2022-11-08T07:45:03-06:00 2021-12-31 010523282 Berry Dunn McNeil & Parker LLC 2211 Congress St Portland ME 04102 990 2021-07-01 010538534 Bangor Nursing & Rehabilitation Center BANG 2079474557 103 Texas Avenue Bangor ME 04401 Melissa Martin Administrator 2079474557 2022-11-04 1 Melissa Martin 999009999 Joseph R Byrne P01289281 2077752387 2022-11-04 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z Melissa Martin 103 Texas Avenue Bangor ME 04401 2901288 0 X www.bangornrc.com X 2001 ME Long-term care nursing facility 11 11 56 22 0 0 1016401 188409 5654048 2653079 1394 665 118270 59135 6790113 2901288 0 0 0 0 2361335 880955 0 0 0 3916240 2357806 6277575 3238761 512538 -337473 3127404 3163906 548932 922907 2578472 2240999 It is the mission of the Bangor Nursing and Rehabilitation Center to provide the highest level of care with the highest level of quality, competency and professionalism that focuses on the health and well-being of the community it serves. 0 0 2776135 2653079 BNRC is a 60-bed skilled nursing facility providing complex nursing and rehabilitation care to a significantly large sub-acute population with short average lengths of stay. 2776135 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 15 0 1 56 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 11 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 0 0 X Brian Donahue 2079474557 103 Texas Ave Bangor ME 04401 Nichi Farnham President 2.00 X X 0 0 0 Helen Burlock RN Vice President 1.00 X X 0 0 0 John Muth Treasurer 1.00 X X 0 0 0 Deborah Laurie Secretary 1.00 X X 0 0 0 Janna Gau Board Member 1.00 X 0 0 0 Eileen McAvoy Board Member 1.00 X 0 0 0 John Miller Board Member 1.00 X 0 0 0 Alicia Murray Board Member 1.00 X 0 0 0 Sandy Nesin Board Member 1.00 X 0 0 0 John Patten Board Member 1.00 X 0 0 0 Stephen Rich Board Member 1.00 X 0 0 0 Kathy Bernier Past Board Member 1.00 X 0 0 0 Geoff Gratwick Past Board Member 1.00 X 0 0 0 Larry Lavigne Past Board Member 1.00 X 0 0 0 Dana Lippitt Past Board Member 1.00 X 0 0 0 Jon Pottle Past Board Member 1.00 X 0 0 0 Jonathan Spraque Past Board Member 1.00 X 0 0 0 Tony Tsismenakis Past Board Member 1.00 X 0 0 0 Melissa Martin Administrator 40.00 X 88347 0 18212 Brian Donahue CFO 40.00 X 107039 0 888 195386 0 19100 1 0 0 0 Medefis Consolidated PO Box 5068 New York NY 10087 Staffing Services 673525 Metz Culinary Management 2 Woodland Drive Dallas PA 18612 Food and Dietary Services 656295 MAS Medical Staffing 156 Harvey Road Londonderry NH 03053 Staffing Services 503195 Select Rehabilitation PO Box 71985 Chicago IL 60694 Rehabilitation Services 379780 Healthcare Services Group PO Box 829677 Philadelphia PA 191829677 Housekeeping, Laundry and Maintenance 293982 10 171572 16837 188409 Resident Revenue 623000 2752262 2752262 Other Revenue 900099 2350 2350 Contractual Adjustment 623000 -101533 -101533 2653079 665 665 59135 0 59135 59135 59135 2901288 2653079 0 59800 X 137760 137760 507984 466120 41864 166049 128372 37677 69162 51854 17308 37500 37500 19877 19877 18000 18000 1479728 1450705 29023 2382 2382 129675 110445 19230 14469 14469 165287 165287 474 192 282 660 660 284 284 81479 81479 18956 18956 Provider Tax Expense 159044 159044 Medical Supplies 145829 145829 Miscellaneous 84162 16524 67638 3238761 2776135 462626 0 X 36213 161498 1121512 1039588 434368 415203 45432 45432 59873 21248 6573408 5316571 1288506 1256837 141500 224100 3127404 3163906 387511 252074 16813 16813 4475 0 140133 654020 548932 922907 X 2578472 2240999 2578472 2240999 3127404 3163906 -337473 0 X 1 X 0 1 0 X 79511 6438 432976 1016401 188409 1723735 5760579 6171312 6029353 5654048 2653079 26268371 5840090 6177750 6462329 6670449 2841488 27992106 0 871499 337218 720451 421883 448462 2799513 871499 337218 720451 421883 448462 2799513 25192593 119862 120791 119812 119664 59800 539929 119862 120791 119812 119664 59800 539929 5959952 6298541 6582141 6790113 2901288 28532035 0.88300 0.88030 0.01890 0.01900 X Schedule A, Part III: In 2021, Bangor Nursing & Rehabilitation Center changed its year end to December 31. The amounts reported in the 2021 column of Schedule A, Part III reflect the short period activity from 7/1/21 to 12/31/21. