2015-08-17T13:54:27-05:00 2014-09-30 390859910 BAKER TILLY VIRCHOW KRAUSE LLP 1650 MARKET STREET SUITE 4500 PHILADELPHIA PA 19103 990 2013-10-01 611386016 ASHLAND NURSING HOME CORP ASHL 6063241414 2500 STATE ROUTE 5 ASHLAND KY 41102 AUTUMN MCFANN TREASURER 6063241414 2015-08-14 1 JULIUS C GREEN CPA JD P00350393 2159720701 2013 2016-03-07 17:11:31Z KINGSBROOK LIFECARE CENTER KRISTIE WHITLATCH 2201 LEXINGTON AVENUE ASHLAND KY 41101 15589535 0 X WWW.KINGSBROOK-LIFECARE.COM X 2002 KY PROVIDE QUALITY CARE TO PATIENTS NEEDING SHORT-TERM REHAB AND/OR LONG-TERM HEALTHCARE. 9 5 323 65 0 0 0 0 15020791 15486664 3806 5171 101520 97700 15126117 15589535 2500 0 0 0 7328225 7688479 0 0 0 6694552 6786873 14025277 14475352 1100840 1114183 13174633 12525272 1522104 1170744 11652529 11354528 OUR MISSION IS TO MEET THE NEEDS OF RESIDENTS AT VARIOUS LEVELS OF CARE INCLUDING SHORT-TERM REHAB AND LONG-TERM HEALTHCARE. 0 0 12791864 15486664 KINGSBROOK PROVIDES QUALITY CARE TO PATIENTS, MEETING THE NEEDS AND DESIRES OF RESIDENTS AT VARIOUS LEVELS OF CARE, INCLUDING SHORT-TERM AND LONG-TERM CARE. KINGSBROOK IS A 147-BED NURSING FACILITY WHICH PROVIDES SKILLED NURSING SERVICES AND REHABILITATION THERAPY TO RESIDENTS DESIRING TO RETURN HOME FROM AN ACUTE CARE HOSPITAL STAY. KINGSBROOK ALSO PROVIDES NURSING SERVICES AND CARE FOR RESIDENTS ON A LONG-TERM BASIS. 12791864 1 0 0 1 0 0 0 0 0 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 1 0 1 323 1 0 0 0 0 0 0 0 0 0 0 X 9 5 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 KY X DAVID THOMAS DIRECTOR OF FINANCE 6063241414 2500 STATE ROUTE 5 ASHLAND KY 41102 EB LOWMAN II CHAIRMAN OF THE BOARD 1.00 0.00 X X 0 0 0 KRISTIE WHITLATCH PRESIDENT (AS OF DEC 2013) 1.00 49.00 X X 0 538465 156840 FRED JACKSON PRESIDENT (UNTIL DEC 2013) 1.00 49.00 X X 0 1209166 30383 AUTUMN MCFANN TREASURER (AS OF FEB 2014) 1.00 49.00 X X 0 160504 27384 JEFF TREASURE TREASURER (UNTIL FEB 2014) 1.00 49.00 X X 0 298543 11243 SHERYL MAHANEY SECRETARY 1.00 49.00 X X 0 340647 119245 TOM BURNETTE DIRECTOR 0.30 1.00 X 0 0 0 PHILIP FIORET MD DIRECTOR 0.30 40.30 X 0 666089 178022 DAVID JONES DIRECTOR 0.30 6.50 X 0 0 0 WILLIE MCCULLOUGH DIRECTOR 0.30 0.00 X 0 0 0 REV JIM NICHOLS DIRECTOR 0.30 0.00 X 0 0 0 ARTHUR MOORE ADMINISTRATOR 40.00 0.00 X 133113 0 0 133113 3213414 523117 1 0 1 0 FUNCTIONAL PATHWAYS INC 614 MABRY HOOD ROAD KNOXVILLE TN 30368 THERAPY CONTRACTING SERVICES 1916295 MEDCARE PHARMACY 350 ARISTOCRAT DRIVE FLORENCE KY 41042 PHARMACEUTICALS 835569 MAY CONTRACTING 12354 VIRGINIA BLVD ASHLAND KY 41102 CONSTRUCTION CONTRACTING SERVICES 231252 3 NET PATIENT SERVICE REVENUE 623000 15486664 15486664 15486664 5171 5171 CAFETERIA/LAUNDRY SERVICES 722210 58102 58102 BEAUTY/BARBER SHOP 812900 31447 31447 VENDING COMMISSION/REBATES 812300 2964 2964 5187 5187 97700 15589535 15486664 0 102871 X 6185655 5381520 804135 1050438 