2012-11-08T10:05:41-06:00 2011-12-31 410746749 CLIFTONLARSONALLEN LLP 101 N TRYON STREET SUITE 1000 CHARLOTTE NC 28246 990 2011-01-01 560529976 GRACE HOSPITAL INC GRAC 8285805000 2201 SOUTH STERLING STREET MORGANTON NC 28655 ROBERT G FRITTS 8285805000 2012-11-06 1 GREGORY W JOHNS P00535091 7049985200 2011 2016-02-24 21:20:13Z KENNETH W WOOD 2201 SOUTH STERLING STREET MORGANTON NC 28655 135011007 0 X WWW.BLUERIDGEHEALTH.ORG X 1906 NC IMPROVING THE HEALTH OF OUR COMMUNITIES BY PROVIDING EXCELLENT AND COMPASSIONATE CARE. 15 13 1138 83 1503458 0 588840 575389 106468654 112599210 3501698 6001070 2759811 1946499 113319003 121122168 273479 234702 0 0 43680548 48039667 0 0 0 65221334 67302953 109175361 115577322 4143642 5544846 198574101 196282646 69545712 67311417 129028389 128971229 X GRACE HOSPITAL IS COMMITTED TO IMPROVING THE HEALTH OF OUR COMMUNITIES BY PROVIDING EXCELLENT AND COMPASSIONATE CARE. 0 0 17284211 234702 15072205 GRACE HOSPITAL PROVIDED 23,517 DAYS OF CARE TO 5,935 PATIENTS ADMITTED. GRACE HOSPITAL HAS 184 BEDS AND OFFERS A BROAD SCOPE OF SERVICES. 13356706 25191591 GRACE HOSPITAL'S SURGICAL SERVICES PERFORMED 1,327 INPATIENT SURGERIES AND 3,524 OUTPATIENT SURGERIES. ORTHOPEDICS, GENERAL SURGERY, SPINE SURGERY, AND OB/GYN ARE THE MAJOR SURGICAL SPECIALITIES OFFERED. 5381054 14759869 EMERGENCY ROOM SAW 39,131 PATIENTS DURING THE YEAR. THE ED IS OPEN 24 HOURS A DAY, 7 DAYS A WEEK AND IS ABLE TO TAKE CARE OF ANY TYPE OF EMERGENCY OR PROBLEM. 59986760 55988429 OTHER PROGRAMS 59986760 55988429 96008731 1 1 0 1 0 0 0 0 0 0 1 1 0 1 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 0 0 0 0 1 1 0 1138 1 1 1 0 0 0 0 0 0 0 0 0 X 15 13 0 1 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 NC X PATRICIA MOLL 8285805000 2201 SOUTH STERLING STREET MORGANTON NC 28655 X KENNETH W WOOD 50.00 X X 0 0 0 J MICHAEL BRIDGES 1.00 X 0 0 0 MH MCCRARY 1.00 X 0 0 0 JAMES ROSTAN 1.00 X 0 0 0 JEFF CARSWELL 1.00 X 0 0 0 PHILIP TATE 1.00 X 0 0 0 CLAY RICHARDSON MD 1.00 X 0 0 0 KENNETH BONFIELD MD 1.00 X 0 1104 0 S ANDREWS DEEKENS MD 1.00 X 0 0 0 LISA BUFF 1.00 X 0 0 0 JOHN BRANSTROM 1.00 X 0 0 0 DORIS FULLWOOD 1.00 X 0 0 0 SHERROD SALSBURY III 1.00 X 0 0 0 ALAN GRIFFIN 1.00 X 0 0 0 ALLEN VANNOPPEN 1.00 X 0 0 0 CHARLES RICE 1.00 X 0 0 0 ROBERT G FRITTS 50.00 X 0 0 0 KATHY BAILEY 50.00 X 0 0 0 LAURA LAMBETH 50.00 X 247376 0 25197 THOMAS EURE 40.00 X 198767 0 35294 ANTHONY FRASCA MD 40.00 X 272209 0 22659 BYRON STROTHER MD 40.00 X 267334 0 32322 JOSEPH MAZZOLA MD 40.00 X 262548 0 24432 1248234 1104 139904 20 0 1 0 NURSE ANESTHESIA OF NORTH CAROLINA PO BOX 6633 HIGH POINT NC 28277 CRNA STAFFING 1924424 ARAMARK CTS 12483 COLLECTIONS CENTER DR CHICAGO IL 60693 FACILITIES