2011-05-16T11:29:46-05:00 2010-09-30 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2009-10-01 311572624 AUGUSTANA HOME OF HASTINGS dba AUGUSTANA HEALTH CARE CENTER OF HAS AUGU 6122385225 1007 EAST FOURTEENTH STREET MINNEAPOLIS MN 55404 CRAIG KITTELSON 6122385225 2011-05-10 1 6123764500 2009 2016-02-24 21:20:13Z TIM TUCKER 1007 EAST FOURTEENTH STREET MINNEAPOLIS MN 55404 7604357 0 X WWW.AUGUSTANACARE.ORG X 1997 MN TO PROVIDE HEALTH CARE, HOUSING AND COMMUNITY SERVICES FOR THE ELDERLY. 7 7 226 109 0 0 120655 11593 7758318 7492948 33015 77429 17804 22387 7929792 7604357 2134 208771 0 4672005 4461267 0 0 3119407 3014760 7793546 7684798 136246 -80441 4859457 4603410 4595863 4426978 263594 176432 TO PROVIDE HEALTH CARE FACILITIES, HOUSING ALTERNATIVES AND COMMUNITY SERVICES FOR THE PHYSICAL, CULTURAL, SOCIAL AND RECREATIONAL NEEDS OF THE ELDERLY AND THE DISABLED IN A CHRISTIAN ENVIRONMENT. 0 0 6784678 208771 7492948 AUGUSTANA HOME OF HASTINGS OWNS AND OPERATES A 91-BED LICENSED NURSING FACILITY IN HASTINGS, MINNESOTA TO FACILITATE THE OBJECTIVES SET FORTH IN THEIR PRIMARY EXEMPT PURPOSE. AUGUSTANA HOME OF HASTINGS SERVED 397 INDIVIDUALS DURING THE YEAR ENDED SEPTEMBER 30, 2010. 6784678 1 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 226 1 0 0 0 0 0 0 0 0 0 7 7 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X CRAIG KITTELSON - AUGUSTANA CARE SE 6122385205 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 X JOHN HERMANSON 2.00 X X 0 0 0 RICH KOOP 2.00 X X 0 0 0 JIM BIERMAIER 2.00 X X 0 0 0 MICHAEL WISE 2.00 X 0 0 0 PR GARY WILKERSON 2.00 X X 0 0 0 MARSHALL MACKAY 2.00 X X 0 0 0 CHARLES PARKS JR 2.00 X X 0 0 0 ERIC RICK ELLINGSON 2.00 X X 0 0 0 PR ELIZABETH BEISSEL 2.00 X 0 0 0 JIM EHLEN 2.00 X 0 0 0 SCOTT RAMSDALE 2.00 X 0 0 0 TIM TUCKER 4.50 X 0 316400 62817 CRAIG KITTELSON 4.50 X 0 251192 59945 TIM MIDDENDORF 4.50 X 0 196561 43531 KATHERINE KOPP 4.50 X 0 215248 33372 0 979401 199665 0 0 1 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 MANAGEMENT SERVICES 429672 1 256 11337 11593 NURSING FACILITIES 623000 7492948 7492948 7492948 74900 74900 9552 9552 9552 9552 2529 2529 2529 2529 DIETARY INCOME 722210 5212 5212 CABLE TV INCOME 812900 3915 3915 TELEPHONE INCOME 812900 3300 3300 408 408 12835 7604357 7492948 0 99816 200000 200000 8771 8771 3723016 3522984 200032 38480 32526 5954 428394 395075 33319 271377 256971 14406 429672 429672 7731 7731 14226 14226 696810 684139 12671 13418 13418 130013 98975 31038 158583 158583 10734 6982 3752 2657 2369 288 228574 228574 236154 236154 39611 39611 NURSING SUPPLIES 464507 464507 LICENSES, PERMITS, FEES 265162 263139 2023 DIETARY EXPENSES 206345 206345 BAD DEBT EXPENSE 79076 79076 DUES AND SUBSCRIPTIONS 13395 1249 12146 18092 17335 757 7684798 6784678 900120 0 1350 1350 752685 691303 34619 36244 6091674 2969830 3299552 3121844 19998 8677 167266 158501 583987 585491 4859457 4603410 463567 403416 4020000 3905000 11785 13025 100511 105537 4595863 4426978 X 245704 158513 17890 17919 263594 176432 4859457 4603410 X 0 1 1 X 0 X 12188 14425 16504 120655 11593 175365 7333371 7469807 7435022 7758318 7492948 37489466 7345559 7484232 7451526 7878973 7504541 37664831 1104 800 1904 0 1104 800 1904 37662927 46885 44089 58858 43620 86981 280433 46885 44089 58858 43620 86981 280433 6769 10340 12431 7199 12835 49574 7399213 7538661 7522815 7929792 7604357 37994838 0.99130 0.99240 0.00740 0.00630 X Schedule A, Part II, Line 12, Explanation of Other Income: DIETARY INCOME FROM TENANTS VENDING MACHINE INCOME FROM TENANTS MISCELLANEOUS INCOME FROM TENANTS TELEPHONE INCOME FROM TENANTS CABLE TELEVISION INCOME FROM TENANTS 0 1 17890 29 256 256 17919 17781 109 267 267 17890 1.00000 0 1 1 588217 588217 4240807 1840851 2399956 1262650 1128979 133671 3121844 ASSETS UNDER BOND INDENTURE AGREEMENTS 468049 DUE FROM AFFILIATES 36257 RESIDENT TRUST FUNDS 13025 HCIR INSURANCE RECIPROCAL 63801 BENEFICIAL INTEREST IN ASSETS HELD BY FOUNDATION 4359 585491 ASSET RETIREMENT OBLIGATION 105537 105537 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. Part V, Line 4: Description of Intended Use of Endowment Funds: 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. 1 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411806946 501(C)(3) 200000 TO SUPPORT GENERAL OPERATIONS. 