2013-11-14T18:05:25-06:00 2012-12-31 381357951 PLANTE & MORAN PLLC 65 EAST STATE ST STE 600 COLUMBUS OH 43215 990 2012-01-01 311480941 GENESIS HEALTHCARE SYSTEM GENE 7404545000 2951 MAPLE AVENUE ZANESVILLE OH 43701 PAUL MASTERSON 7404545000 2013-11-13 1 BERNIE OSTROWSKI P00366367 6148493000 2012 2016-02-24 21:20:13Z MATTHEW PERRY 2951 MAPLE AVENUE ZANESVILLE OH 43701 356857035 0 3727 X WWW.GENESISHCS.ORG X 1997 OH IN 1997, GOOD SAMARITAN MEDICAL CENTER AND BETHESDA HOSPITAL ASSOCIATION, A TAX-EXEMPT COMMUNITY HOSPITAL ALSO LOCATED IN ZANESVILLE, AFFILIATED TO FORM GENESIS HEALTHCARE SYSTEM. GENESIS HAS BEEN GRANTED 501C3 STATUS AS A HOSPITAL. ALL HOSPITAL OPERATIONS AND ASSETS OF GOOD SAMARITAN MEDICAL CENTER WERE TRANSFERRED TO GENESIS WITH THE EXCEPTION OF CERTAIN INVESTMENTS. GOOD SAMARITAN MEDICAL CENTER WILL CONTINUE TO HAVE CONTROL OVER CERTAIN INVESTMENTS WHICH ARE BEING USED BY THE GENESIS HEALTHCARE SYSTEM IN FULFILLING ITS TAX-EXEMPT PURPOSE. 16 11 3251 477 665714 -250933 349173 369745 306080751 336634385 7084413 3570462 6974580 15148859 320488917 355723451 0 40000 0 0 143634510 154196929 0 0 0 153509050 171023118 297143560 325260047 23345357 30463404 261394145 280222455 130414955 142100697 130979190 138121758 X TO PROMOTE CHARITABLE SUPPORT FOR GENESIS HEALTHCARE SYSTEM AS WE SHARE ITS MISSION TO PROVIDE COMPASSIONATE, QUALITY HEALTHCARE. 0 0 154925284 0 127154004 SEE SCHEDULE OGENESIS PROVIDES ACUTE CARE SERVICES INCLUDING MEDICAL, SURGICAL, OBSTETRICAL, PEDIATRIC AND CRITICAL CARE. THE MEDICAL/SURGICAL UNITS ARE STAFFED AT BOTH CAMPUSES FOR A COMBINED TOTAL OF 257 BEDS. TOTAL PATIENTS DISCHARGED FROM THESE UNITS IN 2012 WERE 14,232. OBSTETRICS STAFFS A TOTAL OF 24 BEDS AT THE BETHESDA CAMPUS AND DISCHARGED 1,413 PATIENTS FOR A TOTAL OF 1,353 BIRTHS. THE PEDIATRIC UNIT IS LOCATED AT THE BETHESDA CAMPUS WITH 12 BEDS AND HAD 354 DISCHARGES IN 2012. THERE ARE 21 CRITICAL CARE BEDS BETWEEN THE TWO CAMPUSES AND DISCHARGED 373 PATIENTS DURING THE YEAR AND 25 CARDIOVASCULAR BEDS IN A UNIT LOCATED ON THE GOOD SAMARITAN CAMPUS WITH 1,719 DISCHARGES IN 2012. THERE IS ALSO A CANCER UNIT ON THE GOOD SAMARITAN CAMPUS WITH 928 DISCHARGES IN 2012 AND AN ORTHOPAEDIC UNIT WITH 658 DISCHARGES IN 2012.GENESIS PROVIDES A WIDE RANGE OF DIAGNOSTIC AND SUPPORT SERVICES ON BOTH CAMPUSES FOR INPATIENTS AND OUTPATIENTS. THESE SERVICES ARE COMPRISED OF LABORATORY, IMAGING SERVICES, CARDIAC, AND PHARMACY. LABORATORY SERVICES INCLUDE CHEMISTRY, PATHOLOGY, MICROBIOLOGY, HEMATOLOGY, AND CYTOLOGY FOR TOTAL VOLUMES IN 2012 OF 1,244,387. IMAGING SERVICES INCLUDES RADIOLOGY, NUCLEAR MEDICINE, MRI, ULTRASOUND, CT SCAN, AND PET SCAN WITH TOTAL VOLUMES OF 158,342. PHARMACY PRESCRIPTIONS TOTALED 6,821,199.GENESIS PROVIDES BEHAVIORAL HEALTH SERVICES FOR PSYCHIATRIC ADULTS ON AN OPEN UNIT AND A PROTECTED UNIT. THERE ARE 8 PSYCHIATRIC INTENSIVE TREATMENT BEDS LOCATED WITHIN THE PROTECTED UNIT. WE HAVE A 14-BED CHILD/ADOLESCENT INPATIENT UNIT, WHICH IS PROTECTED. INPATIENT DETOXIFICATION SERVICES ARE PROVIDED AS WELL AS OUTPATIENT DRUG AND ALCOHOL SERVICES. THERE ARE PARTIAL HOSPITAL PROGRAMS FOR CHILDREN, ADOLESCENTS, ADULTS AND A DUALLY DIAGNOSED PARTIAL PROGRAM FOR ADOLESCENTS. A FULL RANGE OF THERAPEUTIC SERVICES IS OFFERED INCLUDING ART, MUSIC, RECREATION AND OCCUPATIONAL THERAPY. OTHER MISCELLANEOUS PROGRAMS INCLUDE DUI SCHOOL, SHOP LIFTING DIVERSION, UNDERAGECONSUMPTION SCHOOLS AND CLASSES FOR DIVORCING PARENTS AND CHILDREN OF DIVORCE. TOTAL INPATIENTS TREATED IN 2012 WERE 1,845. 