2012-07-16T14:55:02-05:00 2011-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2010-09-01 541516476 Mary Immaculate Nursing Center MARY 7576865000 7007 Harbour View Blvd No 108 Suffolk VA 23435 Patricia Robertson 7576865000 2012-07-16 1 Laura L Catlett 7032511000 2010 2016-02-24 21:20:13Z St Francis Nursing Center Michael K Kerner 7007 Harbour View Blvd No 108 Suffolk VA 23435 8301980 0 0928 X www.bonsecourshamptonroads.org X 1989 VA Skilled Nursing Facility 17 14 107 25 0 0 0 0 7180653 8264815 16693 10637 38888 26528 7236234 8301980 0 0 0 0 3562816 4035479 0 0 0 3415959 3766097 6978775 7801576 257459 500404 9214491 9612449 4151891 4229662 5062600 5382787 The mission is to bring compassion to skilled nursing care and to be good help to those in need, especially those who are elderly, poor and dying. 0 0 6035377 5997481 Skilled Nursing Care provided to patients to include assessment of cognitive and physical status, personal hygiene care, nutrition and maintenance of a clean and comfortable environment. 282869 605195 Medication & Diagnostic Treatments to include the administration of medication, ongoing assessment of potential interactions and negative side effects, wound care and facilitation of diagnostic testing as needed. 734430 1662139 Rehabilitation Therapies to include physical therapy, respiratory therapy and occupational therapy so as to maintain each patient's optimal quality of life. 7052676 1 0 0 1 0 0 0 1 0 1 0 0 0 1 1 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 0 1 12 0 1 107 1 0 0 0 0 0 0 0 0 0 0 X 17 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X James Pirtle 7572152709 7007 Harbour View Blvd Suite 108 Suffolk VA 23435 X Susan B Anthony FNP 4.00 X 0 0 0 John H Garrett 4.00 X 0 0 0 Pastor Ivan T Harris 4.00 X 0 0 0 Steven B Hopson 4.00 X 0 5438 0 Matthew James 4.00 X 0 0 0 Sr Lynn Rachelle Pascoe 4.00 X 0 0 0 William F Pile 4.00 X 0 0 0 Robert M Yacobi 4.00 X 0 0 0 Sr Elaine Davia 4.00 X 0 0 0 Timothy J Davis 50.00 X 0 743518 132790 Sr Patricia Heath 50.00 X 0 0 0 Sr M Margaret Jackson 4.00 X 0 0 0 Jon A Nystrom 6.00 X X 0 0 0 Kasia Grzelkowski 6.00 X X 0 0 0 Paul W Garman 6.00 X X 0 0 0 Sr David Ann Niski 6.00 X X 0 0 0 Michael K Kerner 50.00 X X 0 606241 145769 Patricia Robertson 50.00 X 0 376824 28833 Gregory Simia 50.00 X 0 438573 55734 Ernie Padden 50.00 X 0 0 0 Diana Jarrett 50.00 X 0 162553 13852 Joyce S Williams 50.00 X 101841 0 12420 Timothy Short 0.00 X 0 117460 32188 Richard Hanson 0.00 X 0 100022 8651 Joseph Buchheit 50.00 X 0 292884 41939 Eileen Malo 50.00 X 0 222341 7777 101841 3065854 479953 1 1 1 0 Rehabcare Group Inc PO Box 502096 St Louis MO 631502096 Rehabilitation Services 576342 ShiftWise Corporate 1800 SW 1st Avenue Portland OR 97201 Contract Nursing 240197 2 Patient Service Rev. 623110 8264815 8264815 8264815 10637 10637 Laundry Svcs & Other 900099 13429 13429 Beauty & Barber Shop 812900 13099 13099 26528 8301980 8264815 0 37165 3051369 2746232 305137 63424 57082 6342 699884 629896 69988 220802 198722 22080 788 709 79 1024716 922244 102472 901 811 90 48193 43374 4819 16321 14689 1632 150836 135753 15083 3985 3587 398 424 382 42 191635 191635 245164 220648 24516 44421 39979 4442 Medical Expenses 873221 785899 87322 Purchased Services 605436 544892 60544 Repairs 301077 270969 30108 Bad Debt 120915 120915 BSHSI allocation 68832 61949 6883 69232 62309 6923 7801576 7052676 748900 0 0 850 6668593 7142683 782992 876057 2243 38459 4234557 2759079 1713611 1475478 47052 78922 9214491 9612449 573318 696236 13226 3578573 3520200 4151891 4229662 X 5043554 5363741 19046 19046 5062600 5382787 9214491 9612449 X 500404 -180217 X 0 1 1 X 1 1 X 6285696 7449594 7759071 7180653 8264815 36939829 6285696 7449594 7759071 7180653 8264815 36939829 0 0 0 36939829 318807 137669 116804 16693 10637 600610 318807 137669 116804 16693 10637 600610 26529 26529 6604503 7587263 7875875 7197346 8301981 37566968 0.98330 0.97770 0.01600 0.02230 X 0 0 0 0 0 0 0 0 1 788 788 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: Mary Immaculate Nursing Center paid dues to the Virginia Health Care Association, a portion of which is used for lobbying activities. The portion of dues allocated to lobbying activities is $788 or 11.71%. 