2013-11-12T11:59:10-06:00 2012-12-31 161226221 FUST CHARLES CHAMBERS LLP 5784 WIDEWATERS PARKWAY SYRACUSE NY 13214 990 2012-01-01 223187140 ROCHESTER GENERAL LONG TERM CARE ROCH 5856714300 1550 EMPIRE BLVD WEBSTER NY 14580 PAULA TINCH 5856714300 2013-11-06 1 ANGELA M FRANCO P00589741 3154463600 2012 2016-02-24 21:20:13Z HILL HAVEN NURSING HOME MARK C CLEMENT 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 32266582 0 X WWW.ROCHESTERGENERAL.ORG X 1993 NY TO OPERATE LONG TERM HEALTH FACILITIES AND SERVICES FOR THE CARE AND TREATMENT OF SICK, INVALID, INFIRM, AGED, DISABLED OR CONVALESCENT PERSONS. 10 8 581 352 0 0 1397 6896027 27541997 24759888 2038 885 399300 609782 27944732 32266582 50 50 0 0 21087493 20554099 0 0 0 7958388 8081434 29045931 28635583 -1101199 3630999 14067242 19077294 13124980 14504033 942262 4573261 TO ESTABLISH, ACQUIRE, DEVELOP, OWN, OPERATE AND MAINTAIN LONG TERM HEALTH CARE FACILITIES AND SERVICES FOR THE CARE AND TREATMENT OF SICK, INVALID, INFIRM, AGED, DISABLED OR CONVALESCENT PERSONS IN ACCORDANCE WITH THE PUBLIC HEALTH LAW OF THE STATE OF NEW YORK. 0 0 21162257 50 25369670 THE ORGANIZATION PROVIDES 24-HOUR SKILLED NURSING CARE TO THOSE IN NEED OF REHABILITATION, LONG-TERM CARE, TRANSITIONAL CARE, HOSPICE CARE AND CARE FOR ALZEHEIMER'S-TYPE DEMENTIA. THE GOAL IS TO HELP RESIDENTS REACH THEIR GREATEST LEVEL OF PHYSICAL FUNCTIONING AND EMOTIONAL WELL-BEING. THE FACILITY IS A PARK-LIKE SETTING IN WEBSTER, NEW YORK WITH 341 BEDS, DEDICATED ROOMS FOR MINGLING AND RECREATION, AND BEAUTIFULLY LANDSCAPED GROUNDS. RESIDENTS HAVE ACCESS TO IN-HOUSE MEDICAL CARE PROVIDED BY PHYSICIANS, NURSE PRACTITIONERS AND A RANGE OF MEDICAL AND REHABILITATION SPECIALISTS. THE ORGANIZATION IS COMMITTED TO HELPING SENIORS STAY AS CONNECTED TO THE COMMUNITY AS POSSIBLE WITH SPECIAL PROGRAMS AND AN OPEN DOOR FOR FAMILY AND FRIENDS. 21162257 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 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 27 0 1 581 1 0 0 0 0 0 0 0 0 0 0 X 10 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X MATT MINISCE 5859221032 1550 EMPIRE BLVD WEBSTER NY 14580 LINDA BECKER 1.00 4.00 X 0 0 0 MARK C CLEMENT 2.00 53.00 X X 50667 1334507 712572 ROBERT DOBIES 1.00 4.00 X 0 0 0 JEANNE GROVE DO 1.00 4.00 X 0 0 0 ROBERT MAYO MD 1.00 39.00 X 0 331586 62910 DANIEL MEYERS 1.00 4.00 X 0 0 0 THOMAS PENN MD 1.00 4.00 X 0 0 0 JOHN RIEDMAN 1.00 4.00 X 0 0 0 MARGARET SANCHEZ 1.00 4.00 X 0 0 0 ROBERT S SANDS 1.00 4.00 X 0 0 0 PAULA TINCH 2.00 53.00 X 9552 251605 57140 HUGH THOMAS 2.00 53.00 X 21278 560431 170710 RICHARD GANGEMI 2.00 53.00 X 22059 554999 129455 SCOTT SCHABEL 40.00 0.00 X 206672 