SERVICE MANAGEMENT 1174574 ENDURACARE THERAPY MANAGEMENT DEPT AT 952922 GEMINO HC ATLANTA GA 31192 REHABILITATION THERAPY SERVICES 1099758 ARAMARK FACILITIES 22506 NETWORK PLACE CHICAGO IL 60673 FACILITIES SERVICES MANAGEMENT 918871 TRINITY HEALTHCARE STAFFING GROUP 1708 TRAWICK RAOD 220 RALEIGH NC 27604 STAFFING 682956 35 45591 529798 575389 PATIENT REVENUE 621400 103373467 103373467 INTER-FACILITY REVENUE 621400 9514229 9514229 INTEGRATION OPERATING 900099 -600521 -600521 312035 312035 112599210 2303753 2303753 636996 0 636996 636996 636996 17513155 13815838 3697317 3697317 3697317 127727 73001 54726 54726 UNRELATED BUSINESS INC 624110 1503458 1503458 INTEGRATION CAPITAL 900099 -1641842 -1641842 1393161 1393161 1254777 121122168 111012094 1503458 8031227 234702 234702 272573 272573 38791666 27027136 11764530 504029 349928 154101 5916908 4128515 1788393 2554491 1784714 769777 277414 277414 82800 82800 11872 11872 224243 224243 17420078 16427123 992955 960589 960589 202152 202152 2021245 2021245 280071 280071 2418119 2418119 7866891 7866891 1915641 1915641 BAD DEBT 18056055 18056055 SUPPLIES 10699718 10699718 INTERCOMPANY 2703563 2703563 DIETARY SUPPLIES 892279 892279 1270223 846099 424124 115577322 96008731 19568591 0 597214 2105699 3484324 3906225 15260567 15316765 15247732 10556269 1701514 1514823 435877 817535 176042068 101201262 79358482 74840806 15961988 14797339 66526403 72427185 198574101 196282646 7897960 7788064 32257290 30735438 1628670 738731 27761792 28049184 69545712 67311417 X 128998053 128939095 30336 32134 129028389 128971229 198574101 196282646 X 5544846 -5602006 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 11872 11872 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: MEMBERSHIP DUES TO AMERICAN HOSPITAL ASSOCIATION AND NORTH CAROLINA HEALTH CARE FACILITIES ASSOCIATION. 977206 977206 102536161 48481489 54054672 68191540 50376423 17815117 4337161 2343350 1993811 74840806 INVESTMENTS 14797339 F 14797339 OTHER ASSETS 4825694 BOARD DESIGNATED FOR SCHOLARSHIPS 129354 BOARD DESIGNATED AS FUNDED DEPRECIATION 67349084 GUILD 123053 72427185 DUE TO BLUE RIDGE HEALTH SYSTEMS, INC. 24828824 THIRD PARTY SETTLEMENTS 3219615 GUILD 745 28049184 121122168 115577322 5544846 -5605354 3348 -5602006 -57160 115383513 -5605354 -829684 -6435038 121818551 -696383 -696383 121122168 115456410 751109 751109 114705301 872021 872021 115577322 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FILING ORGANIZATION IS A TAX-EXEMPT ORGANIZATION AS DEFINED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE FILING ORGANIZATION'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL AND STATE AUTHORITIES. THE FILING ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS. THE FILING ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. THE FILING ORGANIZATION ADOPTED THE INCOME TAX STANDARD FOR UNCERTAIN TAX POSITIONS. THIS STANDARD CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ORGANIZATION'S FINANCIAL STATEMENTS IN ACCORDANCE WITH THE INCOME TAX STANDARD. THIS STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THIS STANDARD HAD NO IMPACT ON THE FILING ORGANIZATION'S FINANCIAL STATEMENTS FOR THE YEARS ENDED DECEMBER 31, 2011 OR DECEMBER 31, 2010. PART XI, LINE 8 - OTHER ADJUSTMENTS: MISCELLANEOUS 3,348. PART XII, LINE 2D - OTHER ADJUSTMENTS: INVESTMENT FEES -224,243. RECLASSED EXPENSES -607,239. RELEASES FROM RESTRICTION 1,798. PART XII, LINE 4B - OTHER ADJUSTMENTS: GUILD 54,726. DISTRIBUTIONS-PARTNERSHIPS -751,109. RENTAL EXPENSES PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES DISTRIBUTIONS-PARTNERSHIPS 751,109. PART XIII, LINE 4B - OTHER ADJUSTMENTS: RECLASSED EXPENSES 607,239. INVESTMENT FEES 224,243. GUILD 40,539. 1 1 X 1 X 1 X 1 1 1 0 1 1 5484547 1928758 3555789 0.03650 18182537 10154149 8028388 0.08230 372832 219315 153517 0.00160 24039916 12302222 11737694 0.12040 217720 217720 0.00220 41322 41322 0.00040 312256 312256 0.00320 165825 165825 0.00170 737123 737123 0.00750 24777039 12302222 12474817 0.12790 1 5501856 1873356 22554404 26666001 -4111597 X 1 1 1 BLUE RIDGE CARDIOLOGY HEART CATH SVCS 0.50000 0.00000 0.00000 2 CAROLINAS HEALTHCARE SYSTEM MANAGEMENT SERVICES 0.00000 0.00000 0.00000 3 CHS - HEALTHY HOME HOME NURSING & THERAPY 0.18000 0.00000 0.00000 1 1 GRACE HOSPITAL INC

2201 SOUTH STERLING STREET MORGANTON NC 28655

X X X GRACE HOSPITAL INC 1 1 1 120.000000000000 1 250.000000000000 1 X X X X X 1 1 X X X 1 0 1 X 0 0 PART I, LINE 3C: GRACE HOSPITAL USES THE SLIDING SCALE PROVIDED IN THE FEDERAL POVERTY INCOME GUIDELINES PUBLISHED ANNUALLY BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO DETERMINE ELIGIBILITY. AN ASSET TEST IS USED TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE.PART I, LINE 6A:COMMUNITY BENEFIT REPORT IS PREPARED FOR BLUE RIDGE HEALTHCARE SYSTEM (BRHS) WHICH INCLUDES GRACE HOSPITAL, GRACE NURSING CENTER, VALDESE NURSING CENTER, VALDESE GENERAL HOSPITAL, AND BLUE RIDGE HEALTHCARE MEDICAL GROUP. PART I, L7 COL(F): BAD DEBT COST FROM LINE 2 IS BASED ON TOTAL BAD DEBT EXPENSE MULTIPLIED BY THE COST-TO-CHARGE RATIO. CHARITY INCLUDED ON LINE 3 IS CALCULATED BASED ON A STATISTICAL SAMPLE OF SELF PAY PATIENTS THAT QUALIFY FOR CHARITY CARE FROM THE OUTPATIENT SETTING. PER NOTE 8 OF BLUE RIDGE'S AUDITED FINANCIAL STATEMENTS, "UNINSURED DISCOUNTS AND BAD DEBTS - INCLUDES THE COST OF SERVICES PROVIDED TO UNINSURED OR UNDERINSURED