0 1 3166066 2084847 1081219 1028849 673514 355335 39642 718 38924 1475478 I/C LT Liab - MCA Transition Company 3498335 I/C ST Payable - Maryview 404 Cash - Payroll Account 21461 3520200 Part IV, Line 2b: The filing organization holds, safeguards, manages and accounts for the personal funds of residents who have authorized the facility in writing to manage any personal funds. Any resident may deposit money into a personal Resident Fund Account. Deposits may not exceed $2,000 for residents receiving Medicaid. Withdrawal requests greater than $50 must be made prior to 4PM to allow time to obtain funds from the banking institution if necessary. All excess custodial funds are held in interest bearing accounts separate from that of the organization. Description of Uncertain Tax Positions Under FIN 48: Part X: Schedule D, Part X, Line 2 requires that the organization provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48. FIN 48 addresses the accounting for uncertainty in income taxes recognized in an entity's financial statements and prescribes a threshold of more-likely-than-not for recognition and derecognition of tax positions taken or expected to be taken in a tax return. The adoption of FIN 48 by BSHSI on September 1, 2007 did not have a material impact on BSHSI's consolidated financial statements. As the organization does not conduct a separate audit of its financial statements, below is the related statement from the Bon Secours Health System, Inc. consolidated audited financial statements: The System and most of its subsidiaries (including certain joint venture entities) are exempt from federal income taxes under Section 501(c)(3) of the Internal Revenue Code of 1986, as amended. The system accounts for uncertain tax positions in accordance with ASC Topic 740. Income taxes of the System's for-profit subsidiaries are not material to the accompanying consolidated financial statements. The System's taxable subsidiaries have approximately $89,500 and $98,300 of net operating loss carryforwards as of August 31, 2011 and 2010, respectively, which expire in varying periods through 2031 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2011 and 2010. Any changes to the valuation allowance on the deferred tax asset are reflected in the year of the change. X X X X X 1 1 0 0 0 0 0 0 0 Timothy J Davis 0 568101 0 168422 0 6995 0 111800 0 20990 0 876308 0 0 Michael K Kerner 0 463467 0 138768 0 4006 0 116245 0 29524 0 752010 0 0 Patricia Robertson 0 282666 0 67407 0 26751 0 17150 0 11683 0 405657 0 0 Gregory Simia 0 303064 0 69986 0 65523 0 25631 0 30103 0 494307 0 0 Diana Jarrett 0 137365 0 24932 0 256 0 13638 0 214 0 176405 0 0 Timothy Short 0 117360 0 0 0 100 0 3715 0 28473 0 149648 0 0 Richard Hanson 0 91580 0 680 0 7762 0 6444 0 2207 0 108673 0 69611 Joseph Buchheit 0 229525 0 41221 0 22138 0 19617 0 22322 0 334823 0 0 Eileen Malo 0 46769 0 39414 0 136158 0 3842 0 3935 0 230118 0 0 Part I, Lines 4a-b Part I, Line 4a: Bon Secours Health System, Inc. has system wide severance policies for various levels of executive management. Executive positions throughout the system may include, but are not limited to, CEO/President, CFO, COO, EVP, SVP, VP and Directors. Severance periods vary based on length of service, subsequent employment and violations of the severance policy. Generally, severance periods can be up to 24 months. Benefits may include, but are not limited to, base salary, certain health benefits and payment of unused vacation. The following individual(s) received severance payments during the applicable calendar year: Eileen Malo, $136,016. Part II, Line 4b: Mary Immaculate Nursing Center participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirements plans and available only to officers and key employees. The 457F plan is a non-qualified plan and is subject to a minimum three-year service requirement before vesting on deposits are made into this plan. The following individual(s) received a distribution payment in 2010: Richard Hanson, $71,180. Supplemental Information