0 78107 STEPHEN ASH 40.00 0.00 X 133424 0 57295 DEBRA DEMOTT 40.00 0.00 X 119781 0 2708 BRENDA KLOSTER 40.00 0.00 X 106367 0 41015 LOU RUPERT 40.00 0.00 X 106093 0 29535 775893 3033128 1341447 5 0 1 0 NURSEFINDERS PO BOX 910738 DALLAS TX 75391 TEMPORARY SERVICES 180160 UNDERBERG AND KESSLER 300 BAUSCH AND LOMB PLACE ROCHESTER NY 14604 COLLECTIONS 107494 2 6890809 5218 6896027 PATIENT/RESIDENT SERVICE REVENUE 623000 24759888 24759888 24759888 885 885 PHARMACY 446110 326680 326680 CAFETERIA 445100 84201 84201 GIFT SHOP 453220 4626 4626 194275 194275 609782 32266582 25369670 0 885 50 50 333624 288752 44872 15818165 11304933 4513232 971001 696980 274021 2208532 1585275 623257 1222777 877704 345073 20619 14800 5819 20004 14359 5645 1430928 1027114 403814 15401 11055 4346 1734524 1245034 489490 21927 15739 6188 360663 258882 101781 10124 7267 2857 834356 598897 235459 77557 55670 21887 HEALTH ASSESSMENT FACIL 1425762 1425762 BAD DEBTS 727802 727802 PHARMACEUTICALS 440655 316300 124355 TAXES, LICENSES & DUES 82632 59313 23319 878480 630569 247911 28635583 21162257 7473326 0 1409484 3452497 3345578 215114 171160 23691 30154 18820157 6168477 7088719 12651680 1877737 2878722 14067242 19077294 2794905 2328378 10330075 12175655 13124980 14504033 X 942262 4573261 942262 4573261 14067242 19077294 3630999 0 X 0 1 X 1 1 1 X 2946 709 1161 1397 5218 11431 27243696 27206988 26545612 27541997 24759888 133298181 27246642 27207697 26546773 27543394 24765106 133309612 0 0 0 133309612 24446 1480 760 2038 885 29609 24446 1480 760 2038 885 29609 409889 419556 363711 399300 609783 2202239 27680977 27628733 26911244 27944732 25375774 135541460 0.98350 0.98610 0.00020 0.00040 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 12845810 2121436 10724374 1941197 1228782 712415 4033150 2818259 1214891 12651680 WORKERS COMP SELF INSURED 525657 RESIDENT CUSTODIAL FUNDS 208431 DUE FROM AFFILIATES 525022 INSURANCE RECOVERY RECEIVABLES 1607719 MISCELLANEOUS RECEIVABLE 11893 2878722 ESTIMATED THIRD PARTY PAYABLES 2041840 ACCRUED SELF-INSURED LIABILITY 3664454 DUE TO AFFILIATES 6260929 RESIDENT FUNDS 208432 12175655 25375773 0 25375773 6890809 6890809 32266582 28635583 0 28635583 0 28635583 PART XI, LINE 4B - OTHER ADJUSTMENTS: HEAL GRANT 6,890,809. 0 1 0 0 0 0 0 0 0 MARK C CLEMENT 25799 679512 23183 610616 1685 44379 25885 681770 180 4737 76732 2021014 14540 382960 ROBERT MAYO MD 0 244550 0 59215 0 27821 0 55043 0 7867 0 394496 0 0 PAULA TINCH 6964 183424 1579 41593 1009 26588 1927 50758 163 4292 11642 306655 0 0 HUGH THOMAS 12006 316228 7222 190209 2050 53994 5991 157802 253 6664 27522 724897 3681 96946 RICHARD GANGEMI 12064 303518 7956 200183 