2015-05-12T16:00:08-05:00 2014-06-30 860133881 HENRY & HORNE LLP 2055 E WARNER RD STE 101 TEMPE AZ 85284 990 2013-07-01 141906233 HACIENDA SKILLED NURSING FACILITY INC HACI 6022434231 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 WILLIAM TIMMONS CEO 6022434231 2015-05-11 1 COLETTE KAMPS CPA P00367616 4808394900 2015-05-06 2013 2016-03-07 17:11:31Z WILLIAM TIMMONS 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 11124210 0 X WWW.HACIENDAHEALTHCARE.ORG X 2004 AZ SKILLED NURSING AND RESPIRATORY INTERVENTION 9 9 173 15 0 0 49704 1607842 8989929 9515116 849 1252 12401 0 9052883 11124210 0 0 0 0 5609796 6385277 0 0 0 2520458 2832663 8130254 9217940 922629 1906270 14817058 14083373 8976404 6285681 5840654 7797692 TO PROVIDE NURSING AND RESPIRATORY CARE TO THOSE WHO REQUIRE FREQUENT SKILLED NURSING AND RESPIRATORY INTERVENTION. 0 0 9016850 9515116 ARIZONA'S FIRST SKILLED NURSING FACILITY FOR INFANTS, CHILDREN, TEENS, AND YOUNG ADULTS. CARE FOR MEDICALLY FRAGILE PATIENTS WHO REQUIRE FREQUENT SKILLED NURSING AND RESPIRATORY INTERVENTIONS. 9016850 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 6 0 173 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 AZ X THE ORGANIZATION 6022434231 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 X GARY ORMAN PRESIDENT 2.00 X X 0 0 0 TOM POMEROY EXECUTIVE VICE PRESIDENT 2.00 X X 0 0 0 PATRICK WALSH VICE PRESIDENT 2.00 X X 0 0 0 RALPH WALLWORK TREASURER 2.00 X X 0 0 0 KATHRYN L DEL REAL SECRETARY 2.00 X X 0 0 0 DICK KAUPIE BOARD MEMBER 1.00 X 0 0 0 KEVIN BERGER BOARD MEMBER 1.00 X 0 0 0 THOM NIEMIEC BOARD MEMBER 1.00 X 0 0 0 MIKE WADE BOARD MEMBER 1.00 X 0 0 0 WILLIAM TIMMONS CHIEF EXECUTIVE OFFICER 10.00 30.00 X 0 461913 25574 DALE SKURDAHL CHIEF OPERATIONS OFFICER 10.00 30.00 X 0 158593 27773 JOSEPH O'MALLEY CFO 10.00 30.00 X 0 182118 16817 ROXANNE ROSE ADMINSTRATIVE DIRECTOR OF NURSING AT SNF 40.00 X 103794 0 5245 PERRY PETRILLI VP-RESIDENTAL SERVICES 10.00 30.00 X 0 149936 6586 LEAH SHALER VP- HEALTHCARE SUPPORT SERVICES 10.00 30.00 X 0 135546 22262 103794 1088106 104257 1 0 1 0 LOS NINOS HOSPITAL INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 NURSING REGISTRY AND THERAPY SERVICES 484026 HACIENDA INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 MANAGMENT SERVICES 159300 2 1607842 39030 1607842 PRIVATE PATIENT SERVICE REVENUES 623000 8413242 8413242 GOVERNMENT PATIENT SERVICE REVENU 623000 469829 469829 PROGRAM RENTAL INCOME 532000 316666 316666 NURSING FACILITY SUPPLEMENTS 623000 248901 248901 OVERPAYMENTS - INSURANCE 623000 66478 66478 9515116 1252 1252 11124210 9515116 0 1252 5561266 5561266 70610 70610 266157 266157 487244 487244 159300 159300 16250 16250 631854 617564 14290 2778 2778 2394 2394 276708 276708 156328 156328 342613 342613 288030 288030 SUPPLIES 445993 445993 FOOD 127389 127389 BED DEBT EXPENSE 118834 118834 MEDICAL EQUIPMENT 84698 84698 179494 168244 11250 9217940 9016850 201090 0 700 700 1648515 1302713 1296390 5474 5813 3988 2196 11528084 2308865 9465099 9219219 157044 2390569 3402011 14817058 14083373 249098 489874 6000000 4255373 2727306 1540434 8976404 6285681 X 5476884 7416422 363770 381270 5840654 7797692 14817058 14083373 X 1906270 9258 41510 X X 0 1 X 1 0 X 520732 204464 420618 49704 1607842 2803360 7060007 7598206 8037896 8879929 9198450 40774488 7580739 7802670 8458514 8929633 10806292 43577848 300000 265600 565600 0 300000 265600 565600 43012248 3213 2003 671 13250 1252 20389 3213 2003 671 13250 1252 20389 7583952 7804673 8459185 8942883 10807544 43598237 0.98660 0.98140 0.00050 0.00070 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9204689 1553783 7650906 198491 46719 151772 528691 372766 155925 1596213 335597 1260616 9219219 DUE FROM RELATED AFFILIATE 3397631 SCHOOL LOANS RECEIVABLE 4380 3402011 DUE TO RELATED AFFILIATE 