Part III Part I, Line 3: Bon Secours Health System, Inc., a related organization of Bon Secours Maryview Nursing Care Center, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation committee Independent compensation consultant Written employment contracts Compensation survey or study Approval by the board/compensation committee Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc., and the General Minister and General Council of the Bernardine Sisters of the Third Order of St. Francis are the members of Mary Immaculate Hospital, Inc., which in turn is the sole member of Mary Immaculate Nursing Center. Form 990, Part VI, Section A, line 7a The governing body of Mary Immaculate Nursing Center is appointed by its member Mary Immaculate Hospital, Inc., and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Mary Immaculate Nursing Center are reserved to its member or to Bon Secours Health System, Inc. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of a review by the local system's audit and compliance board-committee and providing the form to the local system board of directors to allow for a thorough review by both before the filing date of July 16, 2012. The local system's audit and compliance committee and board of directors have reviewed the Form 990, scheduled time on meeting agendas, and asked questions regarding the Form 990 before the return is filed July 16, 2012. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors compliance with the conflict of interest policy. On an annual basis, all persons subject to the policy, including all officers, directors and key employees are required to make certain disclosures. These include disclosures related to certain personal, financial and organizational relationships that may present a conflict, or the appearance of a conflict of interest with the organization. All disclosures go through a three-part review process: (1) disclosures are reviewed first by the corporate responsibility officer (CRO); (2) a governance team comprised of the CEO, board president, board chair, CRO, and the BSHSI CRO participate in a second review of all disclosures during which recommendations are made as to the resolution of any conflicts or potential conflicts. Depending on the facts and circumstances, resolutions may include ongoing disclosure, recusal or removal of the conflict; and (3) all disclosures and recommendations are reviewed by a board committee (audit and compliance committee reviews the disclosures of management and the governance committee reviews the disclosures of the board and board committee members). Form 990, Part VI, Section B, line 15 The compensation committee of the board of Bon Secours Health System, Inc. (BSHSI) engages in a comprehensive process for the oversight and management of remuneration for executive employees and disqualified parties of the BSHSI. The compensation committee consists of a group of independent board members and engages independent external compensation consultant to ensure they receive appropriate analysis of market and follow the practices necessary to obtain full compliance with the IRS' rebuttable presumption of reasonableness. The committee establishes and maintains a compensation philosophy, reviews pay practices against local, regional and national healthcare organizations and approves all remunerative decisions for this group of individuals. The committee reviews and receives assurances that all levels of pay within the organization are reasonable based on performance and validates incentives are met. These decisions are documented in the BSHSI board of directors and compensation committee minutes. Form 990, Part VI, Section B, Line 15b - Compensation Process Other Officers/ Key Employees: For those key employees and highest paid employees that are not reviewed by the BSHSI compensation committee, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. In the review, the positions of other officers or key employees of the organization were compared to similar position market data in comparably situated organizations taking into consideration geographic location and