2024-05-07T09:53:30-05:00 2023-06-30 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2022-07-01 810518821 LONE TREE SENIOR LIVING LONE 4064882100 216 14TH AVENUE SW SIDNEY MT 59270 TINA MONTGOMERY CFO 4064882100 2024-05-06 1 TINA MONTGOMERY XXX-XX-XXXX 1 KURT BENNION CPA P01469618 4252506100 2024-05-06 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z JEN DOTY 216 14TH AVENUE SW SIDNEY MT 59270 1518975 0 X WWW.LODGEATLONETREE.ORG X 1998 MT TO PROVIDE ASSISTED LIVING SERVICES FOR SENIOR ADULTS. 9 8 30 25 0 0 100636 37095 1323264 1459072 1079 -937 13500 18000 1438479 1513230 0 0 0 0 867173 878757 0 0 0 607638 557118 1474811 1435875 -36332 77355 877725 734100 1261159 1040179 -383434 -306079 OUR MISSION IS TO PROVIDE AN ENRICHED LIVING ENVIRONMENT FOR THOSE SEEKING PRIVACY AND INDEPENDENCE, WHILE NURTURING CONTINUED GROWTH OF THE HUMAN SPIRIT THROUGH FRIENDSHIP, SERVICES AND NURSE-DIRECTED PROGRAMS. 0 0 1255301 0 1459072 THE LODGE IS AN ASSISTED LIVING FACILITY DESIGNED FOR SENIOR ADULTS WHO WISH TO MAINTAIN THEIR INDEPENDENCE IN AN ENRICHED, COMFORTABLE SETTING AMONG FRIENDS, FAMILY AND A DEDICATED STAFF. WE PROVIDE YOU WITH CHOICE, INDEPENDENCE, 24-HOUR SECURITY, SERVICE AS YOU NEED IT, COMPANIONSHIP, HOME-COOKED MEALS, WELLNESS PROGRAMS, MEDICATION SERVICES AND NURSE-DIRECTED PROGRAMS. 1255301 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 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 1 0 0 0 1 3 0 1 30 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 1 0 0 0 1 0 1 1 0 0 0 1 1 1 1 1 0 0 0 X TINA MONTGOMERY 4064802100 216 14TH AVE SW SIDNEY MT 59270 RAJOHN KARANJAI MD TRUSTEE/CMO 1.00 39.00 X 0 1090748 0 LESZEK JASZCZAK MD FORMER OFFICER 0.00 0.00 X 0 681078 32667 MALUA TAMBI MD CHIEF OF MEDICAL STAFF 1.00 39.00 X X 0 545166 43928 RALF KIEHL MD CHIEF OF MEDICAL STAFF (THROUGH 12/31/22) 1.00 39.00 X X 0 447346 23004 JEN DOTY CEO 1.00 39.00 X 0 275289 32627 TINA MONTGOMERY CFO 1.00 39.00 X 0 182722 24993 LANCE AVERETT PRESIDENT & VICE PRESIDENT 1.00 1.00 X X 0 0 0 ROBERT BURNISON TRUSTEE & PRESIDENT 1.00 1.00 X X 0 0 0 RANDY JOHNSON VICE PRESIDENT & TRUSTEE 1.00 1.00 X X 0 0 0 REBECCA BRADLEY SECRETARY/TREASURER 1.00 1.00 X X 0 0 0 ERIC BEENKEN TRUSTEE 1.00 1.00 X 0 0 0 SUSAN DUFFEY TRUSTEE 1.00 1.00 X 0 0 0 STEPHANIE LIVERS TRUSTEE 1.00 1.00 X 0 0 0 KEVIN MAYER TRUSTEE (THROUGH 11/16/22) 1.00 1.00 X 0 0 0 CHERYL VAN EVERY TRUSTEE 1.00 1.00 X 0 0 0 0 3222349 157219 0 1 1 0 0 36219 876 37095 RESIDENT REVENUE 623990 1458125 1458125 OTHER PROGRAM REVENUE 623990 947 947 1459072 4808 4808 18000 0 18000 18000 18000 5745 -5745 -5745 -5745 1513230 1459072 0 17063 X 692055 624662 67393 8244 7441 803 125143 112957 12186 53315 48123 5192 1575 1422 153 148756 134270 14486 3532 3188 344 31561 28488 3073 62648 56547 6101 45145 45145 78516 70870 7646 18395 16604 1791 FOOD 117136 105729 11407 RESIDENT SUPPLIES 23787 21471 2316 MAINTENANCE & REPAIRS 12824 11575 1249 DUES & SUBSCRIPTIONS 4383 3956 427 8860 