2016-07-12T13:35:12-05:00 2015-08-31 990 2014-09-01 541516476 Mary Immaculate Nursing Center Inc MARY 7576865000 7007 Harbour View Blvd No 108 Suffolk VA 23435 Michael K Kerner CEO - BSHRHS 7576865000 2016-07-12 0 2014 2016-09-27 15:27:22Z St Francis Nursing Center Michael K Kerner 7007 Harbour View Blvd No 108 Suffolk VA 23435 9189860 0 0928 X http://bshr.com/ X 1989 VA Skilled Nursing Facility 18 16 163 16 0 0 0 0 8925434 9171971 8979 6953 12560 10936 8946973 9189860 0 0 0 0 4487256 4860256 0 0 0 4587425 4005181 9074681 8865437 -127708 324423 9042875 9438593 4455162 4559153 4587713 4879440 The mission is to bring compassion to skilled nursing care and to be good help to those in need, especially those who are elderly, poor and dying. 0 0 6903786 0 7203207 Skilled Nursing Care provided to patients to include assessment of cognitive and physical status, personal hygeine care, nutrition and maintenance of a clean and comfortable environment. 784889 0 1432492 Rehabilitation Therapies to include physical therapy, respiratory therapy and occupational therapy so as to maintain each patient's optimal quality of life. 468416 0 536272 Medication & Diagnostic Treatments to include the administration of medication, ongoing assessment of potential interactions and negative side effects, wound care and facilitation of diagnostic testing as needed. 8157091 1 0 0 1 0 0 0 0 1 0 1 0 0 1 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 13 0 1 163 1 0 0 0 0 0 0 0 0 0 0 X 18 16 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 X James Pirtle 7572152709 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 X Michael Archuleta Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Brother Arthur Caliman Board Member 2.00 48.00 X 0 0 0 Sister Elaine Davia Board Member 2.00 2.00 X 0 0 0 Timothy Davis Board Member 2.00 48.00 X 0 1019679 151683 Debra Deihl Board Member 2.00 0.00 X 0 0 0 Gabriel Franco Board Member 2.00 0.00 X 0 0 0 John Garrett Chairman (Sep-Dec) 3.00 0.00 X X 0 0 0 Rev Ivan Harris Board Member 2.00 0.00 X 0 0 0 Matthew James Board Member (Sep-Dec) 2.00 0.00 X 0 0 0 Dr Vincent Joseph Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Deborah Jones Board Member 2.00 0.00 X 0 0 0 Michael Kerner CEO - BSHR 1.00 49.00 X X 0 958311 131925 Sister Sandra Lyons Board Member 2.00 0.00 X 0 0 0 Sister Shaun Malone Board Member 2.00 0.00 X 0 0 0 Helena Mock Secretary (Jan-Aug) 2.00 0.00 X X 0 0 0 Jeffrey Morrison DO Board Member 2.00 0.00 X 0 0 0 Sister David Niski President 3.00 0.00 X X 0 0 0 William Pile Sec (Sep-Dec)/Chairman (Jan-Aug) 3.00 0.00 X X 0 0 0 Joseph Ritchie Board Member (Jan-Aug) 2.00 0.00 X 0 0 0 Caroline Sorokos Board Member 2.00 0.00 X 0 0 0 Robert Yacobi Board Member (Sep-Dec) 2.00 0.00 X 0 0 0 Charmaine Rochester Treasurer/VP Finance 1.00 49.00 X 0 243142 16388 Patricia Robertson CEO - MIH & Ext Care 2.00 48.00 X 0 442986 27267 Darlene Stephenson CEO - MIH (Oct-Aug) 2.00 48.00 X 0 219878 22094 0 2883996 349357 0 0 1 0 Tidewater Phys Multispec Group 860 Omni Blvd Suite 304 Newport News VA 23606 Medical Services 276188 Shiftwise PO Box 70870 St Paul MN 551709705 Contract Nursing 144919 Shared Hospital Svcs 3530 Elmhurst Lane Portsmouth VA 23701 Laundry Service 103156 3 Patient Service Rev. 623110 9171971 9171971 9171971 6953 6953 Beauty & Barber Shop 812112 7665 7665 Purchase Discounts 900099 2747 2747 Medical Record Request 900099 140 140 384 384 10936 9189860 9171971 0 17889 3846871 3462184 384687 82794 74515 8279 567954 511159 56795 362637 326373 36264 34994 31495 3499 831 748 83 310428 310428 92947 83652 9295 14983 13485 1498 339776 305798 33978 907 816 91 1773 1596 177 50239 50239 226000 203400 22600 74857 67371 7486 Purchased Services 1143104 1028794 114310 Medical Supplies 829281 829281 0 Bad Debt 592022 592022 0 BSHSI Mgmt Allocation 131343 118209 13134 161696 145526 16170 8865437 8157091 708346 0 850 1001 5807832 6778418 1628436 885962 2396 29216 4639790 3659852 933422 979938 669939 764058 9042875 9438593 373070 393666 7532 9277 4074560 4156210 4455162 4559153 X 4568667 4860394 19046 19046 4587713 4879440 9042875 9438593 X 324423 -32696 X 0 1 X 1 0 X 8264815 8516605 8600177 8925434 9171971 43479002 8264815 8516605 8600177 8925434 9171971 43479002 0 0 0 43479002 10637 11366 10851 8979 6953 48786 10637 11366 10851 8979 6953 48786 26529 23615 24038 12560 10935 97677 8301981 8551586 8635066 8946973 9189859 43625465 0.99660 0.99650 0.00110 0.00140 X Schedule A, Part III, Line 12, Explanation of Other Income: Beauty Barber - 2010 Amount: $ 13,099. 2011 Amount: $ 13,722. 2012 Amount: $ 13,675. 2013 Amount: $ 10,690. 2014 Amount: $ 7,665. Other - 2010 Amount: $ 13,430. 2011 Amount: $ 9,893. 2012 Amount: $ 10,363. 2014 Amount: $ 523. Purchase Discounts - 2013 Amount: $ 1,870. 2014 Amount: $ 2,747. 