2011-05-16T11:27:34-05:00 2010-09-30 LARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2009-10-01 311608696 AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY AUGU 6122385225 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 CRAIG KITTELSON 6122385225 2011-05-10 1 6123764500 2009 2016-02-24 21:20:13Z TIM TUCKER 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 22739837 0 X WWW.AUGUSTANACARE.ORG X 1998 MN TO PROVIDE HEALTH CARE, HOUSING AND COMMUNITY SERVICES FOR THE ELDERLY. 7 7 494 203 0 0 477224 35536 22356265 22365488 97054 112766 194354 192344 23124897 22706134 1026501 23564 0 11318492 11278333 0 0 10513987 10868759 22858980 22170656 265917 535478 43199752 43532125 42099521 41826076 1100231 1706049 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 14115371 22414 16825586 AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY OPERATES A 200-BED LICENSED NURSING FACILITY IN APPLE VALLEY, MINNESOTA. THE HEALTH CARE CENTER SERVED 1,043 INDIVIDUALS DURING THE YEAR ENDED SEPTEMBER 30, 2010. 5282485 1150 5539902 AUGUSTANA REGENT AT BURNSVILLE OPERATES A 136-UNIT SENIOR SERVICE AND CONGREGATE HOUSING COMPLEX IN BURNSVILLE, MINNESOTA. THE REGENT SERVED 201 INDIVIDUALS DURING THE YEAR ENDED SEPTEMBER 30, 2010. 19397856 1 0 0 0 0 0 0 1 1 1 0 1 0 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 0 1 1 0 0 0 1 0 0 494 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 6122385225 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 X SCOTT RAMSDALE 4.00 X X 0 0 0 PAUL HARRINGTON 2.00 X X 0 0 0 DON JACOBSON 2.00 X X 0 0 0 TERRENCE MERRITT 2.00 X 0 0 0 LOWELL WILLIAMS 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 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 GLEN SHAW 45.00 X 113647 0 24247 113647 979401 223912 1 0 1 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 MANAGEMENT SERVICES 1145673 1 35536 35536 NURSING FACILITIES 623000 16825586 16825586 HOUSING FACILITIES 623000 5539902 5539902 22365488 110866 110866 37173 37173 37173 37173 35603 33703 1900 1900 1900 DIETARY INCOME 722210 55101 55101 MISCELLANEOUS INCOME 900099 32477 32477 TELEPHONE INCOME 812900 18517 18517 49076 49076 155171 22706134 22365488 0 305110 23564 23564 9543156 8938389 604767 142542 126713 15829 897778 766230 131548 694857 653425 41432 1145673 1145673 10608 10608 34997 34997 614891 575603 39288 61024 61024 362657 219760 142897 761650 761650 40148 10844 29304 21158 16381 4777 2097380 2097380 1814180 1814180 243843 243843 NURSING SUPPLIES 2068551 2068551 DIETARY EXPENSES 685267 685267 LICENSES, PERMITS, FEES 595317 582533 12784 BAD DEBT EXPENSE 227279 227279 PREADMISSION SCREENING 28165 28165 55971 29221 26750 22170656 19397856 2772800 0 1892410 2559415 1955303 1933673 157246 136650 39219424 4925183 35208045 34294241 779741 726390 3207007 3881756 43199752 43532125 1798304 1658948 20900000 20855000 161405 152536 19152647 18848214 87165 311378 42099521 41826076 X 1097291 1696803 128 6194 2812 3052 1100231 1706049 43199752 43532125 X 0 1 1 X 0 X 100 28452 18786 477224 34575 559137 8867237 14846999 20218677 22356265 22365488 88654666 8867337 14875451 20237463 22833489 22400063 89213803 1272 450 1722 0 1272 450 1722 89212081 82920 127294 116972 137501 148039 612726 82920 127294 116972 137501 148039 612726 6128 206115 195004 152407 156132 715786 8956385 15208860 20549439 23123397 22704234 90542315 0.98530 0.98490 0.00680 0.00680 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 MAINTENANCE INCOME FROM TENANTS GIFT SHOP INCOME FROM TENANTS PENDANT ALARM INCOME FROM TENANTS CABLE TV INCOME FROM TENANTS 0 1 2812 240 166 166 3052 2432 380 154 154 2812 1.00000 0 1 1 3377557 3377557 31605488 3445973 28159515 4134372 1479210 2655162 102007 102007 34294241 TENANT SECURITY DEPOSITS 145167 ASSETS UNDER BOND AND MORTGAGE INDENTURE AGREEMENTS 3073927 BENEFICIAL INTEREST IN NET ASSETS OF THE FOUNDATION 3052 RESIDENT TRUST FUNDS 32936 NOTE RECEIVABLE 626674 3881756 DUE TO AFFILIATES 307965 ASSET RETIREMENT OBLIGATION 3413 311378 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. THE ORGANIZATION'S ENDOWMENT IS HELD AND ADMINISTERED BY AUGUSTANA CARE FOUNDATION. SEE SCHEDULE R FOR ADDITIONAL DETAILS. 1 SCHOLARSHIPS 15 23564 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: 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 THE 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 HEALTH CARE CENTER OF APPLE VALLEY 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. APPLE VALLEY ECONOMIC DEVELOPMENT AUTHORITY 410882559 03788ABK4 2006-01-25 15675000 ACQUIRE & IMPROVE FACILITY 0 0 DAKOTA COUNTY COMMUNITY DEVELOPMENT AGENCY 411253302 23409VDN7 2007-07-12 5176617 ACQUIRE FACILITY 0 0 15675000 1090512 313500 14270988 2006 0 0 1 1 5176617 358800 103532 4714285 2007 0 0 1 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 Form 990, Part VI, Section A, line 3 AUGUSTANA CARE SERVICES PROVIDES MANAGEMENT SERVICES FOR AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY. 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 EARVE AUGUSTANA HEALTH CARE CENTER OF APPLE VALLEY 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. AUGUSTANA REGENT AT BURNSVILLE LLC 14500 REGENT LANE BURNSVILLE MN 55306 208915982 ASSISTED LIVING FACILITY MN 5698726 23946118 N/A 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 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 0 0 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0