2014-05-13T17:31:23-05:00 2013-06-30 860133881 HENRY & HORNE LLP 2055 E WARNER RD STE 101 TEMPE AZ 85284 990 2012-07-01 141906233 HACIENDA SKILLED NURSING FACILITY INC HACI 6022434231 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 WILLIAM TIMMONS 6022434231 2014-05-13 1 COLETTE KAMPS P00367616 4808394900 2014-05-13 2012 2015-11-30 17:44:51Z WILLIAM TIMMONS 1402 EAST SOUTH MOUNTAIN AVENUE PHOENIX AZ 85042 9353120 0 X WWW.HACIENDAHEALTHCARE.ORG X 2004 AZ SKILLED NURSING AND RESPIRATORY INTERVENTION 10 10 170 10 0 0 420618 49704 8037896 8879929 671 849 12489 122401 8471674 9052883 0 0 0 0 5195378 5609796 0 0 0 2465838 2520458 7661216 8130254 810458 922629 13507841 14817058 8763257 8976404 4744584 5840654 TO PROVIDE NURSING AND RESPIRATORY CARE TO THOSE WHO REQUIRE FREQUENT SKILLED NURSING AND RESPIRATORY INTERVENTION. 0 0 7946228 8989929 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. 7946228 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 0 0 0 0 0 1 0 0 0 1 0 0 170 1 0 0 0 0 0 0 0 0 0 0 X 10 10 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 THOM NIEMIEC 1.00 X 0 0 0 PATRICK WALSH 1.00 X 0 0 0 KEVIN BERGER 1.00 X 0 0 0 MIKE WADE 1.00 X 0 0 0 KATHRYN L DEL REAL 1.00 X 0 0 0 PATRICIA SHAW 1.00 X 0 0 0 DICK KAUPIE 2.00 X X 0 0 0 TOM POMEROY 2.00 X X 0 0 0 GARY ORMAN 2.00 X X 0 0 0 RALPH WALLWORK 2.00 X X 0 0 0 WILLIAM TIMMONS 1.00 40.00 X 0 417717 21473 DALE SKURDAHL 1.00 40.00 X 0 207885 31787 MICHAEL STONE 1.00 40.00 X 0 210729 6944 JOSEPH O'MALLEY 1.00 40.00 X 0 165682 15915 JANET LOVELADY 1.00 40.00 X 0 121442 4856 TIFFINAY RICHARDSON 40.00 X 100843 0 7680 ROXANNE ROSE 40.00 X 100221 0 4008 201064 1123455 92663 2 0 1 0 LOS NINOS HOSPITAL INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 NURSING REGISTRY AND THERAPY SERVICES 496599 HACIENDA INC 1402 E SOUTH MOUNTAIN AVE PHOENIX AZ 85042 MANAGEMENT SERVICES 159300 2 49704 9534 49704 NET PATIENT FEES- PRIV 623000 7686791 7686791 NET PATIENT FEES- GOVE 623000 941260 941260 NURSING FACILITY SUPPL 623000 155348 155348 OVERPAYMENTS- INSURANC 623000 96530 96530 8879929 849 849 312638 300237 12401 12401 12401 INSURANCE PROCEEDS 900099 110000 110000 110000 9052883 8989929 0 13250 4844034 4844034 61666 61666 262615 262615 441481 441481 159300 159300 17583 17583 626817 619674 7143 4038 4038 267665 267665 192122 192122 228171 228171 256009 256009 SUPPLIES 389025 389025 FOOD 105340 105340 BED TAX EXPENSE 75971 75971 CLIENT EXPENSES 68361 68361 130056 130056 8130254 7946228 184026 0 700 700 1412093 1648515 24255 1027835 1302713 4355 5474 2416 3988 11431350 1966251 9704491 9465099 1331696 2390569 13507841 14817058 260312 249098 6000000 6000000 2502945 2727306 8763257 8976404 X 4317502 5476884 427082 363770 4744584 5840654 13507841 14817058 X 922629 173441 X X 0 1 X 1 0 X 59509 520732 204464 420618 49704 1255027 6833526 7060007 7598206 8037896 8879929 38409564 6893035 7580739 7802670 8458514 8929633 39664591 37224 300000 265600 602824 0 37224 300000 265600 602824 39061767 8843 3213 2003 671 13250 27980 8843 3213 2003 671 13250 27980 110000 110000 6901878 7583952 7804673 8459185 9052883 39802571 0.98140 0.98210 0.00070 0.00060 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9204689 1317765 7886924 152377 28774 123603 484827 327457 157370 1589457 292255 1297202 9465099 DUE FROM RELATED AFFILIATE 2386189 SCHOOL LOANS RECEIVABLE 4380 2390569 DUE TO RELATED AFFILIATE 2685796 INTEREST RATE SWAP AGREEMENT 41510 2727306 X 9574387 0 9574387 -521504 -521504 9052883 8478317 348063 348063 8130254 0 8130254 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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, 2013, THE ORGANIZATION HAD NO UNCERTAIN TAX POSITIONS THAT QUALIFY FOR EITHER RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. PART XI, LINE 4B - OTHER ADJUSTMENTS: INTEREST EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 -184,588. DEPRECIATION EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 -115,649. GAIN ON INTEREST RATE SWAP AGREEMENT -221,267. PART XII, LINE 2D - OTHER ADJUSTMENTS: INTEREST EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 184,588. DEPRECIATION EXPENSE NETTED WITH RENTAL INCOME ON FORM 990 115,649. BAD DEBT EXPENSE 47,826. X 0 1 0 0 0 0 0 0 0 WILLIAM TIMMONS 0 382717 0 35000 0 0 0 14303 0 7170 0 439190 0 0 DALE SKURDAHL 0 199885 0 8000 0 0 0 8971 0 22816 0 239672 0 0 MICHAEL STONE 0 197129 0 13600 0 0 0 0 0 6944 0 217673 0 0 JOSEPH O'MALLEY 0 152796 0 12886 0 0 0 0 0 15915 0 181597 0 0 SUPPLEMENTAL INFORMATION PART III CERTAIN EMPLOYEES PARTICIPATED IN A SECTION 457B PLAN. THE AMOUNTS LISTED BELOW ARE THE EMPLOYEE CONTRIBUTIONS TO THIS PLAN IN CALENDAR YEAR 2011. WILLIAM TIMMONS - $22.500 DALE SKURDAHL - $20.075 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. COMPENSATION FROM RELATED ORGANIZATION FORM 990, PART VII, LINE 1A 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: GAIN ON INTEREST RATE SWAP AGREEMENT 221,267. BAD DEBT EXPENSE -47,826. FORM 990, PART XII, LINE 2C THE ORGANIZATION'S BOARD OF DIRECTORS, CEO, AND FINANCES DIRECTOR ARE RESPONSIBLE FOR THE OVERSIGHT OF THE FINANCIAL STATEMENTS AND THE AUDIT OF THE FINANCIAL STATEMENTS. 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 0 1 1 0 0 0 0 1 0 0 1 1 1 1 0 0 0