45354910 0 122746713 CARDIAC SERVICES - GENESIS PROVIDES CARDIAC SERVICES INCLUDING AN OPEN-HEART SURGERY PROGRAM. THE MOST COMMON OPEN-HEART SURGERY PERFORMED AT GENESIS IS CORONARY ARTERY BYPASS GRAFTING . HOWEVER, OUR BOARD-CERTIFIED SURGEONS PERFORM SEVERAL HEART AND LUNG SURGICAL PROCEDURES. THE TOTAL NUMBER OF CARDIAC CASES TREATED IN 2012 WERE 3,348. 19341289 0 52344490 RESPIRATORY SERVICES - GENESIS TREATS A LARGE VOLUME OF RESPIRATORY CASES ON INPATIENT BASIS. THIS INCLUDES PATIENTS WITH CHRONIC LUNG DISEASE AS WELL AS PNEUMONIA PATIENTS. THE TOTAL NUMBER OF INPATIENT RESPIRATORY CASES TREATED IN 2012 WERE 2,436. 13622034 40000 36922273 ORTHOPEDIC SERVICES - GENESIS HAS COMBINED SEVERAL SERVICES INTO A COMPLETE ORTHOPEDIC PROGRAM. GENESIS HAS SPECIALLY EQUIPPED OPERATING ROOMS, A DEDICATED INPATIENT UNIT, AN ORTHOPEDIC REHAB PROGRAM, A SKILLED NURSING FACILITY AND SPORTS MEDICINE SERVICES. BUT THE MOST IMPORTANT ELEMENT IS A COMMITMENT TO EXCELLENCE IN CLINICAL QUALITY, MADE POSSIBLE BY A TEAM OF WELL-TRAINED AND DEDICATED STAFF. THE TOTAL NUMBER OF ORTHOPEDIC INPATIENT CASES TREATED IN 2012 WERE 1,246.GRANTS WERE PAID TO GENESIS HEALTHCARE FOUNDATION TO HELP FURTHER THE RELATED TAX-EXEMPT ORGANIZATION'S PURPOSE. GENESIS PROVIDES BEHAVIORAL HEALTH SERVICES FOR PSYCHIATRIC ADULTS ON AN OPEN UNIT AND A PROTECTED UNIT. THERE ARE 8 PSYCHIATRIC INTENSIVE TREATMENT BEDS LOCATED WITHIN THE PROTECTED UNIT. WE HAVE A 14-BED CHILD/ADOLESCENT INPATIENT UNIT, WHICH IS PROTECTED. INPATIENT DETOXIFICATION SERVICES ARE PROVIDED AS WELL AS OUTPATIENT DRUG AND ALCOHOL SERVICES. THERE ARE PARTIAL HOSPITAL PROGRAMS FOR CHILDREN, ADOLESCENTS, ADULTS AND A DUALLY DIAGNOSED PARTIAL PROGRAM FOR ADOLESCENTS. A FULL RANGE OF THERAPEUTIC SERVICES IS OFFERED INCLUDING ART, MUSIC, RECREATION AND OCCUPATIONAL THERAPY. OTHER MISCELLANEOUS PROGRAMS INCLUDE DUI SCHOOL, SHOP LIFTING DIVERSION, UNDERAGECONSUMPTION SCHOOLS AND CLASSES FOR DIVORCING PARENTS AND CHILDREN OF DIVORCE. TOTAL INPATIENTS TREATED IN 2012 WERE 1,845. 13622034 40000 36922273 233243517 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 344 0 1 3251 1 1 1 1 CJ 0 0 0 0 0 0 0 0 X 16 11 0 1 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 0 OH X MARTI NASH 7404545000 2951 MAPLE AVENUE ZANESVILLE OH 43701 MICHAEL BENNETT 3.10 0.00 X X 0 0 0 WALTER OFFINGER 2.50 0.00 X X 0 0 0 JODY BALLAS 3.60 0.00 X X 0 0 0 JERRY NOLDER 3.50 0.00 X X 0 0 0 MARK MOYER 3.10 0.00 X 0 0 0 SR LAURA WOLF 2.70 0.20 X 0 0 0 RANDY COCHRANE 2.10 0.40 X 0 0 0 THOMAS DIEHL MD 2.50 0.00 X 900 0 0 SR THERESA FELDKAMP 1.60 0.20 X 0 0 0 ROBERT KESSLER 3.40 0.00 X 0 0 0 ERIC NEWSOM MD 40.00 0.00 X 373910 0 20032 JAMES MCDONALD 2.30 0.40 X 0 0 0 WILLIAM PHILLIPS 1.30 0.00 X 0 0 0 WILLIAM SHADE MD 12.70 0.00 X 65725 0 0 ERIN WELCH 1.60 0.00 X 0 0 0 WALTER WIELKIEWICZ MD 40.00 0.00 X 251206 0 10961 MATTHEW PERRY 36.40 3.60 X 575709 0 479732 PAUL MASTERSON 35.60 4.40 X 372090 0 210320 RICHARD HELSPER 40.00 0.00 X 197426 0 57070 CASSANDRA PALMER 40.00 0.00 X 275919 0 391432 EDMOND ROMITO 40.00 0.00 X 272401 0 68080 ALAN BURNS 40.00 0.00 X 281717 0 166641 PATRICIA CAMPBELL 39.90 0.10 X 268351 0 368330 REGINA PENNINGTON 39.90 0.10 X 224503 0 55192 DANIEL SCHEERER 40.00 0.00 X 286091 0 63951 TIMOTHY RAYMOND 40.00 0.00 X 386845 0 35898 CHARLES ADAMS JR 40.00 0.00 X 154213 0 18762 ABBY NGUYEN 40.00 0.00 X 142980 0 22717 RAY RYMAN 40.00 0.00 X 149145 0 19107 DIANNA LEVECK 40.00 0.00 X 146666 0 22447 GREGORY PETE HAMILTON 40.00 0.00 X 143552 0 26418 ALAN VIERLING 0.00 0.00 X 129744 0 578 4699093 0 2037668 51 1 1 0 ACCENTURE LLC 161 CLARK ST CHICAGO IL 60601 CONSULTING 3804616 PRIMECARE OF SE OHIO INC 860 BETHESDA DR ZANESVILLE OH 43701 MEDICAL SERVICES 3782224 ZANESVILLE ANESTHESIA