PATIENTS AND TO PATIENTS WHO OTHERWISE DO NOT PAY FOR THEIR HEALTHCARE SERVICES." PART II: NOT APPLICABLE FOR GRACE HOSPITAL. PART III, LINE 4: BRHC'S COST OR 'INVESTMENT IN' ITS MISSION TO CREATE AND OPERATE A COMPREHENSIVE SYSTEM TO PROVIDE HEALTH CARE AND RELATED SERVICES, INCLUDING EDUCATION AND RESEARCH PROGRAMS, FOR THE BENEFIT OF THE PEOPLE IT SERVES, IS MEASURED USING THE FOLLOWING CATEGORIES OF COMMUNITY BENEFIT:COSTS OF FINANCIAL ASSISTANCE TO INDIGENT PATIENTS - INCLUDES THE COST OF SERVICES PROVIDED TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER THE BRHC FINANCIAL ASSISTANCE POLICIES, WHICH PROVIDE CARE WITHOUT CHARGE OR AT DISCOUNTED RATES TO UNINSURED PATIENTS. KEY ELEMENTS USED TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE INCLUDE A PATIENTS DEMONSTRATED ABILITY TO PAY BASED ON FAMILY SIZE AND HOUSEHOLD INCOME RELATIVE TO FEDERAL INCOME POVERTY GUIDELINES.COSTS OF DISCOUNTS EXTENDED TO UNINSURED PATIENTS AND BAD DEBT COSTS BY PATIENTS WHO DO NOT PAY FOR SERVICES - INCLUDES THE COST OF SERVICES PROVIDED TO UNINSURED OR UNDERINSURED PATIENTS AND TO PATIENTS WHO OTHERWISE DO NOT PAY FOR THEIR HEALTH CARE SERVICES.LOSSES INCURRED BY SERVING MEDICARE AND MEDICAID PATIENTS - REPRESENTS THE UNREIMBURSED COST OF SERVICES PROVIDED TO PATIENTS WHO QUALIFY FOR FEDERAL AND/OR STATE GOVERNMENT HEALTH CARE BENEFITS.COMMUNITY BENEFIT PROGRAMS - INCLUDES THE UNREIMBURSED COST OF VARIOUS EDUCATION AND RESEARCH PROGRAMS, NON-BILLED MEDICAL SERVICES, IN-KIND DONATIONS, AND OTHER SERVICES THAT MEET A STRONG COMMUNITY NEED, BUT DO NOT PAY FOR THEMSELVES AND WOULD BE CUT BASED SOLELY ON FINANCIAL CONSIDERATIONS ALONE. PART III, LINE 8: THE MEDICARE COST REPORT IS PREPARED USING THE AUDITED TRIAL BALANCE FOR GRACE HOSPITAL. THE COST REPORT IS PREPARED IN ACCORDANCE WITH ALL APPLICABLE RULES AND REGULATIONS. AS A 501(C)(3) ORGANIZATION, GRACE HOSPITAL ACCEPTS ALL PATIENTS WITHOUT REGARD TO THE INSURANCE OR LACK OF INSURANCE. PART III, LINE 9B: IF FINANCIAL ASSISTANCE IS 100% NO COLLECTION EFFORTS ARE MADE AS ACCOUNT BALANCE IS 0. IF PARTIAL FINANCIAL ASSISTANCE, NORMAL COLLECTION PROCEDURES APPLY FOR PATIENT RESPONSIBILTY AMOUNTS. GRACE HOSPITAL, INC. PART V, SECTION B, LINE 13G: PATIENT ROOM VISIT FROM FINANCIAL COUNSELOR AND SOCIAL WORKER. CONTACT INFO. ON WEBSITE AND PATIENT STATEMENTS. GRACE HOSPITAL, INC. PART V, SECTION B, LINE 19D: ALL PATIENTS RECEIVE SAME CHARGE BASED ON SERVICES PROVIDED. DISCOUNT FOR FINANCIAL ASSISTANCE IS DETERMINED BY POLICY WHICH INCLUDES AN UNINSURED DISCOUNT OF 30% FOR THAT POPULATION. PART VI, LINE 2: GRACE HOSPITAL PERFORMS OUTREACH SERVICES AND HEALTH EDUCATION OPPORTUNITIES FOR THE COMMUNITY