2022-09-12T14:38:11-05:00 2021-12-31 410746749 CLIFTONLARSONALLEN LLP 4 BATTERYMARCH PARK SUITE 100 QUINCY MA 02169 990 2021-01-01 042135768 THE HANNAH BG SHAW HOME INC HANN 5089471184 299 WAREHAM STREET MIDDLEBORO MA 02346 DAVID WYLIE PRESIDENT 5089471184 2022-09-08 1 DAVID WYLIE 999009999 DANIELLE NIHILL P01350943 7819821001 2022-09-08 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z DAVID WYLIE 299 WAREHAM STREET MIDDLEBORO MA 02346 15977995 0 X WWW.THESHAWHOME.ORG X 1938 MA TO PROVIDE SKILLED NURSING, REHABILITATIVE, MEMORY CARE, AND RESIDENTIAL CARE. 5 5 253 5 0 0 1192672 2441025 10238139 9968885 206270 1702545 26177 30703 11663258 14143158 0 0 0 0 7317897 7485002 0 0 0 4408793 5066155 11726690 12551157 -63432 1592001 25489603 24813335 15275166 13245030 10214437 11568305 X THE HANNAH BG SHAW HOME, INC. IS A NON-PROFIT COMMUNITY DEDICATED TOPROVIDING THE HIGHEST QUALITY SKILLED NURSING, REHABILITATIVE, MEMORYCARE, AND RESIDENTIAL CARE TO LEND COMFORT AND SUPPORT TO FAMILIES. INKEEPING WITH THE VALUES AND TRADITION OF OUR FOUNDER, HANNAH B.G. SHAW, WE ARE COMMITTED TO PROVIDING COMPASSIONATE CARE AND RECOGNIZINGINDIVIDUAL NEEDS WHILE RESPECTING THE DIGNITY AND PERSONAL CHOICES OFEACH MEMBER OF OUR COMMUNITY. 0 0 11397275 9999588 THE HANNAH BG SHAW HOME, INC. IS A 40-BED RESIDENTIAL CARE AND 67-BED SKILLED NURSING FACILITY LOCATED IN MIDDLEBORO, MASSACHUSETTS. FOUNDED UPON THE DEATH OF ITS BENEFACTRESS, THE LATE HANNAH BARTLETT GRIFFITH SHAW, THE HOME OPENED ITS DOORS TO FIFTEEN RESIDENTS IN 1941 AS A NOT-FOR-PROFIT CORPORATION. THE WILL OF HANNAH SHAW STATED THAT THE HOME WAS TO BENEFIT SENIORS WHO WERE UNABLE TO CARE FOR THEMSELVES. 11397275 1 1 0 0 0 0 0 0 0 1 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 1 1 0 0 1 13 0 1 253 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 5 5 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 0 1 1 1 0 MA X KRISTINE DONNELLY 5089470332 299 WAREHAM STREET MIDDLEBORO MA 02346 DAVID WYLIE PRESIDENT 3.00 1.00 X X 11500 2500 0 TIMOTHY COE TREASURER 2.00 0.00 X X 8500 0 0 SUSAN CALLAN SECRETARY 2.00 1.00 X X 7500 2500 0 DEBRA BLAIS DIRECTOR 0.00 1.00 X 2500 2500 0 SUSAN OKOLITA DIRECTOR 0.00 0.00 X 2500 0 0 KRISTINE DONNELLY EXECUTIVE DIRECTOR 40.00 0.00 X 153745 0 11360 NANCY ALPHONSE DIRECTOR OF NURSING SERVICES 40.00 0.00 X 126100 0 548 312345 7500 11908 2 0 1 0 PREFERRED THERAPY SOLUTIONS 850 SILAS DEANE HWY 2ND FL WETHERSFIELD CT 06109 REHABILITATION SERVICES 479347 INTELYCARE INC PO BOX 200413 PITTSBURGH PA 15251 AGENCY 289825 LOGICALLY PO BOX 1700 PORTLAND ME 04104 IT 143352 CONNECTRN PO BOX 208685 DALLAS TX 75320 AGENCY 112990 4 267748 2163495 9782 2441025 PATIENT REVENUE 623000 9968885 9968885 9968885 152997 152997 3384385 1834837 1549548 1549548 1549548 HAIRDRESSER INCOME 623000 27670 27670 OTHER INCOME 623000 3033 3033 30703 14143158 9999588 0 1702545 192605 192605 6139824 5729173 410651 18468 16709 1759 607299 549445 57854 526806 476620 50186 32476 32476 84963 84963 50589 50589 750341 709830 40511 14804 14804 150118 150118 261968 259348 2620 425073 420822 4251 857629 849053 8576 137949 126356 11593 ANCILLARIES & OTHER MED 1815844 1815844 FOOD 336543 336543 USER FEES 41811 41811 BAD DEBT EXPENSE 40326 40326 65721 65721 12551157 11397275 1153882 0 1164258 653444 663029 474565 790542 852272 70567 131675 27057797 10646790 17219288 16411007 5165015 5823682 118291 118291 298613 348399 25489603 24813335 771100 867522 198151 0 12083613 11791786 1151500 0 1070802 585722 15275166 13245030 X 10214437 11568305 10214437 11568305 25489603 24813335 X 1592001 -703213 465080 X 0 1 X 1 0 X 479453 339235 345477 1192672 2441025 4797862 7749682 9266131 9584524 10238139 9968885 46807361 8229135 9605366 9930001 11430811 12409910 51605223 326443 338529 288189 267748 1220909 0 326443 338529 288189 267748 1220909 50384314 425858 116446 121154 112777 152997 929232 425858 116446 121154 112777 152997 929232 37413 40410 41190 26177 30703 175893 8692406 9762222 10092345 11569765 12593610 52710348 0.95590 0.95870 0.01760 0.01820 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: OTHER INCOME - 2017 AMOUNT: $ 37,413. 