PHYSICIANS INC 37 S SEVENTH ST ZANESVILLE OH 43701 MEDICAL SERVICES 3480863 CARDIA ANESTHESIA ASSOC 800 FOREST AVE ZANESVILLE OH 43701 MEDICAL SERVICES 1292319 ARUP LABORATORIES 500 CHIPETA WAY SALT LAKE CITY UT 84108 MEDICAL SERVICES 1051883 45 177839 191906 369745 NET PATIENT SERVICES 621110 336139417 336139417 PASSTHROUGH INCOME 621110 494968 494968 336634385 3172864 3172864 972082 1133584 -161502 -161502 -161502 397598 0 397598 397598 397598 CAFETERIA SALES 621110 3621160 107567 3513593 EHR TECHNOLOGY INCOME 621110 3420247 3420247 OCCUPATIONAL HEALTH 621110 1362719 1362719 6906235 1170376 558147 5177712 15310361 355723451 339167480 665714 15520512 40000 40000 1637852 1637852 115975042 82652551 33322491 6291051 4909994 1381057 21840291 15463800 6376491 8452693 5975194 2477499 1240740 601069 639671 1417436 1417436 457105 457105 26536386 13229393 13306993 132276 11482 120794 72472256 63105354 9366902 5755855 1125115 4630740 4449327 325753 4123574 877360 311498 565862 2092640 2092640 14652897 7980500 6672397 381425 363846 17579 BAD DEBT EXPENSE 25275939 25275939 HOSPITAL FRANCHISE FEE 3383899 3383899 PHYSICIAN RECRUITMENT 3322585 3322585 LAB REFERENCE FEES 1262842 1262842 7312150 5132648 2179502 325260047 233243517 92016530 0 5412570 1883985 8796626 7327947 855000 855000 50608666 58598927 4410061 5021209 9328849 10919798 306131108 201177532 97862256 104953576 54916565 66651933 16905822 14274732 1703129 1703129 10594601 8032219 261394145 280222455 27409472 31164867 8540401 7702912 53943286 57017747 40521796 46215171 130414955 142100697 X 130979190 138121758 130979190 138121758 261394145 280222455 X 30463404 4664162 -27984998 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 167971 0 1 17480 185451 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: GENESIS HEALTHCARE SYSTEM PAYS MEMBERSHIP DUES TO THE FOLLOWING ORGANIZATIONS. A PORTION OF THE DUES ARE RELATED TO LOBBYING ACTIVITIES. FSCC HEALTHCARE MINISTRY (FOR CHA): 3.0% OF $14,122 ($424) CATHOLIC CONFERENCE OF OHIO: 5.3% OF $2,022 ($107) OHIO HOSPITAL ASSOCIATION: 5.3% OF $73,599 ($3,901) FSCC HEALTHCARE MINISTRY (FOR AHA): 24.0% OF $48,586 ($11,651) AMERICAN ACADEMY OF SLEEP MEDICINE: 8.0% OF $1,125 ($90) SNHPA: 12.0% OF $5,500 ($660) OHIO HOSPICE AND PALLIATIVE CARE ORG: 7.1% OF $7,000 ($497) NATIONAL HOSPICE AND PALLIATIVE ORG: 3.0% OF $4,959 ($150) IN ADDITION, GENESIS HEALTHCARE SYSTEM PAID MATTHEW KALLNER, LOBBYIST, $77,000 DURING THE YEAR FOR GENERAL LOBBYING RELATING TO OHIO STATEHOUSE ISSUES. LASTLY, THE FIRM WILLIAMS AND JENSEN WAS PAID $90,971 FOR SERVICES IN RELATION TO BUILDING AND STRENGTHENING RELATIONSHIPS WITH OHIO MEMBERS OF CONGRESS AND OTHER RELEVANT MEMBERS AND THEIR STAFFS; IDENTIFYING OPPORTUNITIES IN THE ECONOMIC STIMULUS PACKAGE AND WORKING TO ENSURE THE ORGANIZATION IS WELL POSITIONED TO BENEFIT FROM ANY FUNDING FOR WHICH PROJECTS MAY BE ELIGIBLE; ASSIST IN SEEKING FEDERAL FUNDS THROUGH FISCAL YEAR 2012 APPROPRIATIONS REQUESTS; AND MONITOR, REPORT, AND COLLABORATIVELY IDENTIFY NEW OPPORTUNITIES IN THE FEDERAL LEGISLATIVE, REGULATORY AND/OR FUNDING SECTOR; AND ASSIST IN FINDING SOLUTIONS TO REPLACE THE LOSS OF THE MEDICARE WAGE INDEX RECLASSIFICATION THAT WAS EFFECTIVE 10/1/2011. 