2011-07-11T07:47:35-05:00 2010-08-31 DELOITTE TAX LLP 1750 TYSONS BLVD MCLEAN VA 221024219 990 2009-09-01 650061820 Bon Secours Maria Manor Nursing Care Center BONS 7275761025 10300 Fourth Street N St Petersburg FL 337163814 KAREN REICH 7275761025 2011-07-08 1 7032511000 2009 2016-02-24 21:20:13Z Karen Reich 10300 4th St N St Petersburg FL 33716 22165027 0 0928 X www.bonsecoursstpete.org X 1988 FL Nursing care to the elderly 17 14 478 50 0 0 2269 154474 22334259 21421656 1765 -1879 375174 588897 22713467 22163148 17029 0 0 13233246 12963873 0 0 9604121 9258325 22854396 22222198 -140929 -59050 9805775 8608335 14278388 13349336 -4472613 -4741001 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 20080610 21421656 Bon Secours Maria Manor Nursing Care Center, Inc. is a freestanding, 274-resident nursing care center offering skilled and long-term nursing care for the Tampa Bay area as well as short-term rehabilitation unit. The Center for Rehabilitation at Maria Manor is designated for those with short-term rehabilitation needs. This 32-bed, dedicated short-term unit mirrors the rehabilitation programs offered at many hospital and rehabilitation centers. For those with orthopedic injuries or surgeries, the CORE, or Center for Orthopedic Excellence, has been designed specifically for those rehabilitating from a fractured hip or hip or knee replacement surgery. Services at Maria Manor include, dental and podiatry services, physical occupational and speech therapy, physician visits on site, interdisciplinary team approach to care, specialized end of life care programs, activities programming for each unit, mass or communion services offered daily, and pastoral care. 20080610 1 1 0 1 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 1 0 0 1 19 0 1 478 1 0 0 0 0 0 0 0 0 0 17 14 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 0 FL X Stacy Booth 7275681017 10300 4th Street North St Petersburg FL 33716 James Higgins 50.00 X 0 611038 48044 Donna Fudge 4.00 X 0 0 0 Sr Frances McCabe 4.00 X 0 0 0 Terence McCarthy 4.00 X 0 0 0 Donna Porter 4.00 X 0 0 0 John Shea 50.00 X 0 792042 131791 Robert Sherman 4.00 X 0 0 0 Regina Clifton 4.00 X 0 0 0 Brother Peter Campbell 4.00 X 0 0 0 Dr Karen Bigby 4.00 X 0 0 0 Sr Mary Regina Flatley 4.00 X 0 0 0 John Thomas 4.00 X 0 0 0 Janice Russel 4.00 X 0 0 0 Karen Reich 50.00 X X 0 248890 51084 Brother Arthur Caliman 50.00 X X 0 0 0 Joseph Mark Waterbury 6.00 X X 0 0 0 Harry B Jones 6.00 X X 0 0 0 Kity Khundkar 50.00 X 0 370720 39690 Carlos Salazar 50.00 X 171999 0 18024 171999 2022690 288633 1 0 1 0 Rehabcare Group PO Box 502096 St Louis MO 631502096 Therapy Services 1033640 Nurse Staffing PO Box 4729 Winter Haven FL 327934729 Contract Labor 228118 Arbor Temporary PO Box 354526 Palm Coast FL 32135 Contract Labor 186009 Modular Building 614 E Highway 50 Clermont FL 34711 Construction Services 121552 Extended Care Respiratory Services 8452 118th Ave B Largo FL 33773 Respiratory Services 106210 10 125000 29474 154474 Patient Service Rev. 621110 21421656 21421656 21421656 1879 -1879 -1879 -1879 Beauty & Barber 900099 43493 43493 Gift Shop 900099 24849 24849 Cafe & Vending 900099 4082 4082 516473 516473 588897 22163148 21421656 0 587018 100459 90413 10046 9398550 8458695 939855 142500 128250 14250 2173684 1956316 217368 1148680 1033812 114868 51929 46736 5193 1425 1283 142 3262715 2936443 326272 23552 21197 2355 577894 520105 57789 262671 236404 26267 529559 476603 52956 53687 48318 5369 285 256 29 610269 549242 61027 503544 453190 50354 488460 439614 48846 338382 304544 33838 Medical Supplies 1225236 1102712 122524 Bad Debt 610320 610320 Employee related exp. 126571 113914 12657 Dues and Subscriptions 37589 33830 3759 Taxes and Licenses 34791 31312 3479 519446 487101 32345 22222198 20080610 2141588 0 435921 -85715 3233370 2625815 71427 82710 6231 26283 17146150 11857098 5190795 5289052 868031 670190 9805775 8608335 959707 904446 13318681 12444890 14278388 13349336 X -4472613 -4754300 13299 -4472613 -4741001 9805775 8608335 X 0 1 1 X 1 1 X 3974 21514 3683 2269 154474 185914 19126099 19824086 21349437 22334259 21421656 104055537 19130073 19845600 21353120 22336528 21576130 104241451 0 0 0 104241451 99312 37898 18305 1765 157280 99312 37898 18305 1765 157280 240512 273421 310005 375174 588897 1788009 19469897 20156919 21681430 22713467 22165027 106186740 0.98170 0.98410 0.00150 0.00210 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1425 1425 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Bon Secours Maria Manor Nursing Care Center paid dues to the FL Association of Homes and Services for the Aging, Inc. (FAHSA) and American Association of Homes and Services for the Aging (AAHSA), a portion of which is used for lobbying activities. The portion of dues allocated to lobbying activities for both of these organizations was 9.4% ($1,425). 