2011-01-10T16:11:03-06:00 2010-06-30 Wiplfli LLP 3703 Oakwood Hills Parkway Eau Claire WI 54702 990 2009-07-01 390831153 CUMBERLAND MEMORIAL HOSPITAL & Extended Care unit Inc CUMB 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 DEB KUNFERMAN 7158222741 2011-01-10 1 Holly Pokrandt CPA 7158323407 2010-12-28 2009 2016-02-24 21:20:13Z DEB kunferman 1110 7TH AVENUE CUMBERLAND WI 54829 19992810 0 X www.cumberlandhealthcare.com X 1955 WI Cumberland Memorial Hospital and Extended Care Unit, Inc. is committed to creating a healthier community through provision of an array of high-quality acute care, ambulatory, and skilled nursing facility services to residents of the service area. 6 6 301 122 0 0 111157 148581 20137039 19770180 57828 70279 0 20306024 19989040 2542 5018 0 11987124 12407206 0 0 6950085 7075566 18939751 19487790 1366273 501250 16551731 16586783 6846097 6379899 9705634 10206884 The primary function of Cumberland Memorial Hospital and Extended Care Unit, Inc. (CMH-ECU) is the provision of high quality community-based health care to all people without regard to disability, race, creed, color, national origin or ability to pay. Quality care encompasses curative, restorative, supportive and preventative aspects. In providing this care, the rights, dignity and privacy of the patient/resident will be held in highest regard. Quality health care can best be provided by fostering a quality work environment to attract and retain competent and caring employees. CMH-ECU accepts a leadership role in the community in assessing needs, instituting changes to meet those needs, and planning with other agencies for continuity and comprehensive health care in a cost effective manner. 0 0 14081527 16923884 Cumberland Memorial Hospital-Extended Care Unit, Inc. is an independent, nonprofit, community-based facility that serves northwest Wisconsin. Cumberland Memorial Hospital became a Critical Access Hospital on August 19, 2005, licensed for 25 acute care beds, including 3 in The Birthplace, and 10 psychiatric beds. Among the many kinds of services provided are surgery, radiology, laboratory, emergency room, behavioral health, therapy, and nursery. Acute care days totaled 1,961 in 2010, swing bed days totaled 688, newborn days totaled 108, and behavioral health days totaled 2,215. During fiscal year 2010, Cumberland Memorial Hospital provided 54 inpatient and 423 outpatient surgeries along with 259 scope procedures. There were also 2,696 emergency room visits. 3117173 2677361 Cumberland Extended Care Unit, a 50 bed skilled nursing home, is dedicated to meeting the physical, mental, emotional, and spiritual needs of the residents and families served. Total nursing home days in fiscal year 2010 were 16,833. 147693 168935 The Lakewood Regency Apartments are attached to the Cumberland Memorial Hospital & Extended Care Unit. These spacious apartments were designed as a comfortable and convenient living choice for seniors keeping social interest and personal safety in mind. The occupancy percentage for 2010 was approximately 80%. 17346393 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 40 0 1 301 1 0 0 0 0 0 0 0 0 0 0 0 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X Angie Martens 7158222741 1110 7th avenue Cumberland WI 54829 charles christensen 2.00 X 5250 0 0 keith lIndquist 1.00 X 3075 0 0 joseph vinopal jr 1.00 X 1200 0 0 tom lingen md 1.00 X 2475 0 0 Martin Peters 1.00 X 2700 0 0 Ray Hall 1.00 X 2475 0 0 CANDY COTONE 1.00 X 4250 0 0 Deb Kunferman 40.00 X 223060 0 7534 Mary Ann Clark 40.00 X 102762 0 12565 Angie Martens 40.00 X 70072 0 2123 Dr Charles mayo II 40.00 X 232140 0 31190 Richard Nerbun 40.00 X 105990 0 22942 JEFFreY KUEHN 40.00 X 191456 0 26313 DONALD FULLERTON 40.00 X 171606 0 29694 Benjamin Brenna 40.00 X 105800 0 27399 1224311 0 159760 7 0 1 0 Vonasek & Schieffer 2019 22 1/2 Ave PO Box 557 Rice Lake WI 54868 General contractor 1051849 Shared Medical 2020 W Newton St Rice Lake WI 54868 Radiology 207908 ABM Janitorial Services 75 Remittance Drive Suite 3011 Chicago IL 606753011 Housekeeping 146331 3 116220 32361 148581 Hospital Revenue 621990 16923884 16923884 Nursing home revenue 623000 2677361 2677361 apartment Revenue 623990 168935 168935 19770180 61572 61572 11054 11054 1423 3770 -2347 -2347 -2347 19989040 19770180 0 70279 5018 5018 707230 274216 433014 8764880 8434044 330836 219059 213572 5487 2068651 1918890 149761 647386 596789 50597 21377 21377 78165 78165 2178283 2162060 16223 105756 105756 1981892 1810926 170966 98697 98697 520285 520285 854058 854058 98827 98827 Provision for bad debts 556652 556652 Repairs & Maintenace 319188 285430 33758 Dues, Subscriptions, & 108700 92286 16414 Nursing hoMe assessment 90000 90000 Equipment Rent & Leases 63686 52452 11234 19487790 17346393 2141397 0 329103 692691 1139435 2161936 3195054 2911908 352260 351724 90149 52675 19590952 11812246 7332265 7778706 3721496 2251432 391969 385711 16551731 16586783 1628097 1544899 36000 5170000 4835000 12000 0 6846097 6379899 X 9705634 10206884 9705634 10206884 16551731 16586783 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1656 1656 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Cumberland Memorial Hospital, Inc. pays an annual association membership to the wisconsin hospital association (WHA). These dues are primarily for access to educational materials and staff training and development. WHA has notified CMH that approximately $1,656 of the annual dues were used in conjunction with lobbying activities with the goal of improving the overall healthcare environment. 