0 0 0 0 0 0 0 0 1 831 831 0 Part II-B, Line 1: The filing organization maintains memberships to various professional healthcare associations. Portions of their membership dues are used for lobbying activities. The lobbying portion of such dues is included on line 1i. 0 1 X 3315118 2739494 575624 1103916 919641 184275 220756 717 220039 979938 MedMal & Gen Liab 605161 Medicare Settlement 105204 Due from BSHSI 44380 Assets HIT for Others 9277 Due From Affiliates 36 764058 Due to BSHSI 3498335 MedMal & Gen Liab 605161 Due to Affiliates 46567 Medicare Settlement 6147 4156210 X Part IV, Line 2b: Resident Trust Fund Account - The filing organization holds, safeguards, manages, and accounts for the personal funds of residents who have authorized the facility in writing to manage any personal funds. Any redsudent may deposit money in to a personal resident fund account. Deposits may not exceed $2,000 for residents receiving Medicaid. Withdrawal requests greater than $50 must be made prior to 4 pm to allow time to obtain funds from the banking institution if necessary. All excess custodial funds are held in interest bearing accounts separate from that of the organization. Part X, Line 2: Schedule D, Part X, Line 2 requires that the organization provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under ASC 740. ASC 740 addresses the accounting for uncertainty in income taxes recognized in an entity's financial statements and prescribes a threshold of more-likely-than-not for recognition and derecognition of tax positions taken or expected to be taken in a tax return. The adoption of ASC 740 by BSHSI on September 1, 2007 did not have a material impact on BSHSI's consolidated financial statements. As the organization does not conduct a separate audit of its financial statements, below is the related statement from the Bon Secours Health System, Inc. consolidated audited financial statements: The System and most of its subsidiaries (including certain joint venture entities) are exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. The system accounts for uncertain tax positions in accordance with ASC Topic 740. The System's taxable subsidiaries have approximately $84,748 and $61,513 of net operating loss carryforwards as of August 31, 2015 and 2014, respectively, which expire in varying periods through 2035 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2015 and 2014 as the System considers it more likely than not that these amounts will not be recognized. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. 0 1 0 0 0 0 0 0 0 Timothy Davis Board Member 0 617514 0 191208 0 210957 0 132084 0 19599 0 1171362 0 135985 Michael Kerner CEO - BSHR 0 527082 0 221442 0 209787 0 101956 0 29969 0 1090236 0 125798 Charmaine Rochester Treasurer/VP Finance 0 195153 0 47816 0 173 0 12271 0 4117 0 259530 0 0 Patricia Robertson CEO - MIH & Ext Care 0 291541 0 100199 0 51246 0 15600 0 11667 0 470253 0 0 Darlene Stephenson CEO - MIH (Oct-Aug) 0 171757 0 40496 0 7625 0 3818 0 18276 0 241972 0 0 Part I, Line 3 Bon Secours Health System, Inc., a related organization of the filing organization, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation Committee Independent Compensation Consultant Written Employment Contract Compensation Survey or Study Approval by the Board or Compensation Committee Part I, Line 4b The filing organization participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement plans and is available only to officers and key employees. The 457F plan is a non-qualified plan and is subject to a minimum three-year service requirement before vesting on deposits made into this plan. Individuals that received a distribution include: Timothy Davis, $181,617; Michael Kerner, $164,862. Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc., and the General Minister and General Council of the Bernardine Sisters of the Third Order of St. Francis are the members of Mary Immaculate Hospital, Inc., which in turn is the sole member of Mary Immaculate Nursing Center. Form 990, Part VI, Section A, line 7a The governing body of Mary Immaculate Nursing Center is appointed by its member Mary Immaculate Hospital, Inc., and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Mary Immaculate Nursing Center are reserved to its member or to Bon Secours Health System, Inc. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of a review by the local system's audit and compliance board-committee and providing the form to the local system board of directors to allow for a thorough review by both before the filing date. The local system's audit and compliance committee and board of directors have reviewed the Form 990, scheduled time on meeting agendas, and asked questions regarding the Form 990 before the return is filed. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors compliance with the conflict of interest policy. On an annual basis, all persons subject to the policy, including all officers, directors and key employees are required to make certain disclosures. These include disclosures related to certain personal, financial and organizational relationships that may present a conflict, or the appearance of a conflict of interest with the organization. All disclosures go through a three-part review process: (1) disclosures are reviewed first by the corporate responsibility officer (CRO); (2) a governance team comprised of the CEO, board president, board chair, CRO, and the BSHSI CRO participate in a second review of all disclosures during which recommendations are made as to the resolution of any conflicts or potential conflicts. Depending on the facts and