7746309 7746309 48833495 32192109 16641386 2630655 1083935 1546720 243365205 164827957 78537248 3555444 3073531 481913 104953576 OTHER INVESTMENTS 12221472 F CORPORATE OBLIGATIONS 2053260 F 14274732 ACCRUED MINIMUM PENSION LIABILITY 41035410 ACCRUED PROFESSIONAL LIABILITY 2241687 FAIR VALUE OS INTEREST RATE SWAP 2582113 COST REPORT SETTLEMENT PAYABLE 355961 46215171 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE OR OTHER APPLICABLE TAX AUTHORITIES. MANAGEMENT HAS ANAYLZED THE TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF DECEMBER 31, 2012 AND 2011, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER THERE ARE CURRENLTY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. MANAGEMENT BELIEVES THAT IT IS NOT LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR YEARS PRIOR TO FISCAL YEAR 2009. 1 1 X 1 X 1 X 1 1 0 1 1 8356211 3215795 5140416 0.01710 48929534 37045635 11883899 0.03960 0 0 0.00000 57285745 40261430 17024315 0.05670 268859 13335 255524 0.00090 1228 0 1228 0.00000 5027830 4559875 467955 0.00160 0 0 0.00000 26800 0 26800 0.00010 5324717 4573210 751507 0.00260 62610462 44834640 17775822 0.05930 19056 19056 0.00010 19056 19056 0.00010 0 25275939 3984089 125396851 133196851 -7800000 X 1 1 2 1 GOOD SAMARITAN HOSPITAL

800 FOREST AVE ZANESVILLE OH 43701

X X X ACUTE CARE HOSPITAL 2 BETHESDA HOSPITAL

2951 MAPLE AVE ZANESVILLE OH 43701

X X X ACUTE CARE HOSPITAL GOOD SAMARITAN HOSPITAL 1 1 1 100.000000000000 1 300.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 BETHESDA HOSPITAL 2 1 1 100.000000000000 1 300.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 5 HOSPICE & PALLIATIVE CARE

713 FOREST AVENUE ZANESVILLE OH 43701

HOSPICE & PALLIATIVE CARE CENTER RADIATION ONCOLOGY

817 FOREST AVENUE ZANESVILLE OH 43701

OUTPATIENT RADIATION TREATMENT CENTER CTR FOR OUTPATIENT & OCCUPATIONAL REHAB

740 ADAIR AVENUE ZANESVILLE OH 43701

OUTPATIENT REHAB SERVICES HEALTHPLEX

2800 MAPLE AVENUE ZANESVILLE OH 43701

OUTPATIENT LAB, IMAGING, & URGENT CARE SERVICES BETHESDA PHYSICIAN'S PAVILION

945 BETHESDA DRIVE ZANESVILLE OH 43701

OUTPATIENT CARDIAC REHAB SERVICES PART I, LINE 7: COSTS OF CHARITY CARE AND COMMUNITY BENEFIT ACTIVITIES WERE CALCULATED USING THE HOSPITAL'S COST ACCOUNTING SYSTEM.PART I, LINE 7, COLUMN (F): PERCENTAGE OF TOTAL EXPENSES WAS CALCULATED BASED ON TOTAL EXPENSES LESS BAD DEBT EXPENSE AS REPORTED ON FORM 990, PART IX. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 25275939. PART II: GENESIS HAS AN ACTIVE PRESENCE ON MANY COMMITTEES INVOLVED IN FINDING LOW COST SOLUTIONS TO PHYSICAL AND MENTAL HEALTH ISSUES PREVALENT IN OUR COMMUNITIES, WITH PARTICULAR FOCUS ON SERVING LOW-INCOME, UNINSURED OR OTHERWISE UNDERSERVED. GENESIS NURSES, THERAPISTS, DIABETES COUNSELORS, ADMINISTRATORS AND OTHER PROFESSIONALS PARTICIPATE IN COMMUNITY COALITIONS AND PREVENTION PROGRAMS, PRIMARILY WITH A FOCUS ON DIABETES, DOMESTIC VIOLENCE, FAMILY SERVICES AND WELLNESS INITIATIVES. PART III, LINE 4: THE AMOUNT OF BAD DEBT ATTRIBUTABLE TO CHARITY CARE WAS ESTIMATED BASED UPON BAD DEBT A/R RECLASSIFIED IN 2012 TO CHARITY WITH SERVICE DATES OF 2011 AND PRIOR. BAD DEBT COST IS CALCULATED USING GROSS CHARGES. THE FINANCIAL STATEMENT FOOTNOTE RELATED TO BAD DEBT IS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENT FOOTNOTE 1 "NATURE OF BUSINESS AND SIGNIFICANT ACCOUNTING POLICIES" GROUPED WITH ACCOUNTS RECEIVABLE ON PAGE 8. PART III, LINE 8: CALCULATION WAS BASED ON THE MEDICARE COST TO CHARGE RATIO. THE SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT BASED ON THE AGING POPULATION OF THE AREAS THE HOSPITAL SERVES. PART III, LINE 9B: TRUE SELF-PAY ACCOUNTS AND ACCOUNTS UNDER $500 AFTER INSURANCE HAS PAID RECEIVE THREE STATEMENTS BEFORE GOING TO PRE-COLLECTION (APPROXIMATELY 45 DAYS). BALANCES OVER $500 WITH INSURANCE ARE WORKED IN-HOUSE UNTIL WE REACH APPROXIMATELY DAY 105, AND FIVE STATEMENTS HAVE BEEN ISSUED. ALL ACCOUNTS GO TO FULL COLLECTION AFTER DAY 105 IF NO PRIOR ARRANGEMENTS HAVE BEEN MADE. EACH OF THE COLLECTION AGENCIES ARE INSTRUCTED TO MAKE PHONE CALLS AND SEND LETTERS. IF THEY CANNOT RESOLVE THE BALANCE, OR HAVE NOT BEEN ABLE TO MAKE PAYMENT ARRANGEMENTS, IT IS SENT BACK TO GENESIS AS NON-COLLECTIBLE IN 180 DAYS.COLLECTION PRACTICES DO NOT APPLY TO ACCOUNT BALANCES KNOWN TO QUALIFY FOR CHARITY. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 20D: FAP PATIENTS ARE PROVIDED A MINIMUM DISCOUNT OF 30%. INSURED DISCOUNTS CAN VARY, SOME MORE AND SOME LESS THAN 30%. IN SOME CASES, IT COULD BE POSSIBLE THAT THE DISCOUNT TO FAP PATIENTS COULD BE LESS THAN THE INSURED PATIENTS. BETHESDA HOSPITAL PART V, SECTION B, LINE 20D: FAP PATIENTS ARE PROVIDED A MINIMUM DISCOUNT OF 30%. INSURED DISCOUNTS CAN VARY, SOME MORE AND SOME LESS THAN 30%. IN SOME CASES, IT COULD BE POSSIBLE THAT THE DISCOUNT TO FAP PATIENTS COULD BE LESS THAN THE INSURED PATIENTS. GOOD SAMARITAN HOSPITAL PART V, SECTION B, LINE 22: THIRD PARTY PAYORS FROM AUTO ACCIDENTS, LIABILITY INJURIES, WORK-RELATED ACCIDENTS IN WHICH PATIENT IS UNWILLING TO REPORT, ELECTIVE PROCEDURES. FINANCIAL ASSISTANCE IS PAYOR OF LAST RESORT. BETHESDA HOSPITAL PART V, SECTION B, LINE 22: THIRD PARTY PAYORS FROM AUTO ACCIDENTS, LIABILITY INJURIES, WORK-RELATED ACCIDENTS IN WHICH PATIENT IS UNWILLING TO REPORT, ELECTIVE PROCEDURES. FINANCIAL ASSISTANCE IS PAYOR OF LAST RESORT. PART VI, LINE 2: GENESIS HEALTHCARE SYSTEM, AS A NOT-FOR-PROFIT HEALTH CARE SYSTEM, IS DEDICATED TO MEETING THE HEALTH NEEDS OF OUR COMMUNITIES, REGARDLESS OF ONE'S ABILITY TO PAY. WE ENCOURAGE AND SUPPORT COLLABORATION WITH OTHER COMMUNITY PARTNERS TO IDENTIFY, RESPOND TO AND STRIVE TO IMPROVE THE HEALTH-RELATED NEEDS OF THE POOR, THE UNDERSERVED, AND THE COMMUNITY AT LARGE. WE PLEDGE ALL AVAILABLE FINANCIAL RESOURCES - AFTER OUR OPERATING EXPENSES ARE MET - TO RESPOND TO THE COMMUNITY'S HEALTH NEEDS WITH SERVICE INITIATIVES, FINANCIAL AND PROFESSIONAL SUPPORT, AND EDUCATION AND WELLNESS PROGRAMS.THE COMMUNITY BENEFIT COMMITTEE COLLABORATES WITH GENESIS ADMINISTRATION AND DEPARTMENTS AND WITH COMMUNITY AGENCIES IN OUR DEFINED GEOGRAPHIC MARKET, INCLUDING BUT NOT LIMITED TO THE PUBLIC HEALTH DEPARTMENT, MUSKINGUM VALLEY HEALTH CENTERS, AND THE UNITED WAY, TO ASSESS COMMUNITY HEALTH NEEDS AND STRENGTHS; DEVELOP A COMMUNITY BENEFIT PLAN WITH STRATEGIC GOALS AND INTERVENTIONS; MONITOR IMPLEMENTATION OF COMMUNITY BENEFIT ACTIVITIES; EVALUATE COMMUNITY BENEFIT ACTIVITIES; ADVOCATE FOR THE COMMUNITY BENEFIT PROGRAMS; AND ASSIST IN TELLING THE GENESIS COMMUNITY BENEFIT STORY. PART VI, LINE 3: GENESIS HAS SIGNAGE STRATEGICALLY LOCATED IN THE FACILITY (REGISTRATION AREAS AND CASHIER AREAS) ADVISING OF FREE CARE. BILLING STATEMENTS ALSO CONTAIN THIS INFORMATION ALONG WITH A CHARITY CARE APPLICATION PRINTED ON THE REVERSE SIDE OF THE BILL. THE INFORMATION IS ALSO AVAILABLE ON OUR WEBSITE. WE HAVE A THIRD PARTY THAT WORKS IN THE EMERGENCY DEPARTMENT TO SCREEN PATIENTS FOR CHARITY ASSISTANCE AND LOOK FOR POTENTIAL MEDICAID QUALIFIERS. FOR INPATIENTS, WE ALSO HAVE A THIRD PARTY THAT SCREENS SELF-PAYS, UNDERINSURED AND MEDICARE ONLY PATIENTS FOR MEDICAID AND/OR CHARITY. PART VI, LINE 4: OUR GEOGRAPHIC MARKET AREA IS A SIX-COUNTY RURAL REGION OF SOUTHEAST OHIO, INCLUDING MUSKINGUM, MORGAN, PERRY, COSHOCTON, GUERNSEY AND NOBLE COUNTIES. TOTAL MARKET AREA POPULATION IS APPROXIMATE 250,000, WITH MUSKINGUM COUNTY (80,000) REPRESENTING THE LARGEST COUNTY. GROWTH IS STABLE. MEDIAN HOUSEHOLD INCOME LEVELS RANGE FROM $6,000 TO $11,000 LOWER THAN THE STATE MEDIAN HOUSEHOLD INCOME AND $7,000 TO $12,000 LOWER THAN THE NATIONAL MEDIAN HOUSEHOLD INCOME. PEOPLE LIVING BELOW POVERTY LEVEL RANGES FROM 11.4% TO 