2011-05-16T14:55:22-05:00 2010-06-30 plante & moran pllc 65 east state st ste 600 columbus OH 43215 990 2009-07-01 310892356 FRIENDSHIP VILLAGE OF COLUMBUS OHIO INC FRIE 6148908282 5800 FOREST HILLS BLVD COLUMBUS OH 432312957 DAN SHIELDS 6148908282 2011-05-04 1 Bernie Ostrowski 6148493000 2009 2016-02-24 21:20:13Z DAN SHIELDS 5800 FOREST HILLS BLVD COLUMBUS OH 432312957 16242746 0 X WWW.FRIENDSHIPVILLAGEOH.COM X 1977 OH THE MISSION OF FRIENDSHIP VILLAGE OF COLUMBUS IS TO PROVIDE A LIFE CARE RETIREMENT COMMUNITY FOR PHYSICALLY AND FINANCIALLY QUALIFIED PERSONS ON A FISCALLY SOUND, NOT-FOR-PROFIT BASIS THAT ENHANCES THE DIGNITY, SECURITY, AND INDEPENDENCE OF RESIDENTS. 9 9 334 187 0 0 14860 80042 15474309 15910016 110746 155866 38915 36871 15638830 16182795 23100 38700 0 7611088 7636401 70521 37570 42979 8040049 9099998 15744758 16812669 -105928 -629874 28812926 27928483 34344866 33871252 -5531940 -5942769 THE MISSION OF FRIENDSHIP VILLAGE OF COLUMBUS IS TO PROVIDE A LIFE CARE RETIREMENT COMMUNITY FOR PHYSICALLY AND FINANCIALLY QUALIFIED PERSONS ON A FISCALLY SOUND, NOT-FOR-PROFIT BASIS THAT ENHANCES THE DIGNITY, SECURITY, AND INDEPENDENCE OF RESIDENTS. 0 0 14771069 38700 15910016 FRIENDSHIP VILLAGE OF COLUMBUS, INC. CONSISTS OF 229 APARTMENTS, A 90 BED SKILLED NURSING FACILITY AND A 63 BED ASSISTED LIVING FACILITY, SERVING OVER 300 RESIDENTS. FRIENDSHIP VILLAGE PROVIDES ITS RESIDENTS WITH A SECURE, COMFORTABLE ENVIRONMENT IN A WARM, FRIENDLY AND CONGENIAL ATMOSPHERE THAT ENCOURAGES PHYSICAL AND PSYCHOLOGICAL WELL-BEING, WORTH, AND INDIVIDUAL UNIQUENESS OF RESIDENTS, EMPLOYEES AND OTHERS. SINCE EVERYONE'S NEEDS ARE DIFFERENT, FRIENDSHIP VILLAGE OFFERS A VARIETY OF CARE LEVELS TO ITS RESIDENTS, SUCH AS SKILLED NURSING, INTERMEDIATE CARE, REHABILITATIVE THERAPIES, HOSPICE CARE, PERITONEAL DIALYSIS, SURGICAL WOUND CARE, AND RESPITE CARE. EVERY RESIDENT IS ASSURED OF CONSISTENT, HIGH QUALITY CARE 24 HOURS A DAY, EVERY DAY OF THE YEAR. FRIENDSHIP VILLAGE PROVIDES A HOUSEKEEPING STAFF THAT TAKES CARE OF DETAILS LIKE CLEANING AND WEEKLY LAUNDRY SERVICE. MAINTENANCE TEAMS ARE ON CALL 24 HOURS A DAY. THE HEALTH CARE CENTER OFFERS A VARIETY OF PLANNED CULTURAL, SOCIAL, RELIGIOUS, AND RECREATIONAL ACTIVITIES TO HELP RESIDENTS REMAIN AS ACTIVE AND INVOLVED AS POSSIBLE. FRIENDSHIP VILLAGE PROVIDES HOME-STYLE MEALS THREE TIMES A DAY AND CAN ACCOMMODATE ANY SPECIAL DIET. RIDGEWOOD TERRACE AT FRIENDSHIP VILLAGE OF COLUMBUS, OHIO INC. PROVIDES SPECIALIZED CARE FOR INDIVIDUALS LIVING WITH MEMORY DISORDERS. PROFESSIONALS WORK WITH RESIDENTS AND THEIR FAMILY MEMBERS TO PROVIDE THERAPEUTIC AND RECREATIONAL ACTIVITIES. EXTRA SAFETY PRECAUTIONS HAVE BEEN TAKEN TO INSURE THAT RESIDENTS WILL NOT INJURE THEMSELVES OR OTHERS. EMERGENCY CALL BUTTONS IN EVERY BEDROOM AND BATHROOM ASSURE THAT HELP IS AVAILABLE ANY TIME, DAY OR NIGHT. 