2012-10-28T23:37:31-05:00 2011-12-31 861065772 Deloitte Tax LLP 111 S Wacker Drive Chicago IL 606064301 990 2011-01-01 431592502 Alexian Brothers Sherbrooke Village ALEX 3145441111 4005 Ripa St Louis MO 63125 C Michael Roth 3145441111 2012-10-26 1 Laura Gillespie P00855604 3124861000 2011 2016-02-24 21:20:13Z C Michael Roth 4005 Ripa St Louis MO 63125 11914700 0 0928 X www.alexianbrothershealth.org X 1991 MO ABSV carries out the healing mission of the Catholic Church (Schedule O)as an Alexian Brothers ministry by identifying and developing effective responses to the health and housing needs of those we are called to serve. 5 4 286 4 0 0 13684 12009 10916955 11357937 643515 544754 0 0 11574154 11914700 0 0 0 0 5293477 5462923 0 0 0 3685554 3689103 8979031 9152026 2595123 2762674 27903864 30564969 682057 659403 27221807 29905566 X Alexian Brothers Sherbrooke Village ("ABSV") carries out the healing mission of the Catholic Church as an Alexian Brothers ministry by identifying and developing effective responses to the health and housing needs of those we are called to serve. 0 0 7524930 11357937 Skilled Nursing Facility - Inspired by the healing mission of the Alexian Brothers to the elderly, ABSV provides continuum of care to residents that maximizes dignity and independence. Rooted in the Catholic tradition of caring, the staff is committed to promoting the well being of those we serve through the delivery of quality care. The facility has 164 beds with an average occupancy of 155. In 2011, 7,214 days of care were provided to Medicaid recipients; 3,143 days of care were provided to Medicare recipients. Although reimbursement for services rendered is critical to the operations and stability of the organization, as a charitable organization, it is recognized that not all persons possess the ability to purchase essential services needed for care and our mission is to serve the community with respect to providing health care services. In 2011, $68,622 was provided in charity care. 7524930 1 1 0 0 0 0 0 0 0 0 1 1 0 0 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 1 1 0 0 1 37 0 1 286 1 0 0 0 0 0 0 0 0 0 0 0 X 5 4 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X Peggy Randell 3148808547 4175 Crescent Drive Suite A St Louis MO 63129 X Brother George Bales 1.00 X 0 0 0 Brother Jeffery Callander CFA 1.00 X 0 0 0 Mike Roth 40.00 X X 0 205577 56706 Alec Blanc 1.00 X X 0 0 0 Barbara Prosser 1.00 X X 0 0 0 Patricia Yaeger 1.00 X X 0 0 0 Bonnie Harmon 1.00 X 0 0 0 Virginia Golembiewski 1.00 X 0 69801 16144 Jim Lewandowski 1.00 X 0 372210 66995 0 647588 139845 0 0 1 0 Anthem Blue Cross Blue Shield PO Box 105183 Atlanta GA 303485183 Employee Health Insurance 377082 US Foodservice PO Box 502059 St Louis MO 63150 Food/Dietary Products 319747 Spellman Brady & Co 8251 Maryland Avenue Suite 300 St Louis MO 63105 Interior Planning 263271 Interlock Pharmacy 345 Dunn Road Florissant MO 63031 Pharmaceuticals 196542 Missouri American Water Company PO Box 94551 Palatine IL 600944551 Utilities 128419 7 12009 12009 Skilled Nursing Svces 623000 6199469 6199469 Medicare/Medicaid 623000 3195790 3195790 Residential Care Svces 623000 1898731 1898731 Other Resident Svces 623000 63947 63947 11357937 544754 544754 11914700 11357937 0 544754 4585891 4278446 307445 77933 72708 5225 454912 424462 30450 344187 323529 20658 24256 24256 10596 10596 143648 112315 31333 37424 37424 149917 121476 28441 68709 68709 367779 367779 10811 4696 6115 3683 1794 1889 574626 558016 16610 230348 230348 Food & Medical Supplies 790207 790207 Management Fees 487788 487788 Taxes 373369 379242 -5873 Purchased Svces - Other 193415 3220 190195 222527 87040 135487 9152026 7524930 1627096 0 7938 -111109 798163 601823 22130 18373 41425 36583 22939758 10449532 7531374 12490226 19156101 17261165 346733 267908 27903864 30564969 632058 572593 49999 86810 682057 659403 X 27219402 29903099 2405 2467 0 27221807 29905566 27903864 30564969 X 2762674 -78915 X 0 1 1 X 0 X 43230 44399 27468 13684 12009 140790 9512703 10255876 10762099 10916955 11357937 52805570 9555933 10300275 10789567 10930639 11369946 52946360 0 0 0 52946360 1227199 -2574818 336885 643515 544754 177535 1227199 -2574818 336885 643515 544754 177535 22464 22464 10805596 7725457 11126452 11574154 11914700 53146359 0.99620 0.99350 0.00330 0.00560 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1449000 1449000 11480351 7005192 4475159 3150125 2648535 501590 6860282 795805 6064477 12490226 Beneficial Interest in Alexian Brothers Health System, Inc. Investment Trust 17261165 F 17261165 Outstanding Reserve for Insurance Losses 46867 Due to Affiliates 39943 86810 Description of Uncertain Tax Positions Under FIN 48: Part X: Alexian Brothers Sherbrooke Village does not file a separate audit report, but is part of the Alexian Brothers Health System consolidated audit report. There were no uncertain tax positions, and as a result there was no disclosure related to FIN 48 (ASC740) in the December 31, 2011 audit report. 