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 876 876 0 Part II-B, Line 1: The Organization pays dues to various organizations, a portion of which is attributable to lobbying. 0 1 X 5376470 4350590 1025880 1125621 945801 179820 71317 20180 51137 1256837 Estimated Third-Party Payor Settlements 224100 224100 CARES Act Funding 654020 654020 Part IV, Line 2b: The Organization holds funds for residents and provides these funds to the resident, as needed. The funds are reported as a liability on Form 990, Part X, line 21. Form 990, Part VI, Section A, line 3 Effective December 1, 2021, Covenant Health Systems assumed certain management duties and responsibilities including the execution of operational budgets, management of certain operations, supervision of employee benefit plans, etc. As of December 31, 2021, no one from Bangor Nursing & Rehabilitation Center (including current or former officers, directors, trustees, key employees, or highly compensated employees) received any compensation from Covenant Health Systems. Form 990, Part VI, Section A, line 4 In December 2021, the Organization amended its bylaws. Significant changes include reference to the new sole corporate member as well as powers reserved to the Member. Please refer to Schedule O for responses to Form 990, Part VI, questions 6, 7a, and 7b for a comprehensive list of significant changes made. Form 990, Part VI, Section A, line 6 Prior to December 1, 2021, any person, group of persons, corporation or association with an interest in or expertise useful for the provision of medical, rehabilitative, and support services to individuals served by or who qualify for services by the corporation, shall be eligible to be a voting member. Employees of Bangor Nursing and Rehabiliation Center cannot be members. Effective December 1, 2021, Covenant Health, Inc. became the sole corporate member of the Organization. Form 990, Part VI, Section A, line 7a Effective December 1, 2021, Covenant Heath, Inc. (as sole corporate member of the Organization) has the power to elect the Directors of the Corporation and the remove them with or without cause. Form 990, Part VI, Section A, line 7b Effective December 1, 2021, Covenant Heath, Inc. (as sole corporate member of the organization) has the following governance decisions/powers pursuant to the Organization's amended bylaws: 1. To approve any change in the written statements of philosophy and mission of the Corporation or any subsidiary of the Corporation, and to monitor compliance with same; 2. To amend and to repeal the Articles of Incorporation and the Bylaws of the Corporation, and to approve the adoption, amendment or repeal of the governing instruments of any subsidiary of the Corporation; 3. To appoint and remove the President of the Corporation, including a President secured by management contract; 4. To ratify the Board of Directors' election of the Chair of the Board of Directors; 5. To approve all plans of merger, consolidation, reorganization or dissolution of the Corporation or any subsidiary of the Corporation, or the sale, lease, assignment or transfer of substantially all of the assets of the Corporation or any subsidiary of the Corporation, or the purchase or acquisition by the Corporation or any subsidiary of the Corporation of an interest in any corporation, partnership, joint venture or other entity, whether newly created or previously existing, which interest, in the case of a for-profit entity, represents twenty-five percent (25%) or more of the voting power thereof or equity interest therein, or, in the case of a nonprofit entity, represents twenty-five percent (25%) or