14771069 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 13 0 1 334 1 0 0 0 0 0 0 0 0 0 9 9 0 1 0 0 0 0 0 1 1 1 0 1 1 1 1 1 1 1 1 0 OH X JOE BUCKLEY 6148908282 5800 FOREST HILLS BOULEVARD columbus OH 43231 JOSEPH FOLEY 10.00 X X 0 0 0 MAX THOMPSON 5.00 X X 0 0 0 EDWARD SCHULTZ 5.00 X X 0 0 0 STEVE POTTER 5.00 X 0 0 0 SCOTT CROW 5.00 X 0 0 0 HUGH ALLEN 5.00 X 0 0 0 FRANK SHEPHERD 5.00 X 0 0 0 SUE ANN NORTON 5.00 X 0 0 0 KATHERINE KISKER 5.00 X 0 0 0 PAULETTE LUNEBORG 5.00 X 0 0 0 KATHLEEN GUZLEY 5.00 X 0 0 0 ANNE SKIDMORE 5.00 X 0 0 0 SCOTT POWELL 5.00 X 0 0 0 THOMAS MILLER 50.00 X 121437 0 15150 ERIC DUDASKO 50.00 X 0 0 0 DAN SHIELDS 50.00 X 0 0 0 MONICA KING 50.00 X 79610 0 7641 JOE BUCKLEY 50.00 X 0 0 0 201047 0 22791 1 0 0 0 REHABWORKS LLC PO BOX 503534 ST LOUIS MO 63150 THERAPY SERVICES 800227 SYSCO FOOD SERVICES 2400 HARRISON ROAD COLUMBUS OH 43204 FOOD SERVICES 671851 AMERICAN ELECTRIC POWER 1 RIVERSIDE PLAZA COLUMBUS OH 43215 ELECTRICITY SERVICE 585530 LIFE CARE SERVICES LLC 400 LOCUST ST DES MOINES IA 50309 MANAGEMENT SERVICES 502285 OMNICARE PHARMACY 100 EAST RIVER CENTER BLVD COVINGTON KY 41011 PHARMACEUTICAL SERVICES 229290 16 80042 80042 APTS./SKILLED NURSING 623000 15910016 15910016 15910016 180514 180514 33439 33439 33439 33439 35303 59951 35303 -59951 -24648 -24648 OTHER INCOME 900099 3432 3432 3432 16182795 15910016 0 192737 38700 38700 210819 210819 6221391 5537038 684353 57181 40599 16582 672948 598924 74024 474062 436137 37925 466271 466271 56715 56715 52900 52900 37570 37570 933723 756316 177407 335703 335703 2034706 1932971 101735 30733 30118 615 1050245 1050245 16937 3896 13041 886065 886065 1401591 1356999 44592 135013 135013 BAD DEBT 898264 898264 FRANCHISE TAXES 398852 398852 CAPITAL DEVELOP. LOSS 302398 302398 RECRUITING 58260 58260 RESIDENT ACTIVITIES 32831 32831 8791 3382 5409 16812669 14771069 1998621 42979 1000 1000 673745 820390 1546641 1014924 57702 49812 50796 46287 3899 28518 38468095 19934156 19350726 18533939 2272895 2900013 1738560 1477428 3116962 3056172 28812926 27928483 3568038 2997613 7201208 7922179 17015000 16555000 6560620 6396460 34344866 33871252 X -5740875 -6194259 208935 251490 -5531940 -5942769 28812926 27928483 X 0 1 0 X 0 X 66036 29671 105904 14860 80042 296513 15118859 16336550 16201613 15474309 15934979 79066310 15184895 16366221 16307517 15489169 16015021 79362823 0 0 0 79362823 251096 317928 325683 110746 213953 1219406 251096 317928 325683 110746 213953 1219406 57163 76962 42374 38915 40919 256333 15493154 16761111 16675574 15638830 16269893 80838562 0.98170 0.97890 0.01510 0.01500 X Schedule A, Part II, Line 12, Explanation of Other Income: other income NET ASSETS RELEASED FROM RESTRICTION RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 1252 0 0 0 1252 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: MEMBERSHIP DUES IN THE AMOUNT OF $17,892 WERE PAID TO AOPHA: 7% ($1,252) OF THE DUES RELATED TO LOBBYING. 