2018 AMOUNT: $ 40,410. 2019 AMOUNT: $ 41,190. 2020 AMOUNT: $ 26,177. 2021 AMOUNT: $ 30,703. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 17044098 3551607 278503 20317202 15505977 1836890 298769 17044098 13026731 2832079 352833 15505977 13852411 -472919 352761 13026731 12946818 1080614 175021 13852411 0.00000 0.05000 0.95000 0 1 1 360140 360140 22855069 8254473 14600596 1685714 1315035 370679 2156874 1077282 1079592 16411007 DUE TO AFFILIATE 100000 DERIVATIVE FINANCIAL INSTRUMENT 485722 585722 X PART V, LINE 4: IN ACCORDANCE WITH THE DONOR REQUIREMENTS, THE ENDOWMENT FUNDS ARE HELD IN PERPETUITY UNTIL APPROPRIATED FOR EXPENDITURE TO BE USED FOR GENERAL PURPOSES OF THE ORGANIZATION. PART X, LINE 2: THE CONSOLIDATED FINANCIAL STATEMENTS DO NOT INCLUDE A PROVISION FOR INCOME TAXES BECAUSE THE ORGANIZATIONS HAVE BEEN GRANTED EXEMPT STATUS RELATIVE TO FEDERAL AND STATE CORPORATE INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC) AND APPLICABLE STATE CODES. THE ORGANIZATIONS FOLLOW THE POLICY FOR UNCERTAINTY IN INCOME TAXES TO BE RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE POLICY PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT PRINCIPLES FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. NO UNCERTAIN INCOME TAX POSITIONS WERE IDENTIFIED FOR THE YEARS ENDED DECEMBER 31, 2021 AND 2020. X X 0 0 0 0 0 0 0 0 0 KRISTINE DONNELLY EXECUTIVE DIRECTOR 153745 0 0 0 0 0 0 0 11360 0 165105 0 0 0 FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE ANY COMMITTEES THAT CAN ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD IS RESPONSIBLE AND REVIEWS THE 990 FOR COMPLETENESS AND ACCURACY. THE COMPLETE FORM 990 IS PROVIDED TO THE BOARD PRIOR TO ITS FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S POLICY IS THAT NO INDIVIDUAL ON THE BOARD OF DIRECTORS SHOULD HAVE ANY UNDISCLOSED CONFLICT OF INTEREST WITH THE ORGANIZATION. ACTIVE MONITORING THROUGHOUT THE YEAR IS CONDUCTED BY THE EXECUTIVE DIRECTOR, WHO REPORTS WHEN ANY CONFLICT OF INTEREST IS IDENTIFIED FOR PROPER RESOLUTION BY THE EXECUTIVE DIRECTOR OR BOARD OF DIRECTORS. MONITORING IS ALSO DONE VIA YEARLY ATTESTATION BY ALL BOARD MEMBERS AND CONFLICTS WOULD BE DEALT WITH AT THAT LEVEL. THE BOARD OF DIRECTORS' CLERK WILL COLLECT ALL ATTESTATIONS AND REVIEW. IF A BOARD MEMBER HAS A CONFLICT OF INTEREST, THAT INDIVIDUAL MUST ABSTAIN FROM VOTING ON ANY MATTERS RELATED TO THAT CONFLICT. IN ANY MATTER THAT WOULD RESULT IN A CONFLICT OF INTEREST, SUCH INDIVIDUALS ARE NOT PERMITTED TO PARTICIPATE IN THE DECISION MAKING PROCESS. FORM 990, PART VI, SECTION B, LINE 15 THE EXECUTIVE DIRECTOR'S SALARY IS REVIEWED ANNUALLY BY THE ENTIRE BOARD, THE BOARD UTILIZES COMPARABILITY DATA AND THERE IS CONTEMPORANEOUS DOCUMENTATION OF DECISION. THE EXECUTIVE DIRECTOR RECOMMENDS OTHER OFFICER SALARIES THROUGH UTILIZING THE SAME TYPE OF INFORMATION FOR COMPENSATION ANALYSIS AND THESE AMOUNTS ARE THEN REVIEWED AND APPROVED BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION MAKES ITS FORM 1023 (OR 1024 IF APPLICABLE), 990 AND 990-T AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: DERIVATIVE ADJUSTMENT 465,080. TRUSTEES UW HANNAH BG SHAW 299 WAREHAM STREET MIDDLEBORO MA 02346 046045460 SUPPORTING ORGANIZATION FOR THE BENEFIT OF THE HANNAH BG SHAW HOME, INC. MA 501(C)(3) LINE 12C, III-FI THE HANNAH BG SHAW HOME INC 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TRUSTEES UW HANNAH BG SHAW C 267748 FAIR VALUE TRUSTEES UW HANNAH BG SHAW E -100000 FAIR VALUE TRUSTEES UW HANNAH BG SHAW D 67500 FAIR VALUE