2011-07-12T20:08:10-05:00 2010-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2009-09-01 521578169 Bon Secours - Maryview Nursing Care Center BONS 7578895000 7007 Harbour View Blvd No 108 Suffolk VA 23435 Michael Kerner 7576860488 2011-07-12 1 7032511000 2009 2016-02-24 21:20:13Z X Diana Jarrett 4775 Bridge Road Suffolk VA 23435 9867463 0 0928 X www.bonsecourshamptonroads.com X 1988 VA Skilled Nursing Care 22 20 169 32 0 0 0 9990857 9796655 212923 33219 42008 37589 10245788 9867463 0 0 4625279 4797427 0 0 3425604 3586551 8050883 8383978 2194905 1483485 14780251 16416661 5065628 5218553 9714623 11198108 The mission is to bring compassion to health care and to be good help to those in need, especially those who are poor and dying. As a system of caregivers, we commit ourselves to help bring people and communities to health and wholeness. 0 0 6206338 6834187 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. 370743 721071 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. 1003826 2241397 Rehabilitation Therapies to include physical therapy, respiratory therapy and occupational therapy so as to maintain each patient's optimal quality of life. 7580907 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 27 0 1 169 1 0 0 0 0 0 0 0 0 0 22 20 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 Michael D Blount 4.00 X 0 0 0 Rise Faith E Dajao 4.00 X 0 0 0 William H Kline 4.00 X 0 0 0 Robert W Knapp 4.00 X 0 0 0 Michael S LaRock 4.00 X 0 0 0 Bennie L Marshall 4.00 X 0 0 0 Margaret U Moser 4.00 X 0 0 0 Mary Jane Nero 4.00 X 0 0 0 R B Seal 4.00 X 0 0 0 Deborah K Stearns 4.00 X 0 0 0 Alfred E Abiouness 4.00 X 0 0 0 Sr Rita Thomas 4.00 X 0 0 0 Timothy J Davis 50.00 X 0 1223989 129362 Sr Anne Lutz 50.00 X 0 0 0 J Robert Bray 4.00 X 0 0 0 Arthur Collins 4.00 X 0 0 0 Sr Elaine Davia 4.00 X 0 0 0 Carol Ormond 4.00 X 0 0 0 Wayne K Sawyer 6.00 X X 0 0 0 Linwood E Howard 6.00 X X 0 0 0 Michael Kerner 50.00 X X 0 940681 126469 Sr Patricia Heath 50.00 X X 0 0 0 Patricia Robertson 50.00 X 0 441620 42145 Diana L Jarrett 50.00 X 162358 0 209 Gregory Simia 50.00 X 0 404075 51557 Edward Boyer 50.00 X 0 938417 17317 Richard Hanson 50.00 X 0 772746 108243 Joseph Buchheit 50.00 X 0 354134 44775 Eileen Malo 50.00 X 0 176009 25752 162358 5251671 545829 1 1 1 0 Rehabcare Group Inc 7733 Forsyth Blvd St Louis MO 63150 Rehabilitation Therapies 903094 1 Patient Service Rev. 621110 9796655 9796655 9796655 32670 32670 549 549 Beauty & Barber Shop 900099 14006 14006 Cafe and Vending 722320 4439 4439 Retail Sales 453220 3492 3492 15652 15652 37589 9867463 9796655 0 70808 164969 148472 16497 3681975 3313778 368197 84239 75815 8424 582411 524170 58241 283833 255450 28383 2616 2354 262 24310 21879 2431 48438 43594 4844 224444 202000 22444 11309 10178 1131 241360 241360 241347 217212 24135 59722 53750 5972 Purchased Services 1446124 1301512 144612 Total Other Supplies 938307 844476 93831 Bad Debt 111903 111903 Repairs & Equip Rental 105034 94531 10503 131637 118473 13164 8383978 7580907 803071 0 11384553 12989095 745094 933878 5286 5434 7371425 5494132 2081161 1877293 488462 488179 6869 31778 68826 91004 14780251 16416661 652854 708320 3900000 3900000 512774 610233 5065628 5218553 X 9714623 11198108 9714623 11198108 14780251 16416661 X 0 1 1 X 1 1 X 7586624 7671247 8298190 10032865 9796655 43385581 7586624 7671247 8298190 10032865 9796655 43385581 0 0 0 43385581 364615 508222 298047 212923 33219 1417026 364615 508222 298047 212923 33219 1417026 7951239 8179469 8596237 10245788 9829874 44802607 0.96840 0.96320 0.03160 0.03680 X 2087243 919172 1168071 4418769 3718822 699947 865413 856138 9275 1877293 Due To Third Party 572335 Other Current Liabilities 31500 Resident Trust Fund 6398 610233 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 Michael Kerner 0 467646 0 290947 0 182088 0 99435 0 27034 0 1067150 0 0 Patricia Robertson 0 277753 0 141790 0 22077 0 32266 0 9879 0 483765 0 0 Diana L Jarrett 131227 0 30900 0 231 0 0 0 209 0 162567 0 0 0 Gregory Simia 0 287470 0 69599 0 47006 0 24464 0 27093 0 455632 0 0 Edward Boyer 0 428865 0 416683 0 92869 0 8188 0 9129 0 955734 0 0 Richard Hanson 0 407990 0 335679 0 29077 0 80844 0 27399 0 880989 0 0 Joseph Buchheit 0 224034 0 47590 0 82510 0 28800 0 15975 0 398909 0 0 Eileen Malo 0 -812 0 0 0 176821 0 24910 0 842 0 201761 0 0 Part I, Lines 4a-b: Eileen Malo received a severance payment of $176,821. Part I, Line 4b: Maryview Nursing Care Center participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirement 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 deposits are made into this plan. 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. is the sole member of Bon Secours Hampton Roads Health System, Inc., which in turn is the sole member of Bon Secours - Maryview Nursing Care Center. Form 990, Part VI, Section A, line 7a The governing body of Bon Secours - Maryview Nursing Care Center is appointed by its Member, Bon Secours Hampton Roads Health System, Inc. and subject to approval by Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Bon Secours - Maryview Nursing Care 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 Bon Secours-Maryview Nursing Care Center's audit and compliance board committee and providing the form to the Bon Secours-Maryview Nursing Care Center's board of directors to allow for a thorough review by both before the filing date of July 15, 2011. Bon Secours Maryview Nursing Care Center's audit and compliance board committee and Bon Secours-Maryview Nursing Care 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 Bon Secours-Maryview Nursing Care 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 Bon Secours-Maryview Nursing Care 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 Bon Secours-Maryview Nursing Care 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 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 other key employees or highest paid employees of Bon Secours-Maryview Nursing Care Center 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 Bon Secours-Maryview Nursing Care 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 Immaculate Nursing Center Inc 7007 Harbour View Blvd Ste 108 Suffolk VA 23435 541516476 Nursing Care Center VA 501(c)(3) Line 9: 509(a)(2) N/A Mary Immaculate 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 Ste A Suffolk VA 23435 521538513 Local System Parent Org. VA 501(c)(3) Line 11, Type II: 50 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 Marriottsville 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 150 Kingsley Lane Norfolk VA 23505 541241031 Administrative VA N/A C Tidewater Diversified Inc 160 Kingsley Lane Norfolk VA 23505 541431826 Pharmacy VA N/A C OSF Inc 2 Bernadine Drive Newport News VA 23602 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