2039 51298 4785 120389 164 4117 27008 679505 4727 118933 SCOTT SCHABEL 168585 0 26365 0 11722 0 71542 0 6565 0 284779 0 0 0 STEPHEN ASH 81329 0 19200 0 32895 0 49748 0 7547 0 190719 0 0 0 PART I, LINE 3 THE FILING ORGANIZATION'S RELATED NON-PROFIT ORGANIZATION, ROCHESTER GENERAL HEALTH SYSTEM, UTILIZES THE FOLLOWING METHODS TO ESTABLISH THE COMPENSATION OF THE CEO: A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. PART I, LINE 4B RGHS MAINTAINS A SECTION 457(F) PLAN WHICH WOULD BE CONSIDERED A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2012, NO DISTRIBUTIONS WERE PAID OUT. THE FOLLOWING OFFICERS AND KEY EMPLOYEES LISTED ON FORM 990, PART VII, SECTION A WOULD BE ELIGIBLE PARTICIPANTS IN THE PLAN SINCE THEY WOULD BE ENTITLED TO A DISTRIBUTION UPON SEPARATION FROM SERVICE: HUGH THOMAS RICHARD GANGEMI, MD MARK CLEMENT FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION IS A MEMBERSHIP (NOT A STOCK) CORPORATION UNDER NEW YORK STATE LAW. THE ORGANIZATION'S SOLE CORPORATE MEMBER IS ROCHESTER GENERAL HEALTH SYSTEM (RGHS), A RELATED NOT-FOR-PROFIT ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A IN ACCORDANCE WITH THE TERMS AND REQUIREMENTS OF ITS GOVERNING DOCUMENTS (I.E. BYLAWS), THE ORGANIZATION'S DIRECTORS ARE DIVIDED INTO THREE CLASSES, AND THE CLASSES SERVE FOR STAGGERED THREE-YEAR TERMS. AT EACH ANNUAL MEETING, DIRECTORS IN A CLASS ARE ELECTED BY A MAJORITY VOTE OF THE DIRECTORS THEN IN OFFICE. DIRECTORS ARE ELECTED FROM AMONG NOMINEES CHOSEN BY THE GOVERNANCE AND NOMINATING COMMITTEE OF THE FILING ORGANIZATION'S SOLE CORPORATE MEMBER, ROCHESER GENERAL HEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 7B RGHS, AS THE SOLE CORPORATE MEMBER, ALSO HAS THE RIGHT TO APPROVE OR RATIFY SIGNIFICANT DECISIONS OF THE ORGANIZATION'S GOVERNING BODY INCLUDING AMENDMENT OF BYLAWS AND CHARTERS, REMOVAL OF MEMBERS OF THE GOVERNING BODY, AND THE DECISION TO DISSOLVE THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 PRIOR TO FILING, A COPY OF THE FORM 990 IS PROVIDED TO, AND REVIEWED WITH, ALL MEMBERS OF THE EXECUTIVE COMPENSATION COMMITTEE. THIS REVIEW IS PERFORMED IN CONSULTATION WITH THE ORGANIZATION'S TAX ADVISORS, AND IS BASED ON THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS AND OTHER RELEVANT INFORMATION FOR THE APPROPRIATE TIME PERIOD. FORM 990, PART VI, SECTION B, LINE 12C UPON EMPLOYMENT, ALL EMPLOYEES RECEIVE THE ETHICAL STANDARD OF CONDUCT BOOKLET FOR WHICH THEY SIGN A RECEIPT OF ACKNOWLEDGEMENT. CONFLICT OF INTEREST IS DEFINED, AS IS MANAGEMENT OF A CONFLICT OF INTEREST. EMPLOYEES ARE REQUIRED TO DISCLOSE AND SEEK RESOLUTION TO ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST BEFORE TAKING A POTENTIALLY IMPROPER ACTION AND THEREAFTER, ANNUALLY, EACH KEY EMPLOYEE AND OFFICER OF THE ORGANIZATION IS REQUIRED TO COMPLETE A CONFLICT OF INTEREST FORM, PROVIDING MANAGEMENT WITH SUFFICIENT INFORMATION ABOUT HIS/HER PERSONAL INTERESTS AND RELATIONSHIPS SO THAT MANAGEMENT CAN (1) DETERMINE WHETHER ANY ACTUAL OR PERCEIVED CONFLICT OF INTEREST EXISTS, AND (2) MONITOR WORK ASSIGNMENTS TO AVOID PLACING THE KEY EMPLOYEE OR OFFICER IN A POSITION WHERE THERE MAY BE A QUESTION AS TO HIS/HER OBJECTIVITY AS WELL AS TO AVOID ANY APPEARANCE OF IMPROPRIETY. THROUGHOUT THE YEAR, KEY EMPLOYEES AND OFFICERS OF THE ORGANIZATION ARE ALSO REQUIRED TO NOTIFY MANAGEMENT PROMPTLY IF ANY CHANGE TO THEIR DISCLOSURES OCCURS. IN ADDITION, EACH MEMBER OF THE BOARD OF DIRECTORS MUST ALSO COMPLETE A CONFLICT OF INTEREST AND DISCLOSURE FORM, WHICH MUST BE SUBMITTED TO THE GENERAL COUNSEL. BOARD MEMBERS LEAVE THE ROOM DURING DISCUSSIONS AND ABSTAIN FROM VOTING WHEN THEY HAVE A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION'S OFFICER AND KEY EMPLOYEE COMPENSATION ARRANGEMENTS ARE REVIEWED AND APPROVED BY THE COMPENSATION COMMITTEE OF ROCHESTER GENERAL HEALTH SYSTEM, A RELATED NOT-FOR-PROFIT ORGANIZATION. INFORMATION REVIEWED FOR THE OFFICER/KEY EMPLOYEE INCLUDES COMPARABLE DATA FROM SIMILAR SIZE TAX EXEMPT ORGANIZATIONS IN THE WESTERN/CENTRAL NY COMMUNITY AS WELL AS COMPENSATION FOR THESE POSITIONS (AS DISCLOSED ON FORM 990) WITH OTHER ORGANIZATIONS IN THE HEALTH CARE INDUSTRY THAT ARE OF SIMILAR SIZE, DEMOGRAPHICS AND GEOGRAPHY. REVIEW AND APPROVAL OF THE COMPENSATION ARRANGEMENT BY THE COMPENSATION COMMITTEE IS DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT THE ADMINISTRATIVE OFFICES OF THE AFFILIATED HEALTH SYSTEM AT 100 KINGS HIGHWAY SOUTH, ROCHESTER, NY 14617 AND ADMINISTRATIVE OFFICES OF THE FILING ORGANIZATION. A NOMINAL FEE IS CHARGED IF COPIES ARE REQUESTED. STATEMENT PURSUANT TO TREAS. REG. SEC. 1.6038-2(J)(3) FORM 5471 FILED ON BEHALF OF STATEMENT THE FOLLOWING INFORMATION IS SUBMITTED WITH RESPECT TO ROCHESTER GENERAL LONG TERM CARE'S FORM 5471 (INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS) FILING REQUIREMENT FOR THE ENTITY BELOW: NAME OF FOREIGN CORPORATION: GREATER ROCHESTER ASSURANCE COMPANY, LTD. BEGINNING TAX YEAR OF FOREIGN CORPORATION: JANUARY 1, 2012 ENDING TAX YEAR OF FOREIGN CORPORATION: DECEMBER 31, 2012 THE FORM 5471 FILING REQUIREMENT FOR THIS FOREIGN CORPORATION FOR CATEGORIES 4 AND 5 HAVE BEEN SATISFIED BY INCLUSION IN THE FOLLOWING U.S. FILER'S TAX RETURN: NAME OF U.S. FILER: ROCHESTER GENERAL HEALTH SYSTEMS ADDRESS OF U.S. FILER: 100 KINGS HIGHWAY