHAD JURGENS 4027293351 2011-06-06 1 4023302660 2009 2016-02-24 21:20:13Z CHAD JURGENS PO BOX 277 FAIRBURY NE 68352 1362991 0 X N/A 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 37 0 0 0 2390 300 1305362 1356907 13291 5784 0 1321043 1362991 0 0 392555 416165 0 0 872488 850028 1265043 1266193 56000 96798 3744345 3600352 3681631 3440840 62714 159512 NONE - SEE PAGE 1 FOR DESCRIPTION OF ACTIVITIES. 0 0 1177035 1356907 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 42-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. 57 residents were served from October 2009 through September 2010. Seven of these residents qualified under the Medicaid waiver program. Total days of care provided were 15,364. 1177035 1 0 0 0 0 0 0 0 0 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 37 1 0 0 0 0 0 0 0 0 0 6 6 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 0 0 0 0 0 X CHAD JURGENS 4027293351 PO BOX 277 FAIRBURY NE 68352 X HOMER WARD 1.00 X X 0 0 0 KENNETH FOSTER 1.00 X X 0 0 0 CHAD JURGENS 5.00 X X 0 0 0 RUSSELL GRONEWOLD 1.00 X X 0 0 0 RICK STANTON 1.00 X 0 0 0 SHIRLEY TRAVIS 1.00 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 339850 1 300 300 RESIDENT REVENUE 623000 1253569 1253569 MEDICARE/MEDICAID PAYM 623000 97588 97588 RENTAL INCOME 900002 5750 5750 1356907 5784 5784 1362991 1356907 0 5784 356353 356353 28062 28062 31750 31750 67845 67845 10562 10562 248750 246250 2500 5488 5488 52550 49504 3046 218737 218737 3084 3084 1664 1664 219282 219282 18342 14801 3541 DUES & SUBSCRIPTIONS 3676 3676 MISCELLANEOUS 48 48 1266193 1177035 89158 0 118953 88897 562753 662905 8255 8503 14624 18770 4381192 1562193 3038281 2818999 1479 2278 3744345 3600352 145444 107406 3485000 3280000 51187 53434 3681631 3440840 X 62714 159512 62714 159512 3744345 3600352 X 0 1 0 X 0 X 10548 2390 300 13238 1234223 1268303 1285230 1305362 1356907 6450025 1234223 1268303 1295778 1307752 1357207 6463263 0 0 0 6463263 22502 35013 27585 13564 5784 104448 22502 35013 27585 13564 5784 104448 1256725 1303316 1323363 1321316 1362991 6567711 0.98410 0.98180 0.01590 0.01820 X 60427 60427 4011740 1394674 2617066 225471 121423 104048 83554 46096 37458 2818999 RESIDENT SECURITY DEPOSITS 53434 53434 1362991 1266193 96798 0 96798 1362991 0 1362991 0 1362991 1266193 0 1266193 0 1266193 Part X: Description of Uncertain Tax Positions Under FIN 48: 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, 2010, Cedarwood had no uncertain tax positions accrued. HOSPITAL AUTHORITY NO 1 OF JEFFERSON COUNTY NE REVENUE BONDS SERIES 2003 476006475 473262be2 2003-01-16 4805000 TO FUND CONSTRUCTION OF FACILITY 0 0 4824882 390625 96100 4338157 2004 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 Form 990, Part VI, Section A, line 6 THE MEMBERS OF THE CORPORATION ARE BRYANLGH HEALTH SERVICES, INC. AND JEFFERSON COMMUNITY HEALTH CENTER, BOTH NEBRASKA NONPROFIT CORPORTIONS. Form 990, Part VI, Section A, line 7a The members of the Corporation, BryanLGH Health Services, Inc., 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. CHAD JURGENS, 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 WHICH 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 Facilitys governing documents and financial statements are available to the public upon request. FORM 990, PAGE 11, PART XI, LINE 2C: COMMITTEE WITH OVERSIGHT OF THE AUDIT 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 13: WHISTLEBLOWER POLICY THE ORGANIZATION HAS A POLICY THAT REQUIRES STAFF TO REPORT TO THE DIRECTOR ANY SUSPICIOUS ACTIVITIES AND VIOLATIONS OF POLICIES. THE ORGANIZATION PLANS TO UPDATE THAT POLICY TO SPECIFY HOW IT PLANS TO PROTECT THAT INDIVIDUAL FROM RETALIATION. FORM 990, PART VI, SECTION B, LINE 14: WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY 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: INDEPENDENT REVIEW OF COMPENSATION AS NO OFFICER IS PAID BY THIS ORGANIZATION, NO INDEPENDENT REVIEW OR APPROVAL PROCESS IS CONDUCTED BY THIS ORGANIZATION.