SERVED. FEEDBACK FROM THESE EFFORTS ALONG WITH THE EVALUATION OF THE PATIENTS SERVED ARE CONSIDERED IN ASSESSING THE COMMUNITIES HEALTH CARE NEEDS. IN ADDITION, THE ORGANIZATION HAS CONDUCTED EXTENSIVE RESEARCH INTO THE AREAS MOST SERIOUS HEALTH THREATS AND DEVELOPED A PLAN TO FOCUS ATTENTION ON THESE ISSUES. PART VI, LINE 3: ALL SELF PAY ED PATIENTS ARE SCREENED FOR CHARITY AND-OR FINANCIAL ASSISTANCE IN THE ED AREA. PATIENT SEEN IN OUTPATIENT SURGERY AND INPATIENT SETTINGS ARE SCREENED DURING OR PRIOR TO SERVICES. MONTHLY STATEMENTS REFERENCE THE PHONE NUMBERS TO CALL FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: BRHCS PRIMARY SERVICE AREA INCLUDES THREE COUNTIES (BURKE, MCDOWELL, CALDWELL); PATIENTS FROM A NUMBER OF OTHER OUTLYING COUNTIES ARE ALSO SERVED BY BRHC. THE POPULATION IS PREDOMINANTLY CAUCASIAN. SIGNIFICANT MINORITIES INCLUDE HMONG, AFRICAN-AMERICAN AND HISPANIC RESIDENTS. THE AREA IS ECONOMICALLY DEPRESSED DUE TO THE LOSS OF TRADITIONAL FURNITURE AND TEXTILE INDUSTRIES. PART VI, LINE 5: BRHC IS GOVERNED BY A VOLUNTEER COMMUNITY BOARD OF DIRECTORS. BRHC SYSTEM IS SERVED BY OPEN MEDICAL STAFFS. THE SYSTEM IS ALSO SUPPORTED BY A GROWING BRHC VOLUNTEERS CORPS WHO CONTRIBUTE THOUSANDS OF HOURS IN SERVICE ANNUALLY. BRHC ACTIVELY RECRUITS PRIMARY CARE PHYSICIANS AND PHYSICIAN SPECIALISTS TO MEET SPECIFIC MEDICAL NEEDS IN THE COMMUNITY. PART VI, LINE 6: GRACE HOSPITAL IS PART OF BLUE RIDGE HEALTHCARE SYSTEM. BLUE RIDGE SERVES BURKE COUNTY, NC AND SURROUNDING COUNTIES. BLUE RIDGE IS AFFILIATED WITH CAROLINAS HEALTHCARE SYSTEM BASED IN CHARLOTTE, NC. REPORTS FILED WITH STATES PART VI, LINE 7 NC 1 BLUE RIDGE HEALTHCARE FOUNDATION INC 2201 SOUTH STERLING STREET MORGANTON NC 28655 582063920 501(C)(3) 19937 MEMORIAL DONATIONS AND HEALTHCARE EQUIPMENT BURKE CO - FOOTHILLS ALLIED HEALTH PO BOX 219 MORGANTON NC 28655 566000280 501(C)(3) 37800 DONATION FOR HEALTHCARE EDUCATION CENTER GOOD SAMARITAN CLINIC 305 W UNION ST MORGANTON NC 28655 561939030 501(C)(3) 50597 RETAIL VALUE DONATED PHARMACEUTICALS BURKE COUNTY COMMITTEE OF 100 INC PO BOX 1489 MORGANTON NC 28655 208831851 501(C)(3) 5000 COMMUNITY BENEFIT BURKE COUNTY PUBLIC SCHOOLS PO BOX 889 MORGANTON NC 28655 560935935 GOVERNMENTAL 121368 SCHOOL NURSES AND ATHLETIC TRAINERS 5 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: BLUE RIDGE HEALTHCARE SYSTEM EMPLOYEES AND THEIR FAMILY MEMBERS ARE FIRST CONSIDERED FOR FINANCIAL ASSISTANCE THROUGH SCHOLARSHIPS AND GRANTS IN AID. APPLICANTS PREPARING FOR WORK IN HEALTHCARE RELATED AREAS ARE CONSIDERED NEXT. GENERALLY, THIS DOES NOT INCLUDE AREAS OF STUDY SUCH AS ACCOUNTING OR INFORMATION SYSTEMS. FINANCIAL ASSISTANCE IS BASED ON THE INDIVIDUAL'S