7998 862 1435875 1255301 180574 0 458963 334119 3468 3932 4993 26526 13336 14493 3367715 3012685 396965 355030 877725 734100 168454 144588 36016 50480 1056689 845111 1261159 1040179 X -383434 -306079 -383434 -306079 877725 734100 77355 0 X X 0 1 X 1 0 X 0 14230 271332 100636 37095 423293 1561133 1470261 1335890 1323264 1459072 7149620 1561133 1484491 1607222 1423900 1496167 7572913 0 946291 945145 820101 832417 936008 4479962 946291 945145 820101 832417 936008 4479962 3092951 4300 4748 1024 14579 22808 47459 4300 4748 1024 14579 22808 47459 3817 6097 9914 1569250 1495336 1608246 1438479 1518975 7630286 0.40540 0.41280 0.00620 0.00340 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS REVENUE - 2018 AMOUNT: $ 3,817. 2019 AMOUNT: $ 6,097. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 68003 68003 2688200 2463310 224890 217626 203895 13731 393886 345480 48406 355030 DUE TO RELATED PARTIES 845111 845111 X 105011633 103690834 103690834 1320799 192431 192431 1513230 102446560 101203116 101203116 1243444 192431 192431 1435875 PART IV, LINE 2B: LONE TREE SENIOR LIVING HAS RESIDENT TRUST ACCOUNTS. THE FUNDS ARE HELD IN A SEPARATE BANK ACCOUNT. RESIDENTS CAN ACCESS THEIR FUNDS UPON REQUEST. IF A RESIDENT LEAVES THE FACILITY, ANY REMAINING FUNDS ARE REFUNDED. PART X, LINE 2: THE IRS HAS DETERMINED THAT THE ORGANIZATION IS A TAX-EXEMPT, NONPROFIT CORPORATION UNDER SECTION 501(C)(3) OF THE IRC. THE ORGANIZATION FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: SIDNEY HEALTH CENTER REVENUE PER CONSOLIDATED AFS 103,690,834. PART XI, LINE 4B - OTHER ADJUSTMENTS: SIDNEY HEALTH CENTER ELIMINATIONS PER CONSOLIDATED AFS 189,931. BAD DEBT EXPENSE 2,500. PART XII, LINE 2D - OTHER ADJUSTMENTS: SIDNEY HEALTH CENTER EXPENSES PER CONSOLIDATED AFS 101,203,116. PART XII, LINE 4B - OTHER ADJUSTMENTS: SIDNEY HEALTH CENTER ELIMINATIONS PER CONSOLIDATED AFS 189,931. BAD DEBT EXPENSE 2,500. 0 0 0 0 1 0 1 0 0 RAJOHN KARANJAI MD TRUSTEE/CMO 0 1090748 0 0 0 0 0 0 0 0 0 1090748 0 0 LESZEK JASZCZAK MD FORMER OFFICER 0 680078 0 1000 0 0 0 5861 0 26806 0 713745 0 0 MALUA TAMBI MD CHIEF OF MEDICAL STAFF 0 544066 0 1100 0 0 0 9150 0 34778 0 589094 0 0 RALF KIEHL MD CHIEF OF MEDICAL STAFF (THROUGH 12/31/22) 0 446321 0 1025 0 0 0 7877 0 15127 0 470350 0 0 JEN DOTY CEO 0 272889 0 2400 0 0 0 8456 0 24171 0 307916 0 0 TINA MONTGOMERY CFO 0 180472 0 2250 0 0 0 5607 0 19386 0 207715 0 0 PART I, LINE 3 THE CEO OF LONE TREE SENIOR LIVING IS COMPENSATED THROUGH LONE TREE'S RELATED ORGANIZATION, SIDNEY HEALTH CENTER. THE METHODS USED TO DETERMINE THE CEO'S COMPENSATION ARE (A) COMPENSATION SURVERY OR STUDY AND (B) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 5 SIDNEY HEALTH CENTER PHYSICIANS RECEIVE BONUSES BASED ON PRODUCTIVITY, AMONG OTHER FACTORS, PRODUCTIVITY IS CLOSELY CONNECTED WITH REVENUES. NO BONUS IS PAID BY LONE TREE SENIOR LIVING. PART I, LINE 6 FOR THE EXECUTIVES, ANNUAL RAISES FROM SIDNEY HEALTH CENTER ARE BASED ON MEETING ORGANIZATIONAL