0 1 0 0 0 0 0 0 0 Mike Roth 0 168595 0 18549 0 18433 0 35498 0 21208 0 262283 0 12517 Jim Lewandowski 0 280338 0 56701 0 35171 0 35309 0 31686 0 439205 0 12354 Part I, Line 3 Alexian Brothers Sherbrooke Village follows the requirements set forth in the IRS rebuttable presumption of reasonableness in determining compensation of the CEO and other officers and executives of the Corporation. This function is performed by the Compensation Committee of the Board of Governors of Alexian Brothers Health System, which is composed of independent board members. The process includes review of comparability data, retention of an outside compensation consultant, and contemporaneous substantiation of the deliberation and decision through detailed minutes of the Compensation Committee. All of the items in Schedule J, Part I, Line 3 are used by the Committee to establish compensation for the CEO of the organization. Supplemental Information Part III Part I, Line 4b: Alexian Brothers Health System offers a Supplemental Employee Retirement Plan to all employees who participate in the executive benefits program and whose compensation exceeds the IRS allowable limit for a qualified pension plan. The amount accrued in 2011 was included in income in Schedule J for the following individual: Jim Lewandowski - $5,297. Form 990, Part VI, Section A, line 6 The Organization has two members, Alexian Brothers Health System (the "National Member") and Alexian Brothers Senior Ministries (the "Area Member"). Form 990, Part VI, Section A, line 7a Alexian Brothers Health System has the authority to appoint and remove Directors and Executive Officers of Alexian Brothers Sherbrooke Village. Form 990, Part VI, Section A, line 7b Alexian Brothers Health System has principal authority with respect to the following matters: - Amendment of the Articles of Incorporation and Bylaws as provided by Statute; - Appointment and removal of Directors and Executive Officers; - Adoption, amendment and repeal of fundamental statements of mission, philosophy, spirit, vision, values, charity policy, and the sponsorship of apostolic activities; - Any plan of merger, consolidation, dissolution, sale or lease of all or substantially all of the assets of Alexian Brothers Sherbrooke Village; and - Other certain reserved powers which Alexian Brothers Health System may designate. Form 990, Part VI, Section B, line 11 Alexian Brothers Sherbrooke Village is an affiliate of Alexian Brothers Health System ("ABHS" or "the System"), which is a Catholic health system. Alexian Brothers Health System is the National Member and ultimate parent for each entity within the System. Alexian Brothers Sherbrooke Village's Form 990 goes through an intensive review process at the System's Corporate level prior to being filed with the IRS. The entire Form 990 is reviewed by Alexian Brothers Sherbrooke Village's financial officer and the CEO. The Form 990 is also reviewed at the System Corporate level by the Chief Accounting Officer for the System. The Vice President and General Counsel for the System reviews all sections of the Form 990 with the exception of the compensation section. The Vice President of Human Resources for Alexian Brothers Health System reviews all compensation disclosures for each entity in Alexian Brothers Health System. These reviews were conducted before the Form 990 was signed and filed with the IRS. In addition, there is also a Compensation Committee that reports to the Alexian Brothers Health System Board of Governors. This Committee reviews the Compensation disclosures for all entities in the System. Alexian Brothers Sherbrooke Village's board reports to the Alexian Brothers Health System Board of Governors, which has ultimate oversight of the activities of all entities within the System. The Audit Committee of the Alexian Brothers Health System Board of Governors has responsibility for and oversight of the Tax Compliance process. The Audit Committee provides oversight for the Form 990 process for the entire System and reviews detailed Forms 990 for the System on an as requested basis. It then reports back to the Alexian Brothers Health System Board of Governors on the results of these activities. The Forms 990 not reviewed by the Audit Committee are available to the Audit Committee members upon request. The Audit Committee did not review the 2011 Form 990 for Alexian Brothers Sherbrooke Village. Form 990, Part VI, Section B, line 12c Alexian