913881 136557 452386 393576 58810 30000 26100 3900 8813 7667 1146 4294 3736 558 2241610 1950201 291409 32274 28078 4196 49117 42732 6385 39346 34231 5115 530975 461948 69027 29810 25935 3875 2835 2466 369 87816 76400 11416 781573 679969 101604 112761 98102 14659 SUPPLIES 1102349 959043 143306 PHARMACY 846341 846341 PROVIDER TAX 382288 382288 BAD DEBT EXPENSE 203843 203843 300828 273807 27021 14475352 12791864 1683488 0 1291927 570002 1698815 2016997 30701 126164 67469 66300 78967 120193 16427185 8623167 8185156 7804018 1821598 1821598 13174633 12525272 1173347 1097617 348757 73127 1522104 1170744 X 11652529 11354528 11652529 11354528 13174633 12525272 X 1114183 -1412184 X 0 1 X 1 0 X 13105341 13481597 13419109 15020791 15486664 70513502 13105341 13481597 13419109 15020791 15486664 70513502 0 0 0 70513502 2781 3670 2441 3806 5171 17869 2781 3670 2441 3806 5171 17869 97094 106405 110669 101520 97700 513388 13205216 13591672 13532219 15126117 15589535 71044759 0.99250 0.00030 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: CAFETERIA/LAUNDRY - 2009 AMOUNT: $ 61,075. 2010 AMOUNT: $ 66,174. 2011 AMOUNT: $ 68,362. 2012 AMOUNT: $ 55,460. 2013 AMOUNT: $ 58,102. BEAUTY/BARBER - 2009 AMOUNT: $ 33,524. 2010 AMOUNT: $ 29,492. 2011 AMOUNT: $ 31,795. 2012 AMOUNT: $ 29,682. 2013 AMOUNT: $ 31,447. VENDING COMMISSION/REBATE - 2011 AMOUNT: $ 2,206. 2012 AMOUNT: $ 1,892. 2013 AMOUNT: $ 2,964. OTHER - 2009 AMOUNT: $ 2,495. 2010 AMOUNT: $ 10,739. 2011 AMOUNT: $ 8,306. 2012 AMOUNT: $ 14,486. 2013 AMOUNT: $ 5,187. 0 0 0 0 0 0 0 0 1 4294 4294 0 PART II-B, LINE 1: A PORTION OF DUES PAID TO THE FOLLOWING ARE ATTRIBUTABLE TO LOBBYING: KY ASSOCIATION OF HEALTH CARE FACILITIES $3,934 THE AMERICAN HEALTHCARE SERVICES ASSOCIATION $218 KY ASSOCIATION OF HOMES AND SERVICES FOR THE AGING $142 348396 348396 12863091 6556776 6306315 2399528 1584404 815124 816170 481987 334183 7804018 NURSING HOME BED LICENSES 1819300 GOODWILL - PHARMACY 2298 1821598 DUE TO KING'S DAUGHTERS MEDICAL CENTER 73127 73127 X 15385692 -203843 -203843 15589535 0 15589535 14271509 0 14271509 203843 203843 14475352 PART X, LINE 2: THE MEDICAL CENTER, KHF, KBNH, CDC, KHI, KDMT, KDMS, KDHF, AND KDOH HAVE BEEN RECOGNIZED BY THE IRS AS SECTION 501(C)(3) CHARITABLE ORGANIZATIONS. SECTION 501(C)(3) ORGANIZATIONS ARE EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED INCOME. THESE ORGANIZATIONS DO NOT ENGAGE IN SIGNIFICANT UNRELATED ACTIVITIES AND THEREFORE NO TAX IS RECORDED. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NETTED AGAINST REVENUE ON F/S -203,843. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NETTED AGAINST REVENUE ON F/S 203,843. 