GOALS RELATED TO VARIOUS FACTORS INCLUDING EMPLOYEE RETENTION, PATIENT SATISFACTION, QUALITY METRICS, AND OPERATING MARGIN. FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE CONSISTS OF THE OFFICERS AND ONE OTHER MEMBER OF THE BOARD APPOINTED BY THE PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD, PROVIDED ANY ACTION TAKEN SHALL NOT CONFLICT WITH THE ARTICLES OF INCORPORATION, BYLAWS AND STATE POLICIES. ANY OFFICIAL ACTION TAKEN BY THE EXECUTIVE COMMITTEE IS SUBMITTED TO THE BOARD FOR RATIFICATION AT THE NEXT BOARD MEETING. FORM 990, PART VI, SECTION A, LINE 3 SIDNEY HEALTH CENTER PROVIDES VARIOUS MANAGEMENT SERVICES TO LONE TREE SENIOR LIVING. FORM 990, PART VI, SECTION A, LINE 7A INDIVIDUALS BECOME BOARD MEMBERS OF LONE TREE SENIOR LIVING WHEN THEY BECOME BOARD MEMBERS OF SIDNEY HEALTH CENTER. AN INDIVIDUAL REMAINS A BOARD MEMBER OF LONE TREE SENIOR LIVING AS LONG AS THEY ARE A BOARD MEMBER OF SIDNEY HEALTH CENTER. THE CORPORATE MEMBERS OF SIDNEY HEALTH CENTER ELECT THE BOARD MEMBERS OF SIDNEY HEALTH CENTER. FORM 990, PART VI, SECTION B, LINE 11B BEFORE IT IS FILED, THE FORM 990 WAS REVIEWED BY THE FINANCE DIRECTOR, CFO AND CEO. THE CEO AND CFO WILL REVIEW THE COMPLETED FORM 990 WITH THE BOARD OF DIRECTORS AT THEIR NEXT SCHEDULED MEETING AFTER THE FORM 990 IS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE POLICY OF THE CORPORATION IS TO REQUIRE THAT EACH INDIVIDUAL SUBJECT TO THIS POLICY STATEMENT PROMPTLY AND FULLY DISCLOSE ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST, AND THAT THE CORPORATION WILL NOT ENGAGE IN ANY CONTRACT, TRANSACTION, OR ARRANGEMENT INVOLVING A CONFLICT OF INTEREST UNLESS THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS (ACTING AT A DULY CONSTITUTED MEETING THEREOF) DETERMINE BY A MAJORITY VOTE THAT APPROPRIATE SAFEGUARDS TO PROTECT THE CHARITABLE MISSION OF THE CORPORATION HAVE BEEN IMPLEMENTED. A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED ANNUALLY TO ALL INTERESTED PERSONS (BOARD MEMBERS, OFFICERS, AND COMMITTEE MEMBERS). AN INTERESTED PERSON HAS A CONTINUING OBLIGATION TO DISCLOSE THE EXISTENCE AND NATURE OF ANY ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST HE/SHE MAY HAVE. "DISCLOSURE" MEANS PROMPTLY PROVIDING A WRITTEN DESCRIPTION OF THE MATERIAL FACTS OF THE ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST TO THE EXECUTIVE COMMITTEE ON THE CONFLICTS-OF-INTEREST QUESTIONNAIRE. SUCH DISCLOSURE SHALL BE MADE PROMPTLY ANY TIME AN ACTUAL, APPARENT, OR POTENTIAL CONFLICT OF INTEREST ARISES AND BEFORE THE CONSUMMATION OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT THAT IS THE SUBJECT OF THE POTENTIAL CONFLICT OF INTEREST. AT ANY TIME THAT AN ACTUAL, APPARENT, OR A POTENTIAL CONFLICT OF INTEREST IS IDENTIFIED TO THE BOARD OF DIRECTORS, WHETHER THROUGH THE VOLUNTARY SUBMISSION OF A DISCLOSURE STATEMENT BY AN INTERESTED PERSON, OR BY A DISCLOSURE BY A PERSON OTHER THAN THE SUBJECT INTERESTED PERSON, THE EXECUTIVE