1540434 1540434 X 11133468 9258 9258 11124210 0 11124210 9217940 0 9217940 0 9217940 PART X, LINE 2: THE ORGANIZATION RECOGNIZES UNCERTAIN TAX POSITIONS IN THE FINANCIAL STATEMENTS WHEN IT IS MORE LIKELY THAN NOT THE POSITIONS WILL NOT BE SUSTAINED UPON EXAMINATION BY THE TAX AUTHORITIES. AS OF JUNE 30, 2014, THE ORGANIZATION HAD NO UNCERTAIN TAX POSITIONS THAT QUALIFY FOR EITHER RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. X X 0 1 0 0 0 0 0 0 0 WILLIAM TIMMONS CHIEF EXECUTIVE OFFICER 0 411913 0 50000 0 0 0 15200 0 10374 0 487487 0 0 DALE SKURDAHL CHIEF OPERATIONS OFFICER 0 158593 0 0 0 0 0 6666 0 21107 0 186366 0 0 JOSEPH O'MALLEY CFO 0 164400 0 17718 0 0 0 0 0 16817 0 198935 0 0 PERRY PETRILLI VP-RESIDENTAL SERVICES 0 136208 0 13728 0 0 0 5869 0 717 0 156522 0 0 LEAH SHALER VP- HEALTHCARE SUPPORT SERVICES 0 121818 0 13728 0 0 0 1350 0 20912 0 157808 0 0 FORM 990, SCHEDULE J, PART I, LINE 4B CERTAIN EMPLOYEES PARTICIPATED IN A SECTION 457B PLAN. THE AMOUNTS LISTED BELOW ARE THE EMPLOYEE CONTRIBUTIONS TO THIS PLAN IN CALENDAR YEAR 2013. WILLIAM TIMMONS - $17,500 DALE SKURDAHL - $14,135 JANET LOVELADY - $ 1,300 X 10232 FMV X EQUIPMENT 1 19480 FMV X OFFICE FURNIT 1 8400 FMV X TICKETS 2 917 0 0 0 PART I, COLUMN (B): THE NUMBER REPORTED IN PART I, COLUMN B REPRESENTS THE NUMBER OF CONTRIBUTIONS RECEIVED. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION'S BOARD TREASURER, CEO AND CONTROLLER WILL REVIEW AND APPROVE THE FORM 990 PRIOR TO FILING. THEY WILL THEN REVIEW THE FINAL FORM 990 WITH THE ENTIRE BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY THAT ADDRESSES THE CONSIDERATION OF POTENTIAL CONFLICTS OF INTEREST BY THE BOARD OF DIRECTORS, COMMITTEE MEMBERS, KEY EMPLOYEES, AND THEIR RELATIVES. AS PER THE POLICY, SUCH PERSONS MUST MAKE DISCLOSURE OF ANY POTENTIAL CONFLICTS OF INTEREST AND MUST ABSTAIN FROM VOTING ON ANY ACTION IN WHICH THEY MAY HAVE AN INTEREST. ON AN ANNUAL BASIS, ALL BOARD MEMBERS ARE REQUIRED TO SIGN OFF ON AN ANNUAL CONFLICT OF INTEREST FORM, EITHER STATING ANY KNOWN CONFLICTS, OR STATING THAT THERE ARE NONE. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS DETERMINES REASONABLE AND APPROPRIATE SALARIES FOR KEY EMPLOYEES OF THE ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION GENERALLY MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VII HACIENDA SKILLED NURSING FACILITY, INC. IS RELATED TO TWO TAX EXEMPT AFFILIATES, HACIENDA, INC. AND LOS NINOS HOSPITAL, INC. THESE THREE ORGANIZATIONS SHARE A COMMON MANAGEMENT TEAM. THE INDIVIDUALS ON THE MANAGEMENT TEAM ARE COMPENSATED AS EMPLOYEES THROUGH HACIENDA, INC. HACIENDA, INC. CHARGES A MANAGEMENT FEE FOR THESE SERVICES TO BOTH LOS NINOS HOSPITAL, INC. AND TO HACIENDA SKILLED NURSING FACILITY, INC. THE COMPENSATION AMOUNTS LISTED IN PART VII ARE THE TOTAL GROSS WAGES AND OTHER COMPENSATION PAID TO THESE INDIVIDUALS FOR THEIR SERVICES TO ALL THREE ORGANIZATIONS. FORM 990, PART XI, LINE 9: GAIN ON INTEREST RATE SWAP AGREEMENT 41,510. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. HACIENDA HEALTHCARE 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 272988610 BRAND NAME FOR RELATED ORGAIZATIONS AZ 501(C)(3) LINE 9 N/A 0 HACIENDA INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 860253158 NURSING CARE & RESPIRATORY INTERVENTION AZ 501(C)(3) LINE 9 N/A 0 LOS NINOS HOSPITAL INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 860892673 NON-PROFIT CHILDREN'S HOSPITAL AZ 501(C)(3) LINE 9 N/A 0 SOUTH MOUNTAIN HEALTH SUPPLY 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 860858893 MEDICAL SUPPLY COMPANY AZ HACIENDA HEALTHCARE C 0 INNOVATIVE HOME HEALTH INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 262398755 HOME HEALTH NURSING SERVICES AZ HACIENDA HEALTHCARE C 0 0 0 1 1 1 0 0 0 0 1 0 0 1 1 1 1 0 0 0