0 1 0 0 0 0 0 1 0 KRISTIE WHITLATCH PRESIDENT (AS OF DEC 2013) 0 399389 0 70000 0 69076 0 133650 0 23190 0 695305 0 51727 FRED JACKSON PRESIDENT (UNTIL DEC 2013) 0 839570 0 294107 0 75489 0 7650 0 22733 0 1239549 0 0 AUTUMN MCFANN TREASURER (AS OF FEB 2014) 0 151051 0 9399 0 54 0 4932 0 22452 0 187888 0 0 JEFF TREASURE TREASURER (UNTIL FEB 2014) 0 197709 0 100000 0 834 0 0 0 11243 0 309786 0 0 SHERYL MAHANEY SECRETARY 0 277340 0 0 0 63307 0 96575 0 22670 0 459892 0 53091 PHILIP FIORET MD DIRECTOR 0 539936 0 0 0 126153 0 154314 0 23708 0 844111 0 87982 PART I, LINE 3 COMPENSATION FOR THE CEO IS DETERMINED BY ASHLAND HOSPITAL CORPORATION (RELATED ORGANIZATION) USING THE FOLLOWING METHODS: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY/STUDY AND APPROVAL BY THE BOARD/COMPENSATION COMMITTEE. PART I, LINE 4B SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN PAYMENTS: SHERYL MAHANEY: $53,091 PHILIP FIORET: $87,982 KRISTIE WHITLATCH: $51,727 SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN CONTRIBUTIONS/DEFERRALS: SHERYL MAHANEY - $88,925 PHILIP FIORET - $146,664 KRISTIE WHITLATCH - $126,000 THE CEO AND VICE PRESIDENTS, WHOSE BENEFIT IN THE QUALIFIED TAX SHELTERED ANNUITY PLAN IS LIMITED DUE TO THE IRS COMPENSATION AND BENEFIT LIMITS, RECEIVE A BENEFIT RESTORATION CONTRIBUTION UNDER THE DEFERRED ANNUITY PLAN THAT IS PAID AS A TAXABLE DISTRIBUTION TO THE PARTICIPANT ANNUALLY. PART I, LINE 7 EMPLOYEES RECEIVED BONUSES BASED ON THE MEETING OF CERTAIN CUSTOMER SERVICE AND QUALITY MEASURES BY KDMC AS A WHOLE (SUCH AS A SPECIFIED LENGTH OF STAY, INPATIENT/OUTPATIENT SATISFACTION SCORES, AND OTHER QUALITY MEASURES). THE BONUS IS CALCULATED AS A PERCENTAGE OF THE EMPLOYEE'S BASE ANNUAL COMPENSATION FOR EACH GOAL THAT IS MET AS DETERMINED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 ASHLAND HOSPITAL CORPORATION IS THE SOLE CORPORATE MEMBER OF ASHLAND NURSING HOME CORPORATION. ASHLAND HOSPITAL CORPORATION, A 501(C)(3) ENTITY, IS THE PARENT ORGANIZATION OF AN INTEGRATED HEALTHCARE DELIVERY SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A ASHLAND HOSPITAL CORPORATION ELECTS THE BOARD MEMBERS OF ASHLAND NURSING HOME CORPORATION ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CONTROLLER AND THE CFO OF KING'S DAUGHTERS MEDICAL CENTER. AFTER THIS REVIEW, BUT BEFORE IT IS FILED WITH THE IRS, THE FINAL 990 WILL BE PROVIDED TO THE FULL BOARD OF DIRECTORS USING BOARD EFFECTS SOFTWARE. AN E-MAIL WITH A LINK TO THE POSTING WILL BE SENT TO EACH BOARD MEMBER ONCE THE REPORT HAS BEEN POSTED. FORM 990, PART VI, SECTION B, LINE 12C ANY EMPLOYEE, MANAGER, OR OFFICER WHO REGULARLY INFLUENCES OR MAKES DECISIONS INVOLVING THE EXPENDITURE OF FACILITY FUNDS SHALL SIGN A CONFLICT OF INTEREST STATEMENT. THE FORM SHALL BE REVIEWED YEARLY AND SHALL BE FILED IN THE HUMAN RESOURCES OFFICE. WHEN AN EMPLOYEE HAS REPORTED A POTENTIAL OR ACTUAL CONFLICT OF INTEREST TO THE IMMEDIATE SUPERVISOR, THE RESPONSIBLE MANAGER AND THE ADMINISTRATOR SHALL BE NOTIFIED OF ALL FACTS PERTAINING TO ANY POTENTIAL TRANSACTIONS. IF IT IS DETERMINED THAT A CONFLICT DOES