2011-07-12T20:08:10-05:00 2010-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2009-09-01 541516476 Mary Immaculate Nursing Center MARY 7578895000 7007 Harbour View Blvd No 108 Suffolk VA 23435 Greg Simia 7578866500 2011-07-12 1 Emily Hayes Smith 7032511000 2009 2016-02-24 21:20:13Z X St Francis Nursing Center Diana Jarrett 4 Ridgewood Parkway Newport News VA 236020000 7236234 0 0928 X www.bonsecourshamptonroads.org X 1989 VA Skilled Nursing Facility 16 14 120 35 0 0 0 7759071 7180653 116804 16693 43510 38888 7919385 7236234 0 0 3706759 3562816 0 0 3496679 3415959 7203438 6978775 715947 257459 8807849 9214491 3979443 4151891 4828406 5062600 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 5681416 5112326 Skilled Nursing Care provided to patients to include assessment of cognitive and physical status, personal hygeine care, nutrition and maintenance of a clean and comfortable environment. 31261 531002 Medication & Diagnostic Treatments to include the administration of medication, ongoing assessment of potential interactions and negative side effects, wound care and facillitation of diagnostic testing as needed. 599849 1537325 Rehabilitation Therapies to include physical therapy, respiratory therapy and occupational therapy so as to maintain each patient's optimal quality of life. 6312526 1 0 0 0 0 0 0 0 0 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 1 10 0 1 120 1 0 0 0 0 0 0 0 0 0 16 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 0 X James Pirtle 7578895717 150 Kingsley lane Norfolk VA 23505 John H Garrett 4.00 X 0 0 0 Steven B Hopson 4.00 X 0 0 0 Matthew James 4.00 X 0 0 0 Sr M Margaret Jackson 4.00 X 0 0 0 Robert M Yacobi 4.00 X 0 0 0 Susan B Anthony 4.00 X 0 0 0 Sr Lynn Rachelle Pascoe 4.00 X 0 0 0 Timothy J Davis 50.00 X 0 1223989 129362 Sr Patricia Heath 50.00 X 0 0 0 Sr Anne M Lutz 50.00 X 0 0 0 Sr Elaine Davia 4.00 X 0 0 0 Paul W Garman 6.00 X X 0 0 0 Jon A Nystrom 6.00 X X 0 0 0 Sr David Ann Niski 6.00 X X 0 0 0 Kasia Grzelkowski 6.00 X X 0 0 0 Patricia Robertson 50.00 X X 0 441620 42145 Gregory Simia 50.00 X 0 404075 51557 Michael Kerner 50.00 X 0 940681 126469 Timothy Short 50.00 X 156557 0 30423 Leanne Bailey 50.00 X 0 0 0 Joyce Williams 50.00 X 107749 0 11749 Richard Hanson 50.00 X 0 772746 108243 Joseph Buccheit 50.00 X 0 354134 44775 Eileen Malo 50.00 X 0 176009 25752 264306 4313254 570475 2 1 1 0 Rehabcare Group Inc PO Box 502096 St Louis MO 631502096 Rehabilitative Therapies 726977 1 Patient Service Rev. 623110 7180653 7180653 7180653 16693 16693 Other 900099 23170 23170 Beauty & Barber Shop 900099 15718 15718 38888 7236234 7180653 0 55581 178652 160787 17865 2641223 2377101 264122 55169 49652 5517 487228 438505 48723 200544 180490 20054 11433 10290 1143 18520 16668 1852 21489 19340 2149 142706 128435 14271 4544 4089 455 218341 218341 245367 220830 24537 70543 63489 7054 Purchased Services 1398166 1258350 139816 0 Total Supplies 858948 773053 85895 0 Repairs 192130 172917 19213 0 Bad Debt 97950 97950 0 0 Equipment Rental 24912 22420 2492 0 110910 99819 11091 6978775 6312526 666249 0 6161665 6668593 693062 782992 2243 2243 4227526 2513915 1909093 1713611 41786 47052 8807849 9214491 446035 573318 3533408 3578573 3979443 4151891 X 4809360 5043554 19046 19046 4828406 5062600 8807849 9214491 X 0 1 1 X 1 1 X 6501987 6285696 7449594 7759071 7810653 35807001 6501987 6285696 7449594 7759071 7810653 35807001 0 0 0 35807001 226423 318807 137669 116804 16693 816396 226423 318807 137669 116804 16693 816396 6728410 6604503 7587263 7875875 7827346 36623397 0.97770 0.97500 0.02230 0.02500 X 3166066 1915872 1250194 1007781 597325 410456 53679 718 52961 1713611 I/C LT Liab - MCA Transition Company 3498335 Other Current Liabilities 80238 3578573 Part X: Description of Uncertain Tax Positions Under FIN 48: 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. As the organization does not conduct a separate audit of its financial statement, 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 $98,300 and $117,200 of net operating loss carryforwards as of August 31, 2010 and 2009, respectively, which expire in varying periods through 2030 and are available to offset future taxable income. The System's deferred tax assets are fully reserved at August 31, 2010 and 2009. 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 536658 0 665880 0 21451 0 110185 0 19177 0 1353351 0 0 Patricia Robertson 0 277752 0 141790 0 22078 0 32266 0 9879 0 483765 0 0 Gregory Simia 0 289470 0 69599 0 45006 0 24464 0 27093 0 455632 0 0 Michael Kerner 0 467646 0 290947 0 182088 0 99435 0 27034 0 1067150 0 0 Timothy Short 122306 0 29563 0 4688 0 3832 0 26591 0 186980 0 0 0 Richard Hanson 0 407990 0 335679 0 29077 0 80844 0 27399 0 880989 0 0 Joseph Buccheit 0 224034 0 47590 0 82510 0 28800 0 15975 0 398909 0 0 Eileen Malo 0 176009 0 0 0 0 0 24910 0 842 0 201761 0 0 Part I, Lines 4a-b: Eileen Malo received severance payments of $176,821. Part I, 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. Part I, Line 3: Bon Secours Health System, Inc., a related organization of Mary Immaculate Nursing Center, uses the following to establish the compensation of the organization's CEO/Executive Director: Compensation committee Independent