1828977 1828977 2464997 1055142 1409855 421177 4155093 3742945 833325 8275906 7059011 1216895 5289052 Due from short term affiliates 669522 Other receivables 668 670190 Intercompany Payable BSNY 4220 Intercompany Payable HSO 19425 Long term Pension Liability 190985 Accrued payroll and benefit costs 1078185 Due to HSO 10700000 Other Liabilities 452075 12444890 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 0 1 0 0 0 0 0 0 0 James Higgins 0 313265 0 278478 0 19295 0 37944 0 10100 0 659082 0 0 John Shea 0 446997 0 341161 0 3884 0 116092 0 15699 0 923833 0 0 Karen Reich 0 165681 0 64022 0 19187 0 22479 0 28605 0 299974 0 0 Kity Khundkar 0 226509 0 98694 0 45517 0 27549 0 12141 0 410410 0 0 Carlos Salazar 154751 0 17100 0 148 0 0 0 18024 0 190023 0 0 0 Part I, Line 4b: Bon Secours Health System, Inc. and Frances Schervier Home and Hospital participates in a BSHSI sponsored executive retirement program that allows for deposits into additional retirements plans and is 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. Supplemental Information Part III Part I, Line 3: Bon Secours Health System, Inc., a related organization of Bon Secours Maria Manor Nursing Care 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 VI, Section A, line 2 The Chairman of the Board, Mark Waterbury and another Board Member, Terrence McCarthy, have a business relationship. Form 990, Part VI, Section A, line 6 Bon Secours Health System, Inc. is the sole member of Bon Secours Maria Manor Nursing Care Center. Form 990, Part VI, Section A, line 7a The governing body of Bon Secours Maria Manor Nursing Care Center is appointed by its member Bon Secours Health System, Inc. Form 990, Part VI, Section A, line 7b Certain authorities of Maria Manor Nursing Care Center, Inc. are reserved to its Member. Form 990, Part VI, Section B, line 11 The process the organization uses to review the Form 990 consists of a review by BSSPHS' audit and compliance board committee and providing the form to Bon Secours Maria Manor Nursing Care Center's board of directors to allow for a thorough review by both before the filing date of July 15, 2011. BSSPHS' audit and compliance board committee and Bon Secours Maria Manor 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 Maria Manor 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 Maria Manor 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). 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 Maria Manor 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 officers or key employees of Bon Secours Maria Manor 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 Maria Manor Nursing Care Center provides any documents open to public inspection upon request. 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 VII: Hours worked are not tracked on an entity by entity basis. All officers and directors 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. General Compensation Disclosure Regarding Officers Paid by Related Organizations: The CEO and CFO of Bon Secours St. Petersburg Health System, Inc., James Higgins and Kity Khundkar, serve as CEO and CFO of Bon Secours New York Health System, Inc. (whose tax-exempt entities include Frances Schervier Home and Hospital and Frances Schervier Housing Development Fund Corporation). Bon Secours St. Petersburg Health System reimbursed the organization for these services. James Higgin's compensation is from Bon Secours Health System, Inc., a related organization. The compensation he receives is for his role as the Chief Executive Officer (CEO) of Bon Secours St. Petersburg Health System as well as the related organizations at Bon Secours New York Health System, Inc. Kity Khundar's compensation is from Frances Schervier Home and Hospital, a related organization. The compensation she receives is for her role as the Chief Financial Officer (CFO) of Bon Secours St. Petersburg Health System as well as the related organizations at Bon Secours New York Health System, Inc. Karen Reich's compensation is from Bon Secours Health System, Inc., a related organization. The compensation she receives is for her role as the Executive Vice President (EVP) at Bon Secours Maria Manor Nursing Care Center and Bon Secours St. Petersburg Home Care Services. John Shea's compensation is from Bon Secours Health System, Inc., a related organization. The compensation he receives is for the role as an employee at Bon Secours Health System, Inc. Brother Art Caliman does not receive payroll distributions as he has taken a vow of poverty. 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 St Petersburg Home Care Services 10300 Fourth Street North St Petersburg FL 33716 134334363 Home Care Services FL 501(c)(3) Line 9: 509(a)(2) N/A Frances Schervier Home and Hospital 2975 Independence Avenue Bronx NY 10463 131740397 Long term nursing care NY 501(c)(3) Line 3: 170(b)(1)(A) N/A Bon Secours Place at St Petersburg 10300 4th Street North St Petersburg FL 33716 593589729 Assisted Living/Senior Care FL Bon Secours - Florida Integrated Services Inc Related 202967 5643823 0 0 Bon Secours - Florida Integrated Services Inc 10300 4th Street North St Petersburg FL 33716 650779777 Holding Company/Assisted Living FL Bon Secours Maria Manor Nursing Care Center C 0.80000 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 None