527425 527425 19564083 10281694 9282389 1207903 906742 301161 17168684 8745720 8422964 18533939 GOVERNMENTAL OBLIGATIONS 1205715 F CASH EQUIVALENTS 271713 F 1477428 ASSETS LIMITED AS TO USE HELD BY TRUSTEE 2555309 Bond Issuance Costs, Net 500863 3056172 REFUNDABLE ENTRANCE FEES 6396460 6396460 16182795 16812669 -629874 219045 219045 -410829 15980700 219045 -341098 -122053 16102753 80042 80042 16182795 16471571 0 16471571 341098 341098 16812669 Part XII, Line 2d - Other Adjustments: RECLASS OF HARDSHIP DISCOUNTS: -38700. RECLASS OF DEVELOPMENT LOSS: -302398. Part XII, Line 4b - Other Adjustments: RESTRICTED CONTRIBUTIONS: 80042. Part XIII, Line 4b - Other Adjustments: RECLASS OF HARDSHIP DISCOUNTS: 38700. RECLASS OF DEVELOPMENT LOSS: 302398. X X 1 DOUG ALLINGER CONSULTING 0 0 37570 0 37570 OH 1 HARDSHIP DISCOUNTS 3 38700 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Policy: It is the policy of Friendship Village of Columbus to provide financial assistance to residents of Friendship Village of Columbus who demonstrate a financial need. Purpose: To provide financial assistance to residents who have developed a financial need due to unforeseen or uncontrollable circumstances. Procedure: -Each applicant must submit a current financial statement showing assets and monthly income. -Each application will be reviewed by the Executive Director and a committee of the Board of Trustees for approval under the guidelines adopted by the Board of Trustees. Guidelines: Level of financial standing for discount consideration: A. Assets Single Person: Not more than $1,500 Couple: Not more than $3,000 B. Monthly Income Each Person: The income level at which Friendship Village of Columbus will consider applications for Hardship Discount is determined by whether the resident's monthly income is less than the sum of the following monthly expense. 1. Charge for the standard service fee Plus 2. Charges for two extra meals per day Plus 3. Medical expense not covered by Medicare or insurance over $35/month Plus 4. An allowance of one hundred dollars ($100) per month for incidentals. C. Because of the effect upon other residents where Hardship Discount is granted the following will be used in considering an application for discount: 1. No resident may willingly and knowingly give, transfer or convey his/her assets or pledge the income therefrom to any person (i.e. relative by blood or marriage, friend or institution) during the period of time of residency at Friendship Village of Columbus. 2. The Executive Director may, at his discretion, require of the resident an accounting of assets stated on the entrance application in order to determine that no deliberate divestiture has taken place. 3. If deliberate falsification of the entrance application or deliberate divestiture of assets has been made, the Board of Trustees may terminate the Residency Agreement of that resident for failure to make all or any part of the payments as outlined in the Residency Agreement. 4. If the resident is residing in a one or two bedroom apartment, they will be required to relocate to an alcove unit when one is available. The move will take place within 90 days of the hardship approval date. The transfer will be in accordance with the Internal Transfer Policy (other than the entrance fee refund will be provided the resident at the time of transfer). D. Review: 1. The administration may, at its discretion, request a revised Confidential Financial Statement from any resident receiving financial assistance when it is felt there is a significant change in their financial status. 