SOUTH, ROCHESTER, NY 14617 EIN: 22-2551509 ENDING TAX YEAR OF U.S. FILER: DECEMBER 31, 2012 TYPE OF RETURN FILED: 990-T IRS SERVICE CENTER WHERE RETURN FILED: OGDEN, UTAH 84201-0027 THE ROCHESTER GENERAL HOSPITAL 1425 PORTLAND AVENUE ROCHESTER NY 14621 160743134 HOSPITAL NY 501(C)(3) LINE 3 RGHS 0 ROCHESTER MENTAL HEALTH CENTER 490 EAST RIDGE ROAD ROCHESTER NY 14621 166069131 MENTAL HEALTH NY 501(C)(3) LINE 9 RGHS 0 GRHS FOUNDATION 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 223378111 R/E INV MGMT NY 501(C)(3) LINE 11B, II RGHS 0 THE ROCHESTER GENERAL HOSPITAL FOUNDATION 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 222229425 FUNDRAISING NY 501(C)(3) LINE 11B, II RGHS 0 NEWARK WAYNE COMMUNITY HOSPITAL DRIVING PARK AVENUE NEWARK NY 14513 150584188 HOSPITAL NY 501(C)(3) LINE 3 RGHS 0 RGHS WORKERS' COMPENSATION TRUST 1425 PORTLAND AVENUE ROCHESTER NY 14621 166429300 SEE PART VII NY 501(C)(3) LINE 11B, II RGHS 0 CONTINUING CARE NETWORK INC (CCN) 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 222963016 SUPPORT RGH NY 501(C)(3) LINE 11B, II RGHS 0 ROCHESTER GENERAL HUDSON HOUSING 2066 HUDSON AVENUE ROCHESTER NY 14617 223210351 LOW INC HOUSING NY 501(C)(3) LINE 9 RGHS 0 INDEPENDENT LIVING FOR SENIORS 2066 HUDSON AVENUE ROCHESTER NY 14617 161491059 ADULT CARE NY 501(C)(3) LINE 9 RGHS 0 WESTERN NEW YORK MEDICAL PRACTICE PC 1425 PORTLAND AVENUE ROCHESTER NY 14621 611654232 PHYS PRAC NY 501(C)(3) LINE 9 RGHS 0 ROCHESTER GENERAL HEALTH SYSTEM 100 KINGS HIGHWAY SOUTH ROCHESTER NY 14617 222551509 SYSTEM PARENT NY 501(C)(3) LINE 11B, II N/A 0 NEWARK WAYNE COMMUNITY HOSPITAL FOUNDATION DRIVING PARK AVENUE NEWARK NY 14513 222963015 FUNDRAISING NY 501(C)(3) LINE 11B, II NWCH 0 GREATER ROCHESTER ASSURANCE COMPANY LTD GEORGE TOWN GRAND CAYMAN CJ INSURANCE CJ N/A C 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 INDEPENDENT LIVING FOR SENIORS K 1498452 FMV INDEPENDENT LIVING FOR SENIORS O 62059 FMV ROCHESTER GENERAL HEALTH SYSTEM WORKERS' COMPENSATION TRUST O 629705 FMV ROCHESTER GENERAL HOSPITAL O 1030547 FMV GREATER ROCHESTER ASSURANCE COMPANY LTD O 52083 FMV ROCHESTER MENTAL HEALTH CENTER L 55080 FMV ROCHESTER GENERAL HEALTH SYSTEM O 331290 FMV RELATED TAX-EXEMPT ORGANIZATION - PRIMARY ACTIVITY SCHEDULE R, PART II, COLUMN B: RGHS WORKERS' COMPENSATION TRUST SUPPORTS THE GENESEE HOSPITAL, ROCHESTER GENERAL HOSPITAL, ROCHESTER GENERAL HOSPITAL FOUNDATION, NEWARK WAYNE COMMUNITY HOSPITAL, NEWARK COMMUNITY HOSPITAL FOUNDATION, INDEPENDENT LIVING FOR SENIORS, ROCHESTER GENERAL LONG TERM CARE, ROCHESTER GENERAL HUDSON HOUSING, GRHS FOUNDATION, BEHAVIORAL HEALTH NETWORK, AND ROCHESTER GENERAL HEALTH SYSTEMS.