2011-05-16T11:28:09-05:00 2010-09-30 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2009-10-01 410693953 AUGUSTANA CHAPEL VIEW HOMES INC AUGU 6122385225 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 CRAIG KITTELSON 6122385225 2011-05-13 1 6123764500 2009 2016-02-24 21:20:13Z TIM TUCKER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 40612002 0 X www.augustanacare.org X 1908 MN TO PROVIDE HEALTH CARE, HOUSING AND COMMUNITY SERVICES FOR THE ELDERLY. 7 7 879 272 3341 -1665 1224501 154082 39750023 38933835 306973 457926 587719 672963 41869216 40218806 1630247 1067155 0 22117843 21359124 0 0 18204991 18160604 41953081 40586883 -83865 -368077 43739152 43040649 37694492 37124125 6044660 5916524 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 31314820 1067055 34150905 NURSING HOME: AUGUSTANA CHAPEL VIEW HOMES OPERATES TWO LICENSED LONG TERM CARE FACILITIES WITH A TOTAL OF 414 LICENSED BEDS. THESE AUGUSTANA CHAPEL VIEW FACILITIES SERVED 1,801 INDIVIDUALS DURING THE YEAR ENDED SEPTEMBER 30, 2010. 4886500 100 4782930 SENIOR HOUSING: AUGUSTANA CHAPEL VIEW HOMES OPERATES TWO ATTACHED CONGREGATE HOUSING FACILITIES OF 422 UNITS. THESE AUGUSTANA CHAPEL VIEW FACILITIES SERVED 458 INDIVIDUALS DURING THE YEAR ENDED SEPTEMBER 30, 2010. 36201320 1 1 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 879 1 1 1 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 6122385225 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 X PR DAN SEIDELMANN 2.00 X X 0 0 0 ED VICTORSEN 2.00 X X 0 0 0 SCOTT SWISHER 2.00 X X 0 0 0 DONALD BROWN 2.00 X 0 0 0 PR MICHELENE VERLAUTZ 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 JEAN COLE 40.00 X 120986 0 24696 MARY ROY 40.00 X 107669 0 23437 228655 979401 247798 2 0 1 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 MANAGEMENT SERVICES 2265117 1 154082 154082 NURSING 623000 34150905 34150905 ASSISTED LIVING 623000 4782930 4775124 7806 38933835 457926 457926 851798 393196 458602 458602 3341 455261 OTHER REVENUE 900099 214361 214361 214361 40218806 38926029 3341 1135354 1000000 1000000 67155 67155 17668149 16842339 825810 261599 238416 23183 2120574 2015832 104742 1308802 1248238 60564 2265117 2265117 32197 32197 59610 59610 3188628 3099738 88890 83351 83351 689907 517451 172456 2048456 2048456 23305 13404 9901 24918 22444 2474 2027764 2027764 2259709 2259709 332534 332534 NURSING SUPPLIES 1816131 1816131 DIETARY EXPENSES 1534259 1534259 LICENSES, PERMITS, FEES 1328409 1263050 65359 BAD DEBT EXPENSE 206902 206902 PREADMISSION SCREENING 91203 91203 148204 95731 52473 40586883 36201320 4385563 0 78814 58749 533594 548201 3523392 3128423 180732 184331 67680360 36701643 32155529 30978717 39996 17354 990314 934838 6236781 7190036 43739152 43040649 3190644 2993120 128185 134921 31160000 30310000 337571 311996 1955795 1876175 922297 1497913 37694492 37124125 X 3542926 3367628 17775 42176 2483959 2506720 6044660 5916524 43739152 43040649 X 0 1 1 X 0 X 1131756 599565 398791 1224501 154082 3508695 35542150 36489828 38440969 39750023 38933835 189156805 36673906 37089393 38839760 40974524 39087917 192665500 14506 11328 4698 565 31097 0 14506 11328 4698 565 31097 192634403 296545 598567 575025 1111197 1064528 3645862 296545 598567 575025 1111197 1064528 3645862 754231 302021 404142 10568 214361 1685323 37724682 37989981 39818927 42096289 40366806 197996685 0.97290 