QUALIFICATIONS AND DEMONSTRATED FINANCIAL NEEDS. A GRADE POINT AVERAGE OF AT LEAST 2.5 ON A 4.0 SCALE IS REQUIRED. THE SCHOLARSHIP COMMITTEE MEETS TWICE A YEAR OR AS OFTEN AS NEEDED TO DECIDE ON RECIPIENTS. IF ALL APPLICATIONS SATISFY SELECTION CRITERIA, THEN MONIES ARE AWARDED BASED ON OTHER FINANCIAL ASSISTANCE AWARDED, DEMONSTRATED FINANCIAL NEED, AREA OF STUDY, AND GRADE POINT AVERAGE. ALL SELECTED APPLICATIONS INTERVIEWED BY THE SCHOLARSHIP COMMITTEE CHAIRPERSON. X 1 1 X X 0 0 0 0 0 1 1 0 0 LAURA LAMBETH 187442 0 59934 0 0 0 7352 0 17845 0 272573 0 0 0 THOMAS EURE 158485 0 33527 0 6755 0 7031 0 28263 0 234061 0 0 0 ANTHONY FRASCA MD 272209 0 0 0 0 0 8846 0 13813 0 294868 0 0 0 BYRON STROTHER MD 267334 0 0 0 0 0 9575 0 22747 0 299656 0 0 0 JOSEPH MAZZOLA MD 262548 0 0 0 0 0 1584 0 22848 0 286980 0 0 0 PART I, LINE 1A BENEFITS PROVIDED TO OFFICERS TO FACILITATE BUSINESS RELATIONSHIPS. PART I, LINE 3 UNCHECKED ITEMS ARE CONDUCTED BY CHS AS PART OF THE MANAGEMENT AGREEMENT. THE ORGANIZATION COMPENSATION COMMITTEE REVIEWS AND APPROVES. PART I, LINE 6 BONUSES ARE PAID IF THE ORGANIZATION'S RESULTS MEET CERTAIN PERFORMANCE INDICATORS. SUPPLEMENTAL INFORMATION PART III PART II: COMPENSATION FOR KENNETH WOOD, KATHY BAILEY, AND ROBERT FRITTS IS PAID BY CAROLINA HEALTH SYSTEMS THROUGH A MANAGEMENT SERVICE CONTRACT. KENNETH WOOD VOTING BOARD MEMBER AND CEO 0 HIS COMPENSATION IS PAID BY CAROLINA HEALTH SYSTEM 0 FORM 990, PART VI, SECTION A, LINE 3 IN 1999, THE ORGANIZATION ENTERED INTO A MANAGEMENT SERVICES CONTRACT WITH CAROLINAS HEALTHCARE SYSTEM. THE TERMS OF THE CONTRACT CALL FOR THE ORGANIZATION TO PAY CAROLINAS HEALTHCARE SYSTEM AN ANNUAL MANAGEMENT FEE BASED UPON THE ORGANIZATION'S NET OPERATING REVENUES. IN ADDITION, CAROLINAS HEALTHCARE SYSTEM IS REQUIRED TO FURNISH THE ORGANIZATION WITH A CHIEF EXECUTIVE OFFICER, CHIEF OPERATING OFFICER, AND CHIEF FINANCIAL OFFICER. THE ORGANIZATION REIMBURSES CAROLINAS HEALTHCARE SYSTEM FOR THE SALARY AND BENEFITS' COST OF THESE INDIVIDUALS. FORM 990, PART VI, SECTION B, LINE 11 THE CHIEF FINANCIAL OFFICER AND THE EXECUTIVE COMMITTEE WILL REVIEW THE PREPARED FORM 990 BEFORE IT IS FILED WITH THE IRS. A DRAFT OF FORM 990 WAS POSTED FOR ACCESS BY THE GOVERNING BODY BEFORE IT WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CORPORATE COUNSEL, WHO REVIEWS ALL ANNUAL CONFLICT OF INTEREST DISCLOSURES, IS PRESENT AT EVERY BOARD MEETING TO ENSURE THAT ANY POTENTIAL CONFLICTS ARE APPROPRIATELY HANDLED BY MEMBERS ABSTAINING FROM VOTES AS APPROPRIATE. FORM 990, PART VI, SECTION B, LINE 15 SUCH A PROCESS WAS PERFORMED FOR DETERMINING THE COMPENSATION OF THE ORGANIZATION'S PRESIDENT/CEO, CFO AND AND COO DURING 2011 AND