2. A current Confidential Financial Statement on a form furnished by Friendship Village of Columbus must be re-submitted in the month of July each year for all resident needing continued financial assistance. E. Emergency Clause: 1. The Board of Trustees authorizes the Executive Director to grant up to a $150 one time discount on an emergency basis without board approval providing the applicant meets the above financial guidelines. 2. The Board of Trustees authorizes the Executive Director to approve deferred payment of monthly service fee for a period of time up to 90 days in order for a resident to make adjustments in personal finances to be able to meet the monthly service payment. Further authorized deferred payment of monthly service fees must be approved by the Board of Trustees. Form 990, Part VI, Section A, line 3 A MANAGEMENT CONTRACT TO OVERSEE DAILY OPERATIONS IS ADMINISTERED BY LIFE CARE SERVICES, INC. LIFE CARE SERVICES, INC. PROVIDES INFORMATION SYSTEMS, MARKETING, HUMAN RESOURCES, RISK MANAGEMENT, AND FINANCIAL SYSTEM SUPPORT UNDER THE CONTRACT AGREEMENT. THE EXECUTIVE DIRECTOR (THOMAS MILLER, LATER REPLACED BY INTERIM ERIC DUDASKO, LATER REPLACED BY DAN SHIELDS) IS EMPLOYED BY LIFE CARE SERVICES. TOTAL COMPENSATION AND BENEFITS IN 2009 TOTALED $136,587. Form 990, Part VI, Section B, line 11 FORM 990 IS REVIEWED BY THE EXECUTIVE DIRECTOR. AN ELECTRONIC COPY OF THE FORM IS PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING, ALONG WITH A SUMMARY OF THE INCREASED FILING REQUIREMENTS BEGINNING IN 2008. Form 990, Part VI, Section B, line 12c EACH BOARD MEMBER IS REQUIRED TO SIGN A CONFLICT OF INTEREST POLICY AGREEMENT UPON ACCEPTANCE OF THE POSITION AS WELL AS ON AN ANNUAL BASIS AFTERWARD. ANNUALLY AT THE JUNE BOARD MEETING, THE POLICY IS REVIEWED BY THE PRESIDENT AND DISCLOSURE SHEETS ARE SIGNED BY EACH TRUSTEE AND KEPT ON FILE IN THE ADMINISTRATIVE FILE. IF NEW CONFLICTS ARISE, THE CONFLICT IS DISCLOSED IMMEDIATELY TO THE BOARD FOR DISCUSSION AT THE MONTHLY BOARD MEETING AND THE BOARD MEMBER WITH A CONFLICT OF INTEREST WOULD ABSTAIN FROM VOTING IN ANY RELATED MATTER. Form 990, Part VI, Section B, line 15 MANAGEMENT PREPARES AND/OR REVIEWS THE ANNUAL PERFORMANCE REVIEW IN EACH INSTANCE FRIENDSHIP VILLAGE OF COLUMBUS HIRES A NEW EXECUTIVE DIRECTOR, DIRECTOR OF ACCOUNTING, OR ADMINISTRATIVE MEMBER. COMPENSATION FOR SIMILAR POSITIONS IS COMPILED AND COMPARED ON A REGIONAL AND NATIONAL LEVEL THROUGH AOPHA'S SALARY SURVEY TO MAINTAIN COMPETITIVE SALARIES WITHIN THE INDUSTRY. Form 990, Part VI, Section C, line 18 FORM 990 AND FORM 1023 ARE AVAILABLE UPON REQUEST. Form 990, Part VI, Section C, line 19 BOOKS ARE KEPT IN THE RESIDENT LIBRARY, ADMINISTRATIVE OFFICE, AND FRIENDSHIP VILLAGE'S SYSTEMS NETWORK. FORM 990, PART VI, LINE 9: THE FOLLOWING OFFICERS CAN BE REACHED AT THE NOTED ADDRESS: THOMAS MILLER - 970 SUMMER PARKWAY, COPLY, OH 44321 ERIC DUDASKO - ONE HOKE SMITH BLVD, GREENVILLE, SC 29615