0.97510 0.01840 0.01440 X Schedule 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 LAUNDRY INCOME FROM TENANTS HCIR INSURANCE RECIPROCAL RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 1950375 8145 80637 0 80637 0 1958520 1905706 44669 88455 88455 1950375 1.00000 0 1 1 1737654 1737654 53037217 25634408 27402809 12905489 11067235 1838254 30978717 ASSETS UNDER BOND INDENTURE AGREEMENT 3402980 RESIDENT TRUST FUNDS 108321 HRIR INSURANCE RECIPROCAL 325815 CONTRACT FOR DEED 325000 BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION 1365704 DUE FROM AFFILIATES 1662216 7190036 ANNUITY OBLIGATIONS 180601 RESERVATION DEPOSITS 97500 ASSET RETIREMENT OBLIGATIONS 175774 DUE TO AFFILIATES 1044038 1497913 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: 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. A PORTION OF 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) 1000000 GENERAL OPERATING SUPPORT 1 1 SCHOLARSHIPS 27 67155 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: AUGUSTANA CHAPEL VIEW HOMES MAKES INTERCOMPANY TRANSFERS TO RELATED ORGANIZATIONS. AUGUSTANA CHAPEL VIEW HOMES AND THE RELATED ORGANIZATIONS ARE UNDER COMMON MANAGEMENT WHO REGULARLY MONITOR THE USE OF THE 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 EACH SCHOLARSHIP PAYMENT RECEIVED, WHICH WILL BE DEDUCTED FROM THE RECIPIENT'S FINAL 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 Supplemental Information Part III PART I, LINE 3: FOR THE PURPOSE OF DETERMINING COMPENSATION, AUGUSTANA CHAPEL VIEW HOMES 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. CITY OF MINNEAPOLIS MINNESOTA 416005375 603908KZ6 2005-02-24 3310000 REFINANCE 0 0 CITY OF MINNEAPOLIS MINNESOTA 416005375 603908MD3 2005-05-31 12470000 CONSTRUCTION AND REMODELING 0 0 CITY OF MINNEAPOLIS MINNESOTA 416005375 603908LW2 2005-05-31 2160000 CONSTRUCTION AND REMODELING 0 0 CITY OF MINNEAPOLIS MINNESOTA 416005375 603926CC8 2006-05-19 7010000 REFINANCE 0 0 CITY OF MINNEAPOLIS MINNESOTA 416005375 603926BR6 2004-01-28 8621449 CONSTRUCTION AND REMODELING 0 0 3310000 3243800 66200 2005 1 0 1 1 12470000 920547 756116 249400 10543937 2006 0 0 1 1 2160000 159089 356160 43200 1601551 2006 0 0 1 1 7010000 286610 6583190 140200 2006 1 0 1 1 8621449 731832 5577188 172429 2140000 2006 1 0 1 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 Form 990, Part VI, Section A, line 3 AUGUSTANA CARE SERVICES PROVIDES MANAGEMENT SERVICES FOR AUGUSTANA CHAPEL VIEW HOMES. 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. AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS MUST BE APPROVED, BY A 2/3-MAJORITY VOTE, BY THE BOARD OF DIRECTORS OF THE SOLE MEMBER, AUGUSTANA CARE CORPORATION. AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS THAT RELATE TO THE REQUIREMENTS FOR AFFILIATION WITH THE EVANGELICAL LUTHERAN CHURCH IN AMERICA MUST BE APPROVED BY THE DIVISION FOR SOCIAL MINISTRY ORGANIZATIONS OF THE EVANGELICAL LUTHERAN CHURCH IN AMERICA. 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 CHAPEL VIEW HOMES 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. 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 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 AUGUSTANA HOME OF HASTINGS 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 311572624 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 1 0 0 0 0 1 0 0 1 0 1 1 0 0 0