KEY EMPLOYEE DURING 2011. FORM 990, PART VI, SECTION C, LINE 19 BY-LAWS ARE AVAILABLE UPON REQUEST THROUGH CORPORATE COUNSEL. ARTICLES OF INCORPORATION ARE FILED WITH NC STATE AND ARE AVAILABLE ON THEIR WEBSITE. FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART VII, DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS: OFFICERS AND KEY EMPLOYEES LISTED ON PART VII WORK AN AVERAGE OF 40-50 HOURS PER WEEK. THEIR TIME IS SHARED BETWEEN THE FILING ORGANIZATION AND OTHER RELATED ENTITIES LISTED ON SCHEDULE R. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -5,605,354. MISCELLANEOUS 3,348. TOTAL TO FORM 990, PART XI, LINE 5: -5,602,006. FORM 990, PART XII, LINE 2C: NO CHANGES FOR APPROVING AUDITED FINANCIAL STATEMENTS OR SELECTION OF INDEPENDENT ACCOUNTANTS HAVE OCCURRED FROM THE PRIOR YEAR. GRACE HEALTH VENTURES INC 2201 SOUTH STERLING STREET MORGANTON NC 28655 561581317 RELATED NC -512 35284 BLUE RIDGE HEALTHCARE SYSTEMS INC VALDESE GENERAL HOSPITAL INC 720 MALCOLM BOULEVARD VALDESE NC 28690 560634510 HEALTHCARE NC 501(C)(3) N/A N/A 0 VALDESE NURSING HOME INC 95 LOCUST STREET RUTHERFORD COLLEGE NC 28671 581978560 HEALTHCARE NC 501(C)(3) 509(A)(2) N/A 0 GRACE LIFECARE INC 500 LENOIR ROAD MORGANTON NC 28655 561722754 HEALTHCARE NC 501(C)(3) 509(A)(2) N/A 0 GRACE NURSING CENTER INC 109 FOOTHILLS DRIVE MORGANTON NC 28655 561838369 HEALTHCARE NC 501(C)(3) 509(A)(2) N/A 0 GRACE PROPERTIES INC 500 LENOIR ROAD MORGANTON NC 28655 561727514 HEALTHCARE NC 501(C)(3) 509(A)(3) N/A 0 BLUE RIDGE FOUNDATION INC 2201 SOUTH STERLING STREET MORGANTON NC 28655 582063920 HEALTHCARE NC 501(C)(3) 509(A)(1) N/A 0 BLUE RIDGE MEDICAL GROUP INC 2201 SOUTH STERLING STREET MORGANTON NC 28655 020777195 HEALTHCARE NC 501(C)(3) 509(A)(2) N/A 0 BLUE RIDGE HEALTHCARE SYSTEMS INC 2201 SOUTH STERLING STREET MORGANTON NC 28655 562150313 HEALTHCARE NC 501(C)(3) 509(A)(3) N/A 0 BLUE RIDGE MOBILE IMAGING LLC 2201 SOUTH STERLING STREET MORGANTON NC 28655 020777199 HEALTHCARE NC 501(C)(3) N/A N/A 0 BLUE RIDGE CARDIOLOGY 2201 SOUTH STERLING STREET MORGANTON NC 28655 753158601 CARDIAC CATHETERIZATION SERVICES NC BRHC & MEDCATH RELATED 9769 330906 0 0 0.50000 HEALTHY HOME LLC 4425 GOLF ACRES DR CHARLOTTE NC 29202 261451047 HOME HEALTH SERVICES NC THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY RELATED -119350 -119350 0 0 0.18000 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 0 0 GRACE LIFECARE INC P 299052 INTERCOMPANY ACTIVITY BLUE RIDGE MEDICAL GROUP INC P 241625 INTERCOMPANY ACTIVITY BLUE RIDGE MEDICAL GROUP INC J 640649 INTERCOMPANY ACTIVITY BLUE RIDGE CARDIOLOGY L 1274423 INTERCOMPANY ACTIVITY BLUE RIDGE HEALTHCARE SYSTEMS INC O 3910380 INTERCOMPANY ACTIVITY