circumstances, resolutions may include ongoing disclosure, recusal or removal of the conflict; and (3) all disclosures and recommendations are reviewed by a board committee (audit and compliance committee reviews the disclosures of management and the governance committee reviews the disclosures of the board and board committee members). Form 990, Part VI, Section B, line 15b The compensation committee of the board of Bon Secours Health System, Inc. (BSHSI) engages in a comprehensive process for the oversight and management of remuneration for executive employees and disqualified parties of the BSHSI. The compensation committee consists of a group of independent board members and engages an independent external compensation consultant to ensure they receive appropriate analysis of market and follow the practices necessary to obtain full compliance with the IRS's rebuttable presumption of reasonableness. The committee establishes and maintains a compensation philosophy; reviews pay practices against local, regional and national healthcare organizations and approves all remunerative decisions for this group of individuals. The committee reviews and receives assurances that all levels of pay within the organization are reasonable based on performance and validates incentives are met. These decisions are documented in the BSHSI board of directors and compensation committee minutes. Compensation Process Other Officers/ Key Employees: For those key employees and highest paid employees that are not reviewed by the BSHSI compensation committee, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. In the review, the other officers or key employees of the organization were compared to other hospitals' employees in the area that hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in human resources. Form 990, Part VI, Section C, line 19 The filing organization makes all documents available to the general public upon request. Form 990, Part VII Board Member positions are generally voluntary in nature. Compensated employees of the filing organization and other related organizations who also hold board positions are compensated only in relation to their employment and do not receive additional compensation for their board responsibilities. The governing bodies of Mary Immaculate Hospital and Mary Immaculate Nursing Care Center are comprised of the same board members and board officers (Chairman, President, Secretary and Treasurer). These governing bodies are referred to as the Mary Immaculate Joint Board. Hours reported for these voluntary board positions represent total hours worked per week, which include responsibilities for both entities). Br. Art Caliman does not receive payroll distributions as he has taken a vow of poverty. Form 990, Part XI, line 9: BSHSI Principal Debt & Swap Payments -32,696. Bon Secours Health System Inc 1505 Marriottsville Road Marriottsville MD 21104 521301088 Parent Org. - Management Services MD 501(c)(3) Line 11c, III-FI Bon Secours Inc 0 Bon Secours Hampton Roads Health System Inc 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 521538513 Local System Parent Org. VA 501(c)(3) Line 11c, III-FI Bon Secours Health System Inc 0 Maryview Hospital 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 540506463 Healthcare VA 501(c)(3) Line 3 Bon Secours Hampton Roads Health System 0 Mary Immaculate Foundation 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 311644734 Fundraising VA 501(c)(3) Line 11c, III-FI Mary Immaculate Hospital 0 Mary Immaculate Hospital Inc 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 540548200 Healthcare VA 501(c)(3) Line 3 Bon Secours Health System Inc 0 Bon Secours Maryview Foundation 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 521694731 Fundraising VA 501(c)(3) Line 7 Bon Secours Hampton Roads Health System 0 Bon Secours Maryview Nursing Care Center 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 521578169 Nursing Care Center VA 501(c)(3) Line 9 Bon Secours Hampton Roads Health System 0 Bon Secours DePaul Medical Center 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 541820093 Healthcare VA 501(c)(3) Line 3 Bon Secours Hampton Roads Health System 0 Bon Secours DePaul Health Foundation 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 541843876 Fundraising VA 501(c)(3) Line 7 Bon Secours Hampton Roads Health System 0 Bayley Properties 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 541424748 Rental VA 501(c)(2) Bon Secours DePaul Medical Center Inc 0 Mary Immaculate Hospital Auxiliary 7007 Harbourview Blvd Suffolk VA 23435 546040266 Auxiliary VA 501(c)(3) Line 9 N/A 0 Province Place of Maryview LLC 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541842697 Assisted Living VA N/A Province Place of DePaul LLC 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541950880 Assisted Living VA N/A Professional Health Care Mgmt Inc 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541241031 Administrative VA N/A C 0 Tidewater Diversified Inc 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541431826 Pharmacy VA N/A C 0 OSF Inc 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541369919 Rental VA N/A C 0 0 0 0 1 1 0 0 0 0 0 0 1 1 0 0 1 0 0 0