1 0 SCHOLARSHIPS 4 8771 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Augustana Health Care Center of Hastings makes intercompany transfers to related organizations. Augustana Health Care Center of Hastings and the related organizations are under common management who regularly monitor the use of funds. Recipients of scholarships 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 and a detailed verification of the cost 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 training for which scholarship was granted, the recipient will work for the organization at least two years and a minimum of 2,000 hours or will reimburse the organization a prorated amount of each scholarship payment received, which will be deducted for their last paycheck. 0 1 0 0 0 0 0 0 0 TIM TUCKER 0 247016 0 42593 0 26791 0 38049 0 24768 0 379217 0 0 CRAIG KITTELSON 0 185011 0 34507 0 31674 0 29598 0 30347 0 311137 0 0 TIM MIDDENDORF 0 167002 0 21877 0 7682 0 21610 0 21921 0 240092 0 0 KATHERINE KOPP 0 171994 0 28545 0 14709 0 19697 0 13675 0 248620 0 0 Part I, Line 4a THE 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 - $12,500 KATHERINE KOPP, VICE PRESIDENT OF SENIOR DEVELOPMENT - $9,500 MICHAEL JOHNSON, VICE PRESIDENT AND DIRECTOR OF HUMAN RESOURCES - $12,500 Supplemental Information Part III PART I, LINE 3: FOR THE PURPOSE OF DETERMINING COMPENSATION, AUGUSTANA HOME OF HASTINGS 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. Form 990, Part VI, Section A, line 3 AUGUSTANA CARE SERVICES PROVIDES MANAGEMENT SERVICES FOR AUGUSTANA HOME OF HASTINGS. 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 4 Changes were made to all governing documents of all legal entities in the organization. Changes included: 1.) Updates for consistency among entities 2.) Updates for changes in state law and ELCA affiliation standards 3.) Updates for improving governance focus on strategic direction and robust leadership 4.) Updates for consistency with third party financing requirements No changes in fundamental inter-entity control relationships or tax exemption considerations were made. Form 990, Part VI, Section A, line 6 THE SOLE MEMBER OF THE ORGANIZATION IS AUGUSTANA CARE. Form 990, Part VI, Section A, line 7a THE ORGANIZATION'S BOARD OF DIRECTORS ARE APPOINTED BY A MAJORITY VOTE FROM THE BOARD OF DIRECTORS OF THE SOLE MEMBER, AUGUSTANA CARE AT THE ANNUAL MEETING. Form 990, Part VI, Section A, line 7b THE 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 THEREFOR; (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 11 THE 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 12c THE ORGANIZATION'S CONFLICT OF INTEREST POLICY COVERS ALL BOARD MEMBERS AND 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 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII, LINE 1A EXPLANATION FOR HOURS WORKED TIM TUCKER, CRAIG KITTELSON, TIM MIDDENDORF AND KATHERINE KOPP EACH SERVE AUGUSTANA HOME OF HASTINGS 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. JIM BIERMAIER, JOHN HERMANSON, RICH KOOP, AND MICHAEL WISE ARE BOARD MEMBERS OF AUGUSTANA HOME OF HASTINGS. THEY ARE ALSO BOARD MEMBERS OF A RELATED ORGANIZATION: AUGUSTANA APARTMENTS OF HASTINGS. EACH INDIVIDUAL SERVES EACH ORGANIZATION FOR APPROXIMATELY 2 HOURS PER WEEK, FOR A TOTAL OF 4 HOURS PER WEEK. APPLE VALLEY VILLA APARTMENTS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608691 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A AUGUSTANA APARTMENTS OF HASTINGS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608701 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A AUGUSTANA CARE 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411728753 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 7 N/A AUGUSTANA CARE FOUNDATION 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411360678 CHARITABLE FOUNDATION MN 501(C)(3) 11 - TYPE 1 N/A AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411806946 MANAGEMENT SERVICES MN 501(C)(3) 11 - TYPE 1 N/A AUGUSTANA CHAPEL VIEW HOMES INC 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 410693953 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A AUGUSTANA COMMUNITY PARTNERS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411783680 HOME HEALTH CARE SERVICES MN 501(C)(3) 9 N/A AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311608696 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A OPEN CIRCLE ADULT DAY CENTER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 411424801 HEALTH CARE FACILITIES/SERVICES MN 501(C)(3) 9 N/A AUGUSTANA SENIOR DEVELOPMENT INC 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 481293891 CONSULTING MN N/A C 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0