295897 295897 11438152 6073328 5364824 7856903 5738918 2117985 0 7778706 CD's, Savings Accounts, 2251432 F 2251432 19989040 19487790 501250 0 501250 20011234 22194 22194 19989040 0 19989040 19509984 22194 22194 19487790 0 19487790 Part XII, Line 2d - Other Adjustments: Dietary Revenue netted against dietary expenses: 22194. Part XIII, Line 2d - Other Adjustments: Dietary expenses netted against dietary revenue: 22194. Part X, Line 2 - The Facility is a nonprofit corporation as described in Section 501(c)(3) of the Internal Revenue Code and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Facility is also exempt from state income taxes. In order to account for any uncertain tax positions, ASC Topic 740-10, Accounting for Uncertainty in Income Taxes, requires an organization to assess whether it is more likely than not that a tax position will be sustained upon examination of the technical merits or the position, assuming the taxing authority has full knowledge of all information. If the tax position does not meet the more likely than not recognition threshold, the benefit of the tax position is not recognized in the financial statements. The Facility recorded no assets or liabilities for uncertain tax positions or unrecognized tax benefits. Federal returns for the years ended June 30, 2009, 2008, and 2007, remain subject to examination by the Internal Revenue Service. The return for the year ended June 30, 2010, is not yet due and has not yet been filed. 1 1 1 X 1 X 150.000000000000 1 1 1 0 1 1 160856 160856 0.00850 3454089 3346339 107750 0.00570 418074 266158 151916 0.00800 4033019 3612497 420522 0.02220 40940 40940 0.00220 13250 13250 0.00070 54190 54190 0.00290 4087209 3612497 474712 0.02510 1 335485 16774 5252970 5407446 -154476 X 1 1 CUMBERLAND MEMORIAL HOSPITAL Inc

1110 7th avenue Cumberland WI 54829

X X X X Part I, Line 7: The calculated percent of total expenses excludes bad debt expense totaling $556,652. The expenses recognized in the table were calculated using the cost-to-charge ratio from the medicare cost report. Part III, Line 4: The cost-to-charge ratio was calculated using the medicare cost report.Patient accounts receivable are uncollateralized patient obligations that are stated at the amount management expects to collect from outstanding balances. These obligations are primarily from local residents, most of whom are insured under third-party payor agreements. The Facility bills third-party payors on the patients' behalf, or if a patient is uninsured, the patient is billed directly. Once claims are settled with the primary payor, any secondary insurance is billed, and patients are billed for copay and deductible amounts that are the patients' responsibility. Payments on patient accounts receivable are applied to the specific claim identified on the remittance advice or statement. The Facility does not have a policy to charge interest on past due accounts. The carrying amounts of patient accounts receivable are reduced by allowances that reflect management's best estimate of the amounts that will not be collected. Management provides for contractual adjustments under terms of third-party reimbursement agreements through a charge to gross revenue and a credit to the patient accounts receivable. In addition, management provides for probable uncollectible amounts, primarily uninsured patients and amounts patients are personally responsible for, through a charge to operations and a credit to a valuation allowance based on its assessment of historical collection likelihood and the current status of individual accounts. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable. Patient accounts receivable are recorded in the accompanying balance sheets net of contractual adjustments and allowances for uncollectible accounts. Part III, Line 8: The short fall should be treated as a community benefit expense because the hospital professionals offer classes to the community aimed at maintaining and improving the general health of the population. The cost to charge ratio was calculated using the medicare cost report. Part III, Line 9b: The patient is asked to fill out a charity care application prior to sending to a collection agency. If the paperwork is not received the account is handled through the normal collection process. Part VI, Line 2: The organization assesses the needs of the community through surveys and by recognizing why certain patients are referred out of the area. The organization then attempts to get specialists in the identified areas into the facility to see patients and meet their needs. Part VI, Line 3: If a patient is identified as uninsured, hospital staff works with the patient or their family to determine if they are eligible for any type of government program or qualify for the hospital's charity care program. Part VI, Line 4: The organization serves the communities of Cumberland, WI and Almena, WI and surrounding communities within