Brothers Sherbrooke Village collects annual attestations from board members, officers, directors and key employees. The attestations are reviewed by the Alexian Brothers Sherbrooke Village compliance officer and any conflicts are shared with the Alexian Brothers Sherbrooke Village Chief Executive Officer. The conflicts are also reviewed by the System's Vice President, Corporate Responsibility Officer . The Audit Committee of the Alexian Brothers Health System Board of Governors monitors and receives reports on the completion of this process. Form 990, Part VI, Section B, line 15 Alexian Brothers Sherbrooke Village follows the requirements set forth in the IRS rebuttable presumption of reasonableness in determining compensation of the CEO and other officers and executives of the Corporation. This function is performed by the Compensation Committee of the Board of Governors of Alexian Brothers Health System, which is composed of independent board members. The process includes review of comparability data, retention of an outside compensation consultant, and contemporaneous substantiation of the deliberation and decision through detailed minutes of the Compensation Committee. Form 990, Part VI, Section C, line 19 The financial statements of Alexian Brothers Sherbrooke Village are available through the National Reporting Municipal Services Information Repository (NRMSIR). Conflicts of Interest and Alexian Brothers Sherbrooke Village's governing documents are not made available to the public. Form 990, Part VII: Average hours devoted to related organizations when related compensation is reported: - Virginia Golemblewski worked 40 hours per week for Alexian Brothers Health System; - Jim Lewandowski worked 40 hours per week for Alexian Brothers Health System; - Mike Roth worked 40 hours per week for the filing organization. Form 990, Part VII, Coloumn E: Description of reasonable effort made to obtain compensation from related organization: Payroll records are kept that identify which officers/key employees are paid by a related entity. These documents also show the organization being charged for the officer's/key employee's salary. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -78,977. Other Adjustment 62. Total to Form 990, Part XI, Line 5: -78,915. Part VIII, Line 3; Schedule D, Part VII: The amount reflected as dividends and interest reflects Alexian Brothers Sherbrooke Village's share of interest, dividends and realized gains from Alexian Brothers Sherbrooke Village's beneficial share in the Alexian Brothers Health System, Inc. Investment Trust (ABHSIT). ABHSIT is a related entity whose purpose is to pool the investments of the not-for profit entities in ABHS and acts as an internal mutual fund. Details of gains and losses are shown on the Form 990 of ABHSIT. Alexian Brothers of America Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 362606768 Religious order of Roman Catholic men TX Section 501(c)(3) 1 N/A 0 Brothers of St Alexius Health and Welfare Fund Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 362976617 Provides for health & welfare payments for religious sponsor TX Section 501(c)(3) 1 Alexian Brothers of America Inc 1 Alexian Brothers Bonaventure House 825 Wellington Avenue Chicago IL 60657 363527899 Housing and supportive care services for persons with HIV/AIDS IL Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Health System 3040 W Salt Creek Lane Arlington Heights IL 600051069 363260495 Supports provision of healthcare services for related corporations IL Section 501(c)(3) 11, III-FI Alexian Brothers of America Inc 1 Alexian Brothers Health System Inc Investment Trust 3040 W Salt Creek Lane Arlington Heights IL 600051069 363801585 Manages pooled investments of related not-for-profit entities IL Section 501(c)(3) 11, III-FI Alexian Brothers Health System 1 Alexian Brothers of America Investment Trust 3040 W Salt Creek Lane Arlington Heights IL 600051069 364390471 Manages pooled investments of related not-for-profit entities IL Section 501(c)(3) 11, III-FI Alexian Brothers of America Inc 1 Alexian Brothers Specialty Group 3040 W Salt Creek Lane Arlington Heights IL 600051069 800710751 Specialty physician practice group IL Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers of Chicago 3040 W Salt Creek Lane Arlington Heights IL 600051069 Inactive Corporation IL Section 501(c)(3) 9 Alexian Brothers of America Inc 1 Alexian Brothers of San Jose Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 941530037 Acute care hospital (sold in 1998) TX Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Services Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 431295333 HUD housing MO Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Village