COMMITTEE SHALL REVIEW THE MATTER AND DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON SHALL NOT BE PRESENT DURING ANY MEETING IN WHICH THE EXECUTIVE COMMITTEE CONDUCTS ITS EVALUATION, EXCEPT TO ANSWER QUESTIONS AS MAY BE NECESSARY. THE EXECUTIVE COMMITTEE MAY REQUEST ADDITIONAL INFORMATION FROM ALL REASONABLE SOURCES AND MAY INVOLVE THE GENERAL COUNSEL IN ITS DELIBERATIONS. ONCE ALL NECESSARY INFORMATION HAS BEEN OBTAINED, EXECUTIVE COMMITTEE SHALL MAKE A FINDING AS TO WHETHER A CONFLICT OF INTEREST INDEED EXISTS, AND SHALL FORWARD THAT FINDING TO THE BOARD OF DIRECTORS FOR DISCUSSION AND VOTE. ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER A CONFLICT OF INTEREST EXISTS. THE SUBJECT INTERESTED PERSON MAY NOT BE PRESENT WHEN THIS VOTE IS TAKEN. ONCE THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS HAVE DETERMINED THAT AN ACTUAL CONFLICT OF INTEREST EXISTS WITH RESPECT TO A PARTICULAR TRANSACTION OR ARRANGEMENT: (I) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS SHALL EXERCISE DUE DILIGENCE TO DETERMINE WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES AND, IF APPROPRIATE, SHALL APPOINT A NON-INTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT. (II) IN CONSIDERING WHETHER TO ENTER INTO THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT, THE BOARD OF DIRECTORS MAY APPROVE SUCH A CONTRACT, TRANSACTION, OR ARRANGEMENT ONLY IF THE DISINTERESTED DIRECTORS DETERMINE BY A MAJORITY VOTE THAT: (A) THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTERESTS AND FOR THE CORPORATION'S OWN BENEFIT; AND (B) THE PROPOSED TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION, TAKING INTO ACCOUNT, AMONG OTHER RELEVANT FACTORS, WHETHER THE CORPORATION COULD OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, OR ARRANGEMENT WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. (III) THE DISINTERESTED MEMBERS OF THE BOARD OF DIRECTORS MAY, IN THEIR DISCRETION, REQUIRE THE INTERESTED PERSON TO LEAVE THE ROOM WHILE THE PROPOSED CONTRACT, TRANSACTION, OR ARRANGEMENT IS DISCUSSED. THE INTERESTED PERSON SHALL LEAVE THE ROOM WHILE THE MATTER IS VOTED ON AND ONLY DISINTERESTED DIRECTORS MAY VOTE TO DETERMINE WHETHER TO APPROVE THE TRANSACTION OR ARRANGEMENT. FORM 990, PART VI, SECTION B, LINE 15 ALL COMPENSATION DETERMINATIONS ARE MADE BY SIDNEY HEALTH CENTER, A RELATED ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENT ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 134,270. MANAGEMENT AND GENERAL EXPENSES 14,486. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 148,756. FORM 990, PART XII, LINE 2C: THE PROCESS FOR OVERSIGHT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. SIDNEY HEALTH CENTER 216 14TH AVENUE SW SIDNEY MT 59270 810233499 HOSPITAL MT 501(C)(3) LINE 3 N/A 0 FOUNDATION FOR COMMUNITY CARE OF RICHLAND COUNTY 221 2ND STREET NW SIDNEY MT 59270 810417465 FUNDRAISING MT 501(C)(3) LINE 12A, I SIDNEY HEALTH CENTER 0 0 0 1 0 1 0 0 0 0 0 0 1 1 1 1 1 0 0 0