14.2% IN THE REGION VERSUS 11.7% FOR STATE AND 12.7% FOR NATION. PART VI, LINE 5: ONGOING COMMUNITY HEALTH EDUCATION IS PROVIDED THROUGH REGULARLY SCHEDULED HEALTH AND WELLNESS PROGRAMS PRESENTED BY GENESIS STAFF AND AFFILIATED PHYSICIANS. PREVENTATIVE HEALTH SCREENINGS ARE ALSO ROUTINELY SCHEDULED. INDIVIDUALS AT RISK ARE ENCOURAGED TO SEE A PHYSICIAN AND PROVIDED ASSISTANCE WITH PHYSICIAN ACCESS AS NEEDED. PROGRAM TOPICS ARE BASED ON COMMUNITY NEED AS DETERMINED BY FEEDBACK FROM PARTICIPANTS, A COMMUNITY ADVISORY GROUP AND INTERNAL CLINICAL GROUP. GENESIS ALSO REGULARLY PROVIDES HEALTH AND WELLNESS EDUCATION THROUGH COMMUNITY-BASED HEALTH FAIRS HELD THROUGHOUT THE COMMUNITY. PART VI, LINE 6: SYSTEM MEMBER ORGANIZATIONS ROUTINELY PARTICIPATE WITH THE HOSPITAL IN PROVIDING HEALTH AND WELLNESS PROGRAMS AND SCREENINGS. SPECIFICALLY, FITNESS CENTER STAFF PROVIDES ADVICE ON EXERCISE AND THE RETAIL PHARMACY OFFERS ONGOING SCREENINGS THROUGH A WELL-ESTABLISHED WELLNESS PROGRAM AND SERVES AS THE HOSPITAL'S SCREENING PARTNER FOR COMMUNITY-BASED INITIATIVES. 1 GENESIS HEALTHCARE FOUNDATION 2951 MAPLE AVENUE ZANESVILLE OH 43701 311629304 501(C)(3) 40000 GRANTS WERE PAID THE RELATED TAX-EXEMPT ORGANIZATION TO HELP SUPPORT ITS PURPOSE. PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GRANTS WERE PAID TO GENESIS HEALTHCARE FOUNDATION TO HELP FURTHER THE RELATED TAX-EXEMPT ORGANIZATION'S PURPOSE. X 1 1 X X X X X 1 1 0 0 0 0 0 0 0 ERIC NEWSOM MD 373910 0 0 0 0 0 5748 0 14284 0 393942 0 0 0 WALTER WIELKIEWICZ MD 251206 0 0 0 0 0 0 0 10961 0 262167 0 0 0 MATTHEW PERRY 485966 0 89743 0 0 0 462418 0 17314 0 1055441 0 0 0 PAUL MASTERSON 296576 0 75514 0 0 0 192359 0 17961 0 582410 0 0 0 RICHARD HELSPER 197400 0 26 0 0 0 56361 0 709 0 254496 0 0 0 CASSANDRA PALMER 220341 0 55578 0 0 0 378828 0 12604 0 667351 0 0 0 EDMOND ROMITO 220183 0 52218 0 0 0 53462 0 14618 0 340481 0 0 0 ALAN BURNS 224569 0 57148 0 0 0 153798 0 12843 0 448358 0 0 0 PATRICIA CAMPBELL 214563 0 53788 0 0 0 357830 0 10500 0 636681 0 0 0 REGINA PENNINGTON 180797 0 43706 0 0 0 39414 0 15778 0 279695 0 0 0 DANIEL SCHEERER 232304 0 53787 0 0 0 51873 0 12078 0 350042 0 0 0 TIMOTHY RAYMOND 247047 0 46338 0 93460 0 19522 0 16376 0 422743 0 0 0 CHARLES ADAMS JR 121034 0 33179 0 0 0 8062 0 10700 0 172975 0 0 0 ABBY NGUYEN 126928 0 16052 0 0 0 10377 0 12340 0 165697 0 0 0 RAY RYMAN 148899 0 246 0 0 0 7329 0 11778 0 168252 0 0 0 DIANNA LEVECK 138241 0 8425 0 0 0 9298 0 13149 0 169113 0 0 0 GREGORY PETE HAMILTON 134593 0 8959 0 0 0 10596 0 15822 0 169970 0 0 0 ALAN VIERLING 0 0 0 0 129744 0 0 0 578 0 130322 0 0 0 PART I, LINE 1A THE ORGANIZATION PAYS COUNTRY CLUB DUES AND RELATED BUSINESS EXPENSES FOR FIVE MEMBERS OF LEADERSHIP. PERSONAL USAGE IS PAID BY THE INDIVIDUAL AND THE PERCENTAGE OF DUES RELATED TO PERSONAL USAGE ARE ADDED TO THE INDIVIDUALS W-2. PART I, LINES 4A-B PART I, LINE 4A: ALAN VIERLING RECEIVED AN INSTALLMENT SEVERANCE PAYMENT OF $129,744 DURING 2012. THIS WAS THE FINAL PAYMENT. TIMOTHY RAYMOND RECEIVED INSTALLMENT SEVERANCE PAYMENTS IN 2012 TOTALING $93,460. FINAL PAYMENTS WERE MADE IN 2012. PART I, LINE 4B: GENESIS HEALTHCARE SYSTEM MADE CONTRIBUTIONS TO NONQUALIFIED RETIREMENT PLANS FOR THE FOLLOWING INDIVIDUALS: MATTHEW PERRY, $416,429 PAUL MASTERSON, $161,511 CASSANDRA PALMER, $210,277 PATRICIA CAMPBELL, $199,442 EDMOND ROMITO, $32,499 ALAN BURNS, $128,190 REGINA PENNINGTON, $28,197 DANIEL SCHEERER, $35,360 RICHARD HELSPER, $45,500 JOK COMPANY INC BOARD MEMBER, ROBERT KESSLER, IS A PARTNER OF JOK COMPANY, INC. 139535 LEASE PAYMENTS ON OFFICE SPACE 0 ZANDEX HEALTH CARE CORP BOARD MEMBER, WILLIAM SHADE, IS A MEDICAL