of Milwaukee Inc 9301 N 76th Street Milwaukee WI 53223 391351584 Continuing care retirement community WI Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Community Services 425 Cumberland Street Suite 110 Chattanooga TN 37404 364344423 Provides comprehensive & coordinated community based services IL Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Senior Neighbors 250 East 10th Street Chattanooga TN 37402 620646376 Supports the provision of community services for senior citizens TN Section 501(c)(3) 7 Alexian Brothers Health System 1 Alexian Village of Tennessee 437 Alexian Way Signal Mountain TN 37377 621136742 Continuing care retirement community TN Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Senior Ministries 3040 W Salt Creek Lane Arlington Heights IL 600051069 364484290 Supports the provision of healthcare for related corporations IL Section 501(c)(3) 11, III-FI Alexian Brothers Health System 1 Alexian Elderly Services Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 392039667 Community outreach WI Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Lansdowne Village 4624 Lansdowne St Louis MO 63116 431470362 Skilled nursing facility MO Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers of St Louis Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 430653236 Acute care hospital (sponsorship transferred in 1997) MO Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Hospital Network 3040 W Salt Creek Lane Arlington Heights IL 600051069 363276552 Supports the provision of healthcare services for related corporations IL Section 501(c)(3) 11, III-FI Alexian Brothers Health System 1 Savelli Properties Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 363308965 Owns or leases properties where healthcare services are delivered IL Section 501(c)(2) N/A Alexian Brothers Health System 1 Alexian Brothers Center for Mental Health 3436 N Kennicott Avenue Arlington Heights IL 60004 363045007 Outpatient community mental health services IL Section 501(c)(3) 7 Alexian Brothers Health System 1 Alexian Brothers Behavioral Health Hospital 1650 Moon Lake Blvd Hoffman Estates IL 60194 364251848 Behavioral health hospital IL Section 501(c)(3) 3 Alexian Brothers Health System 1 St Alexius Medical Center 1555 Barrington Road Hoffman Estates IL 60194 364251846 Acute care hospital IL Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Ambulatory Group 3040 W Salt Creek Lane Arlington Heights IL 600051069 364336931 Physician services IL Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Medical Center 800 Biesterfield Road Elk Grove Village IL 60007 362596381 Acute care hospital TX Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Rehabilitation Services LLC 935 Beisner Road Elk Grove Village IL 60007 300221481 Rehabilitation hospital IL N/A Illinois NeuroMeg Center LLC 3040 W Salt Creek Lane Arlington Heights IL 600051069 870783164 Provision of NeuroMeg services IL N/A Elk Grove MOB Limited Partnership 3040 W Salt Creek Lane Arlington Heights IL 600051069 363853289 Medical office building IL N/A Workplace Solutions LLC 1100 E Woodfield Road Schaumburg IL 60173 364095007 Provision of EAP services IL N/A Bonaventure Medical Foundation LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 363978153 Manages managed care contracts DE N/A Neurosciences Equipment LLC 3040 W Salt Creek Lane Arlington Heights IL 600051069 861115516 Ownership of Gamma Knife IL N/A St Alexius Center for Sleep Health LLC 665 W North Avenue Lombard IL 60148 205876371 Operation of sleep lab IL N/A Thelen Corporation 3040 W Salt Creek Lane Arlington Heights IL 600051069 363266316 Owns/leases property; joint venture partner IL N/A C Edessa Insurance Company Ltd 3040 W Salt Creek Lane Arlington Heights IL 600051069 Captive insurer located in Bermuda BD N/A C Alexian Brothers Health Providers Association Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 363853286 Messenger model IPA IL N/A C Alexian Brothers Corpus Christi Housing Project LLC 3040 W Salt Creek Lane Arlington Heights IL 600051069 943465394 Tax credit financed housing IL N/A C Alexian Village of Elk Grove 3040 W Salt Creek Lane Arlington Heights IL 600051069 352211303 Tax credit financed housing IL N/A C 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 Alexian Brothers Community Services K 104679 FMV Alexian Brothers Health System O 487788 FMV Alexian Brothers Health System P 402678 FMV Alexian Brothers Senior Ministries O 246088 FMV Schedule R, Part V, Line 2: Alexian Brothers Sherbrooke Village tracks all transactions with related organizations in the general ledger or subsidiary schedules to the general ledger. Amounts are valued based on the fair market value of the transaction.