compensation consultant Written employment contract Compensation survey or study Approval by the board or compensation committee Form 990, Part I, Item C Doing Business As St Francis Nursing Center 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 Mary Immaculate Nursing Center's audit and compliance board committee and providing the form to the Mary Immaculate Nursing Center's board of directors to allow for a thorough review by both before the filing date of July 15, 2011. Mary Immaculate Nursing Center's audit and compliance board committee and Mary Immaculate Nursing Center's board of directors will review the Form 990 and ask any additional questions regarding the Form 990 before the return is filed July 15, 2011. Form 990, Part VI, Section B, line 12c Mary Immaculate Nursing Center 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 Mary Immaculate Nursing Center. 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 participates 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). Part VI, Section B, Line 14: Document Retention and Destruction Policy While Bon Secours Health System, Inc. does not have a written organization-wide document retention and destruction policy, individual department policies and practices are in place to ensure that each department of the organization maintains their documentation in compliance with state and federal requirements. In addition, any areas responsible for medical records have department policies in compliance with Medicare and HIPAA requirements. An organization-wide policy is currently in place for fiscal year ending August 31, 2011. Form 990, Part VI, Section B, line 15 The compensation committee of the board of Bon Secours Health System, Inc. engages in a comprehensive process for the oversight and management of remuneration for executive employees and disqualified parties of Mary Immaculate Nursing Center as well as other officers, key employees and highest paid employees. The compensation committee consists of a group of independent board members and engages an independent external compensation consultant to ensure the reasonableness of compensation paid to executives and disqualified parties. The committee maintains a Board-approved 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 reported to the BSHSI Board of Directors and documented in the BSHSI 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 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 other key employees or highest paid employees were compared to other hospitals' employees in the area that hold the same title. 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. 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. Michael 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. 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. Patricia Robertson's compensation is paid by Bon Secours Health System, Inc., a related organization. The compensation she receives is for her role as the Executive Vice President of Mary Immaculate Hospital. Sr. Pat Heath and Sr. Anne Lutz do not receive payroll distributions as they have taken vows of poverty. Mary Immculate Hospital Inc 7007 Harbour View Blvd Ste 108 Suffolk VA 23435 540548200 Healthcare VA 501(c)(3) Line 3: 170(b)(1)(A) N/A Bon Secours Hampton Roads Health System Inc 5818 Harbourview Blvd Suffolk VA 23435 521538513 Local System Parent Org. VA 501(c)(3) Line 11, Type II: 50 N/A Bon Secours Maryview Nursing Care Center 7007 Harbour View Blvd Ste 108 Suffolk VA 23435 521578169 Nursing Care Center VA 501(c)(3) Line 9: 509(a)(2) N/A Maryview Hospital 7007 Harbour View Blvd Ste 108 Suffolk VA 23435 540506463 Healthcare VA 501(c)(3) Line 3: 170(b)(1)(A) N/A Bayley Properties 150 Kingsley Lane Norfolk VA 23505 541424748 Rental VA 501(c)(2) N/A N/A Bon Secours Health System Inc 1505 Marriottsville Road Marriottsvile MD 21104 521301088 Parent Org. Management Services MD 501(c)(3) Line 11, Type II: 50 N/A Bon Secours DePaul Health Foundation 7007 Harbour View Blvd Ste 108 Suffolk VA 23435 541843876 Fundraising VA 501(c)(3) Line 11, Type III-FI N/A Bon Secours DePaul Medical Center 7007 Harbour View Blvd Ste 108 Suffolk VA 23435 541820093 Healthcare VA 501(c)(3) Line 3: 170(b)(1)(A) N/A Bon Secours Maryview Foundation 7007 Harbour View Blvd Ste 108 Suffolk VA 23435 521694731 Fundraising VA 501(c)(3) Line 11, Type III-FI N/A Mary Immaculate Foundation 150 Kingsley Lane Norfolk VA 23505 311644734 Fundraising VA 501(c)(3) Line 11, Type III-FI N/A Province Place of Maryview LLC 7007 Harbourview Blvd Ste 108 Suffolk VA 23435 541842697 Assisted Living VA N/A Related 0 0 Province Place of DePaul LLC 7007 Harbourview Blvd Ste 108 Suffolk VA 23435 541950880 Assisted Living VA N/A Related 0 0 Western Tidewater Diagnostic Imaging LLC c/o Roberts Dean PLC 150 Bousch St Norfolk VA 23510 383655545 Healthcare VA N/A Related 0 0 Professional Health Care Mgmt Inc 7007 Harbourview Blvd Ste 108 Suffolk VA 23435 541241031 Administrative VA N/A C Tidewater Diversified Inc 7007 Harbourview Blvd Ste 108 Suffolk VA 23435 541431826 Pharmacy VA N/A C OSF Inc 7007 Harbourview Blvd Ste 108 Suffolk VA 23435 541369919 Rental VA N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 None