organization size where appropriate. During the review and approval of the compensation, documentation of the decision was recorded in human resources. Form 990, Part VI, Section C, line 19 Mary Immaculate Nursing Center provides any documents open to public inspection upon request. Form 990, Part VII: Hours worked are not tracked on an entity by entity basis. All officer's and director's hours reported on Form 990, Part VII, Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors represent aggregate hours worked per week. Voluntary Board Members are not compensated for their time. Michael K. Kerner's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the Chief Executive Officer of Bon Secours Hampton Roads Health System which includes direct management, monitoring and oversight of Bon Secours Hampton Roads Health System and its related organizations. Greg Simia's compensation is paid by Maryview Hospital, a related organization. The compensation he receives is for his role as the Chief Financial Officer of Bon Secours Hampton Roads Health System and all related organizations. Diana L. Jarret's compensation is paid by Maryview Hospital, a related organization. The compensation she receives is for her role as the Executive Director, Extended Care. This position includes responsibilities over both nursing care facilities in the Hampton Roads Health System. Sr. Patricia Heath does not receive payroll distributions as she has taken a vow of poverty. Timothy J. Davis' compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as Executive Vice President and Chief Administrative Officer of Bon Secours Health System, Inc. Sr. Patricia Heath does not receive payroll distributions as they have taken vows of poverty. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Transfers to Affiliates -180,217. Total to Form 990, Part XI, Line 5: -180,217. Bon Secours Health System Inc 1505 Marriottsville Road Marriottsvile MD 21104 521301088 Parent Org.- Management Services MD 501(c)(3) 11b Bon Secours Inc 0 Bon Secours Hampton Roads Health System Inc 5818 Harborview Blvd Ste A Suffolk VA 23435 521538513 Local System Parent Org. VA 501(c)(3) 11b Bon Secours Health System Inc 0 Maryview Hospital 3636 High Street Portsmouth VA 23707 540506463 Healthcare VA 501(c)(3) 3 Bon Secours Hampton Roads Health System 0 Mary Immaculate Foundation 2 Bernadine Drive Newport News VA 23602 311644734 Fundraising VA 501(c)(3) 11c Mary Immaculate Hospital 0 Mary Immaculate Hospital Inc 4 Ridgewood Parkway Newport News VA 23602 540548200 Healthcare VA 501(c)(3) 3 Bon Secours Hampton Roads Health System 0 Bon Scours Maryview Foundation 3520 High Street Ste 100 Portsmouth VA 23707 521694731 Fundraising VA 501(c)(3) 11c Bon Secours Hampton Roads Health System 0 Bon Scours Maryview Nursing Care Center 4775 Bridge Road Suffolk VA 23435 521578169 Nursing Care Center VA 501(c)(3) 9 Bon Secours Hampton Roads Health System 0 Bon Secours DePaul Medical Center 150 Kingsley Lane Norfolk VA 23505 541820093 Healthcare VA 501(c)(3) 3 Bon Secours Hampton Roads Health System 0 Bon Secours DePaul Health Foundation 150 Kingsley Lane Norfolk VA 23505 541843876 Fundraising VA 501(c)(3) 11c Bon Secours Hampton Roads Health System 0 Bayley Properties 150 Kingsley Lane Norfolk VA 23505 541424748 Rental VA 501(c)(2) N/A Bon Secours DePaul Medical Center Inc 0 Province Place of Maryview LLC 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541842697 Assisted Living VA Professional Health Care Mgmt Related 0 0 0.00000 Province Place of DePaul LLC 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541950880 Assisted Living VA Professional Health Care Mgmt Related 0 0 0.00000 Professional Health Care Mgmt Inc 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541241031 Administrative VA Bon Secours Hampton Roads Health System Inc C Tidewater Diversified Inc 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541431826 Pharmacy VA Bon Secours DePaul Medical Center Inc C OSF Inc 7007 Harbourview Blvd Suite 108 Suffolk VA 23435 541369919 Rental VA Mary Immaculate Hospital Inc C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0