a 20 mile radius. There are three other hospitals located in the rural area that the organization serves. Part VI, Line 5: While there is growing agreement in the United States about what constitutes a non-profit hospital's 'community benefit,' this is a work in progress. Our hospital provides significant charity care and other community benefits as defined by the IRS. But in addition, we believe that we provide a critically important community benefit which is not quantified. Our hospital, like most rural hospitals, was created and is maintained in order to provide care locally - care that without our hospital, would not be available locally.Beyond inpatient hospitalizations, we provide local access to many health services: Psychiatric services, Ambulance Services, Birthing Center, Diagnostics, Emergency Services & Urgent Care, Extended Care, Inpatient Care, Laboratory Services, Occupational Health, Rehabilitation Services, Specialty Medicine, Sleep Center, Speech, and Surgical Services. Part VI, Line 6: A majority of our organization's governing body is comprised of persons who reside in the organization's primary service area who are neither employees nor contractors of the organization, nor family members thereof. Our organization extends medical staff privileges to all qualified physicians in its community for some or all of its departments. We also participate in community health fairs and provide service at sporting events. Surplus funds are invested back into the facility and its equipment to ensure the needed services are continued to be provided in this community. WI 1 Scholarships given out to employees to continue their education. 2 5018 Other Information: Part IV: All full and part-time employees are eligible to apply for the continuing education program. The employee must have worked at Cumberland Memorial Hospital & Extended Care Unit Inc. (CMH-ECU) at least two years prior to start of coursework and the course must be fulfilled while employed at CMH-ECU. The course must be job related or directly related to a position needed by CMH-ECU. The employee must earn a grade of "B" or better and submit documentation including transcripts detailing grade received for coursework and receipt for the course and textbooks. The maximum scholarship to each employee shall not exceed $3,000 lifetime. The Human Resources Director will make a determination of approval of the scholarship application forms. X X X X 0 0 0 0 0 0 0 0 0 Deb Kunferman 169460 0 50000 0 3600 0 6591 0 943 0 230594 0 0 0 Dr Charles mayo II 232140 0 0 0 0 0 7145 0 24045 0 263330 0 0 0 JEFFreY KUEHN 191456 0 0 0 0 0 7844 0 18469 0 217769 0 0 0 DONALD FULLERTON 171606 0 0 0 0 0 5346 0 24348 0 201300 0 0 0 City of Cumberland 396005423 230849FE6 2008-10-23 5166566 Remodeling project 0 0 5166566 517000 103400 2524863 2009 1 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 Form 990, Part VI, Section B, line 11 Cumberland Memorial Hospital & Extended Care Unit, Inc.'s board members reviewed the Form 990 at the board meeting prior to submission. Once all the questions regarding the Form 990 were addressed, the 990 was approved by board members for submission to the IRS. Form 990, Part VI, Section B, line 12c Cumberland Memorial Hospital & Extended Care Unit,Inc. requires its board members to sign a conflict of interest statement annually. Officers and key employees of Cumberland Memorial Hospital & Extended Care Unit, Inc. sign a code of conduct statement in the code of conduct statement it mentions the conflict of interest. Form 990, Part VI, Section B, line 15 Effective July 1, 2008, wage scales were set for all non-union employees. These scales would include all highly compensated employees. The scales were set based on an area survey of 6 other healthcare facilities. It was the goal of the Cumberland Memorial Hospital-Extended Care Unit, Inc. to set scales that ran at about the midlevel of all facilities surveyed for most positions. These scales are evaluated on a yearly basis using the salary survey tool available through the St. Croix Valley Employer's Association. The only time an employee hourly wage may exist outside of the scale is if the employee is at the top of the scale yet their merit increase of up to 1% for the year brings them to a wage outside of the scale. The CEO, officers and key employee's salary are approved by the board of directors (those without conflict) annually and the CEO approves all other employees' salaries annually also. Documentation is maintained in personnel files. Form 990, Part VI, Section C, line 18 Cumberland Memorial Hospital & Extended Care Unit, Inc. makes its Form 990 available to the public upon request. Form 990, Part VI, Section C, line 19 Cumberland Memorial Hospital & Extended Care Unit, Inc. makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part XI, line 2c Oversight of the Audit and independent accountant Cumberland Memorial Hospital & Extended Care Unit Inc.'s entire board of directors is responsible for the financial statement audit and selection of the independent accountant. The audited financial statements are reviewed by the board of directors annually and any questions or concerns regarding them are addressed by the independent accountants.