DIRECTOR OF ZANDEX HEALTH CARE 476963 NURSING HOME SERVICES FOR HOSPICE PATIENTS 0 MUSKINGUM VALLEY HEALTH CENTER (MVHC) BOARD MEMBER, RANDY COCHRANE, IS BOARD MEMBER OF MVHC 106870 PROFESSIONAL FEES 0 FORM 990, PART VI, SECTION A, LINE 3 THE MANAGEMENT OF PHYSICIAN OFFICE SPACE (PROPERTY MANAGEMENT) IS OUTSOURCED AND THE MANAGER REPORTS TO A VP OF THE HOSPITAL. THE MANAGEMENT OF FOOD & NUTRITION AND PLANT OPERATION IS ALSO OUTSOURCED. THE DIRECTORS OF THESE AREAS ALSO REPORT TO A VP OF THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 6 FRANCISCAN SISTERS OF CHRISTIAN CHARITY SPONSORED MINISTRIES, INC., AND BETHESDA CARE SYSTEM (OR THEIR RESPECTIVE SUCCESSORS AN ASSIGNS) ARE THE MEMBERS OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF THE FILING ORGANIZATION, HAVE THE RIGHT TO ELECT OR APPOINT ONE OR MORE MEMBERS OF THE ORGANIZATION'S GOVERNING BODY, WHETHER PERIODICALLY, OR AS VACANCIES ARISE, OR OTHERWISE. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBERS OF THE FILING ORGANIZATION, HAVE THE RIGHT TO APPROVE OR RATIFY DECISIONS OF THE ORGANIZATION'S GOVERNING BODY SUCH AS APPROVAL OF THE GOVERNING'S BODY'S DECISION TO DISSOLVE THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 WE PLAN TO REVIEW THE DETAILED 990 WITH THE EXECUTIVE COMMITTEE OF THE BOARD IN DECEMBER 2013 DUE TO TIMING OF THE PREPARATION OF THE 990. WE HAVE HISTORICALLY REVIEWED THE 990 WITH THE EXECUTIVE COMMITTEE PRIOR TO FILING AND MADE AVAILABLE UPON REQUEST COMPLETE COPIES TO THE GENESIS HEALTHCARE SYSTEM BOARD MEMBERS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY STATES THAT BOARD MEMBERS AND OFFICERS HAVE A DUTY TO GOVERN HONESTLY AND ECONOMICALLY. ALL POTENTIAL CONFLICTS OF INTEREST MUST BE DISCLOSED TO THE BOARD OF DIRECTORS AND THE BOARD WILL DETERMINE IF A CONFLICT EXISTS AND APPROPRIATE PROCEDURES TO MITIGATE THE SITUATION, SUCH AS ALTERNATIVE TRANSACTIONS AND PARTICIPATION AND VOTING RESTRICTIONS. THE COMPLIANCE OFFICER MONITORS AND ENFORCES THESE POLICIES. ALL OFFICERS AND DIRECTORS REVIEW AND SIGN A CONFLICT OF INTEREST DISCLOSURE STATEMENT ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE CEO IS MANAGED THROUGH A THIRD PARTY THAT IS A NATIONALLY RECOGNIZED FIRM SPECIALIZING IN COMPENSATION BENCHMARKING AND ANALYSIS. THE FIRM IS RECOGNIZED FOR THEIR EXPERTISE IN EVALUATING TOTAL COMPENSATION AT THE EXECUTIVE LEVEL. THIS FIRM PRESENTS THEIR RECOMMENDATIONS AND ANALYSIS TO THE COMPENSATION COMMITTEE, WHICH IS MADE UP OF INDEPENDENT MEMBERS OF THE GENESIS BOARD OF DIRECTORS. THE COMMITTEE IS RESPONSIBLE FOR MAKING A RECOMMENDATION TO THE BOARD OF DIRECTORS REGARDING THE EXECUTIVE COMPENSATION POLICY AND SPECIFIC COMPONENTS OF THE TOTAL COMPENSATION OF THE CEO. THE CEO IS ACTIVELY INVOLVED IN THE REVIEW, ANALYSIS AND RECOMMENDATION RELATED TO THE TOTAL COMPENSATION FOR THE REMAINING MEMBERS OF THE SENIOR LEADERSHIP TEAM. THE CEO DETERMINES THE COMPENSATION OF THE SENIOR LEADERSHIP TEAM MEMBERS WITHIN THE PARAMETERS ESTABLISHED BY THE COMPENSATION COMMITTEE. THIS COMPENSATION PROCESS WAS LAST COMPLETED IN 2012. FORM 990, PART VI, SECTION C, LINE 18 FORM 1023, FORM 990, AND FORM 990-T ARE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND CONSOLIDATED FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: GAIN IN FAIR VALUE OF PERPETUAL TRUST -3,823,699. PLEDGE RECEIVABLE FROM RELATED PARTY -24,011,813. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT -149,486. FORM 990, PART XII, LINE 2C: THE FINANCE COMMITTEE OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS AND IS INVOLVED IN THE SELECTION OF THE INDEPENDENT ACCOUNTANT WHICH COMPLETES THE AUDIT. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. SEPARATE RETURN COVERED BY A GROUP RULING: FORM 990, PAGE 1, LINE H(D): THIS IS THE PARENT RETURN FOR A GROUP: GENESIS HEALTHCARE SYSTEM GROUP RETURN, EIN: 31-1773259 PART VI, SECTION B, LINE 16B: ALTHOUGH THE ORGANIZATION DOES NOT HAVE A WRITTEN POLICY REGARDING JOINT VENTURES, LEGAL COUNSEL EVALUATES EACH VENTURE IN ADVANCE AND THE BOARD MUST APPROVE. CURRENTLY GENESIS HEALTHCARE SYSTEM IS INVOLVED IN ONE JOINT VENTURE, OF WHICH IT OWNS 57.5%. SCHEDULE L, PART IV, COLUMN B: BOARD MEMBER WILLIAM SHADE IS A BOARD MEMBER OF ZANDEX HEALTH CARE CORPORATION. ZANESVILLE SURGERY CENTER 2907 BELL STREET ZANESVILLE OH 43701 311620813 SURGICAL CENTER OH 0 0 GENESIS HEALTHCARE SYSTEM GENESIS HEALTHCARE FOUNDATION 2951 MAPLE AVENUE ZANESVILLE OH 43701 311629304 FUNDRAISING FOR GHS OH 501(C)(3) 3 GENESIS HEALTHCARE SYSTEM 1 GOOD SAMARITAN MEDICAL CENTER FOUNDATION 2951 MAPLE AVENUE ZANESVILLE OH 43701 310969646 FUNDRAISING FOR GHS OH 501(C)(3) 3 GENESIS HEALTHCARE FOUNDATION 1 BETHESDA HOSPITAL FOUNDATION 2951 MAPLE AVENUE ZANESVILLE OH 43701 310885513 FUNDRAISING FOR GHS OH 501(C)(3) 3 GENESIS HEALTHCARE FOUNDATION 1 FRANCISCAN SISTERS OF CHRISTIAN CHARITY 2951 MAPLE AVENUE ZANESVILLE OH 43701 391530622 SPONSOR OF GHS WI 501(C)(3) 7 GOOD SAMARITAN MEDICAL CENTER 1 GOOD SAMARITAN MEDICAL CENTER 2951 MAPLE AVENUE ZANESVILLE OH 43701 314379479 MAINTAINS REAL ESTATE TITLE FOR HOSPITAL OH 501(C)(3) 3 GENESIS HEALTHCARE SYSTEM 1 BETHESDA CARE SYSTEM 2951 MAPLE AVENUE ZANESVILLE OH 43701 311067174 SPONSOR OF GHS OH 501(C)(3) 9 GENESIS HEALTHCARE SYSTEM 1 BETHESDA HOSPITAL ASSOCIATION 2951 MAPLE AVENUE ZANESVILLE OH 43701 314380038 MAINTAINS REAL ESTATE TITLE FOR HOSPITAL OH 501(C)(3) 11C GENESIS HEALTHCARE SYSTEM 1 ALTERNACARE 2951 MAPLE AVENUE ZANESVILLE OH 43701 311487187 STERILIZATIONS OH 501(C)(3) 3 BETHESDA CARE SYSTEM 1 CARESERVE 2951 MAPLE AVENUE ZANESVILLE OH 43701 311099924 FORMERLY OPERATED 2 NURSING HOMES THAT WERE SOLD PRIOR TO 2012 OH 501(C)(3) 3 GENESIS HEALTHCARE SYSTEM 1 COMMUNITY AMBULANCE SERVICE 2951 MAPLE AVENUE ZANESVILLE OH 43701 341773323 AMBULANCE SERVICE OH 501(C)(3) 9 GENESIS HEALTHCARE SYSTEM 1 GENESIS CAREGIVERS 2951 MAPLE AVENUE ZANESVILLE OH 43701 311282152 2 NURSING HOMES & HOME CARE SERVICES OH 501(C)(3) 3 CARESERVE 1 BETHESDA HOSPITALITY SHOP 2951 MAPLE AVENUE ZANESVILLE OH 43701 316050713 GIFT SHOP OH 501(C)(3) 3 GENESIS HEALTHCARE SYSTEM 1 GENESIS PROFESSIONAL CORPORATION 2951 MAPLE AVENUE ZANESVILLE OH 43701 311599754 PHYSICIAN PRACTICES OH 501(C)(3) 3 GENESIS HEALTHCARE SYSTEM 1 CARELIFE LLC 2951 MAPLE AVENUE ZANESVILLE OH 43701 311128717 FITNESS CENTER, CHILDCARE SVCS, PHARMACY, DME OH GENESIS HEALTHCARE SYSTEM C 126690043 27144296 1.00000 0 SOUTHEAST OHIO MEDICAL INSURANCE COMPANY FIRST CARIBBEAN HOUSE GEORGE TOWN CAYMAN ISLANDS CJ 980436356 CAPTIVE INSURANCE COMPANY CJ GENESIS HEALTHCARE SYSTEM C 1180731 19098311 1.00000 0 0 0 1 0 1 0 0 0 0 1 1 1 1 0 1 1 0 1 1 CARELIFE LLC O 3198960 ACCRUAL TRANSACTION CARELIFE LLC S 372224 ACCRUAL TRANSACTION CARELIFE LLC R 373464 ACCRUAL TRANSACTION CARELIFE LLC L 1187905 ACCRUAL TRANSACTION CARELIFE LLC M 62460 ACCRUAL TRANSACTION CARELIFE LLC K 162406 ACCRUAL TRANSACTION CARELIFE LLC P 5250 ACCRUAL TRANSACTION GENESIS HEALTHCARE FOUNDATION C 177839 ACCRUAL TRANSACTION COMMUNITY AMBULANCE SERVICE M 1254153 ACCRUAL TRANSACTION COMMUNITY AMBULANCE SERVICE O 235098 ACCRUAL TRANSACTION GENESIS HEALTHCARE SYSTEM GROUP R 1520000 ACCRUAL TRANSACTION GOOD SAMARITAN MEDICAL CENTER S 840000 ACCRUAL TRANSACTION BETHESDA CARE SYSTEM E 644426 ACCRUAL TRANSACTION