EXIST, THEN THE EMPLOYEES SHALL BE REMOVED FROM ANY PART OF THE DECISION-MAKING PROCESS, AND SHALL HAVE NO ROLE IN THE INSTANCE WHERE THE CONFLICT OF INTEREST EXISTS. THE EMPLOYEE'S IMMEDIATE SUPERVISOR SHALL ASSUME OR ASSIGN THE AUTHORITY TO ACT ON BEHALF OF THE EMPLOYEE IN ALL ACTIONS INVOLVING THE AREA OF CONFLICT. FAILURE TO REPORT CONFLICTS OF INTEREST IS A DIRECT VIOLATION OF KINGSBROOK'S POLICY AND WILL RESULT IN DISCIPLINARY ACTION. WHEN A MANAGER OF THE FACILITY REPORTS A POTENTIAL CONFLICT, THE MANAGER SHALL REMOVE HIMSELF/HERSELF FROM ANY DISCUSSION OR VOTING REGARDING THE POTENTIAL CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 COMPARABILITY DATA IS USED FOR SALARY ADJUSTMENTS. THE HUMAN RESOURCE DEPARTMENT INITIATES THE ANNUAL EVALUATION AND THE ADMINISTRATOR APPROVES ALL ADJUSTMENTS OF KEY EMPLOYEES. THE GOVERNING BODY APPROVES SALARY ADJUSTMENTS OF THE ADMINISTRATOR. THE PROCESS INCLUDES A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. FORM 990, PART VI, SECTION C, LINE 19 ON A QUARTERLY BASIS, THE FINANCIAL STATEMENTS ARE REPORTED TO EMMA AND MADE AVAILABLE ON THEIR WEBSITE. GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 63,707. MANAGEMENT AND GENERAL EXPENSES 291,409. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 355,116. PHYSICAL THERAPY FEES: PROGRAM SERVICE EXPENSES 1,886,494. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,886,494. FORM 990, PART XI, LINE 9: PARTIAL RETURN OF INVESTMENT TO AFFILIATE -1,412,184. ASHLAND HOSPITAL CORPORATION 2201 LEXINGTON AVE ASHLAND KY 41101 610444716 HEALTHCARE KY 501(C)(3) 3 KING'S DAUGHTERS HEALTH SYSTEM 0 KENTUCKY MEDICAL LOGISTICS INC (DBA KINGS DAUGHTERS TRANS) 425 22ND STREET ASHLAND KY 41101 264736971 MEDICAL TRANSPORT KY 501(C)(3) 9 ASHLAND HOSPITAL CORPORATION 0 KING'S DAUGHTERS HEALTH SYSTEM 2201 LEXINGTON AVE ASHLAND KY 41101 274553836 HEALTHCARE KY 501(C)(3) 11-II N/A 0 PORTSMOUTH HOSPITAL CORP 1901 ARGONNE AVE PORTSMOUTH OH 45662 453215312 HEALTHCARE OH 501(C)(3) 3 ASHLAND HOSPITAL CORPORATION 0 KENTUCKY HEART FOUNDATION 2201 LEXINGTON AVE ASHLAND KY 41101 260791997 MEDICAL RESEARCH KY 501(C)(3) 7 ASHLAND HOSPITAL CORPORATION 0 KING'S DAUGHTERS HEALTH FOUNDATION INC 2201 LEXINGTON AVE ASHLAND KY 41101 611035701 FUNDRAISING KY 501(C)(3) 11-III-FI ASHLAND HOSPITAL CORPORATION 0 CHILD DEVELOPMENT CENTER CORPORATION 2201 LEXINGTON AVE ASHLAND KY 41101 010560598 DAYCARE KY 501(C)(3) 9 ASHLAND HOSPITAL CORPORATION 0 KING'S DAUGHTERS MEDICAL SPECIALTIES INC 2201 LEXINGTON AVE ASHLAND KY 41101 264183569 PHYSICIANS KY 501(C)(3) 9 ASHLAND HOSPITAL CORPORATION 0 KENTUCKY HEART INSTITUTE 2201 LEXINGTON AVE ASHLAND KY 41101 611255904 PHYSICIANS KY 501(C)(3) 9 ASHLAND HOSPITAL CORPORATION 0 ASHLAND MEDICAL PROPERTIES INC 2201 LEXINGTON AVE ASHLAND KY 41101 611079090 RENTALS KY N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1