more of the voting power thereof or membership interest therein; 6. To approve all long-range strategic plans of the Corporation before their implementation; 7. To approve the acquisition, sale or encumbrance by the Corporation or any subsidiary of the Corporation of any real estate valued in excess of the amount set by the Member in writing from time to time; 8. To approve all capital budgets of the Corporation and non-budgeted expenses which are in excess of the amount set by the Member in writing from time to time, and to approve the Corporation's operating budget in accordance with policies set by the Member in writing from time to time; 9. To approve all debt of the Corporation, not part of the approved budget, in excess of limits set by the Member in writing from time to time before such debt is incurred; 10. To appoint the auditors of the Corporation and any subsidiary of the Corporation; 11. To approve the sale, assignment or transfer by the Corporation or any subsidiary of the Corporation of any equity interest or membership interest in any subsidiary of the Corporation; 12. To approve any reclassification or other change of any capital stock or other equity security of any subsidiary of the Corporation, or any recapitalization of any subsidiary of the Corporation; and 13. To approve the issuance of, or the creation of any obligation to issue, any equity security of any subsidiary of the Corporation, or any increase or decrease in the total number of shares of authorized capital stock or other equity security of any subsidiary of the Corporation. Form 990, Part VI, Section B, line 11b The 990 is initially reviewed by the Administrator and CFO. It then is presented to the entire board who are asked for any updates before filing. The board is asked to review this thoroughly. Form 990, Part VI, Section B, line 12c A copy of the conflict of interest policy is given to every officer, board member, and key employee on an annual basis, along with an annual disclosure statement, listing any known financial interest that the individual, or a member of the individual's family, has in any business entity that transacts business with the organization. The executive committee of the board then reviews and maintains the disclosure statements for future reference. If a conflict arises, the board member will recuse themself from participation in the deliberations and decisions relating to the conflict. The administrator personally approves contracts, dealings with subcontractors, and any internal hires to ensure that there is no conflict of interest. The Organization also maintains an electronic disclosure policy that requires an annual manager review and sign off. The board is also made aware of any contractors of consequence and is alerted to any potential conflicts of interest. Form 990, Part VI, Section B, line 15a The compensation packages of officers and key employees are determined by independent members of the board. The compensation arrangements are approved in advance and are based upon appropriate comparability data. The deliberations and decisions made by the board are contemporaneously substantiated in written meeting minutes. Comparability data involves looking to compensation levels paid by similarly situated organizations for functionally comparable positions, including the use of compensation surveys and studies from outside organizations. Form 990, Part VI, Section C, line 19 The Organization maintains copies of these documents on file. They are made available to the public upon request. Form 990, Part IX, line 11g Consultant Services: Program service expenses 25,744. Management and general expenses 0. Fundraising expenses 0. Total expenses 25,744. Service Contracts: Program service expenses 286,937. Management and general expenses 18,222. Fundraising expenses 0. Total expenses 305,159. Contract Labor: Program service expenses 996,942. Management and general expenses 0. Fundraising expenses 0. Total expenses 996,942. Outside Services: Program service expenses 141,082. Management and general expenses 10,801. Fundraising expenses 0. Total expenses 151,883. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Bangor Nursing & Rehabilitation Center 103 Texas Avenune Bangor, ME 04401 EIN 01-0538534 Bangor Nursing & Rehabilitation Center is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). Alternative Health Services 360 Broadway Bangor ME 04402 010422885 Homes health and hospice ME 501(c)(3) Line 10 St Joseph Healthcare Foundation 0 CHS of Waltham Inc dba Maristhill Nursing & Rehab Center 66 Newton Street Waltham MA 02453 043333609 Nursing home and restorative facility MA 501(c)(3) Line 10 Covenant Health Inc 0 CHS of Worcester Inc dba St Mary Care Center 39 Queen Street Worcester MA 01610 043419625 Nursing home and restorative facility MA 501(c)(3) Line 10 Covenant Health Inc 0 Community Clinical Services PO Box 7291 Lewiston ME 04243 010409788 Physician practice ME 501(c)(3) Line 10 St Mary's Health System 0 Covenant Health Foundation Inc 100 Ames Pond Drive Tewksbury MA 01876 800199674 Charitable foundation MA 501(c)(3) Line 12a, I Covenant Health Inc 0 Covenant Health Investment Trust 420 Bedford Street Lexington MA 02420 046835128 Investment trust MA 501(c)(3) Line 12a, I Covenant Health Inc 0 Covenant Health Inc 100 Ames Pond Drive Tewksbury MA 01876 222484505 Health care management and resource organization MA 501(c)(3) Line 11 N/A 0 Fanny Allen Corporation Inc 790 College Parkway Colchester VT 05446 222495808 Charitable foundation VT 501(c)(3) Line 12a, I Covenant Health Inc 0 Fanny Allen Holdings Inc 790 College Parkway Colchester VT 05446 030181052 Real estate holding company VT 501(c)(3) Line 12a, I Covenant Health Inc 0 Helping Hands of St Marguerite Inc 799 Concord Avenue Cambridge MA 02138 800199674 Private home-care health services MA 501(c)(3) Line 10 Covenant Health Inc 0 M & J Company 360 Broadway Bangor ME 04402 222480150 Lease holding company ME 501(c)(2) St Joseph Healthcare Foundation 0 Mary Immaculate Guild Inc 172 Lawrence Street Lawrence MA 01841 463073987 Supporting grants and donations MA 501(c)(3) Line 12a, I Covenant Health Inc 0 MI Adult Day Health Care Center Inc 189 Maple Street Lawrence MA 01841 042921888 Adult day care services MA 501(c)(3) Line 10 Covenant Health Inc 0 MI Management Inc 172 Lawrence Street Lawrence MA 01841 042857794 Assisted living services MA 501(c)(3) Line 12a, I Covenant Health Inc 0 MI Nursing Restorative Center Inc 172 Lawrence Street Lawrence MA 01841 042104851 Nursing home and restorative facility MA 501(c)(3) Line 10 Covenant Health Inc 0 MI Residential Community II Inc 189 Maple Street Lawrence MA 01841 042679954 HUD low income housing MA 501(c)(3) Line 10 Covenant Health Inc 0 MI Residential Community III Inc 189 Maple Street Lawrence MA 01841 042186043 HUD low income housing MA 501(c)(3) Line 10 Covenant Health Inc 0 MI Residential Community Inc 189 Maple Street Lawrence MA 01841 042647207 HUD low income housing MA 501(c)(3) Line 10 Covenant Health Inc 0 MI Transportation Inc 189 Maple Street Lawrence MA 01841 042921889 Elderly transportation services MA 501(c)(3) Line 10 Covenant Health Inc 0 Mount St Rita Health Centre 15 Sumner Brown Road Cumberland RI 02864 050342330 Nursing home RI 501(c)(3) Line 10 Covenant Health Inc 0 Neighborhood Housing Initiative PO Box 7291 Lewiston ME 04243 010539730 Affordable housing services ME 501(c)(3) Line 10 St Mary's Health System 0 Penacook Place Inc 150 Water Street Haverhill MA 01830 237090088 Nursing home MA 501(c)(3) Line 10 Covenant Health Inc 0 Souhegan Nursing Association 24 North River Road Milford NH 03055 020222795 Home health and hospice NH 501(c)(3) Line 10 St Joseph Hospital of Nashua NH Inc 0 St Andre Health Care Facility 407 Pool Street Biddeford ME 04005 010342399 Nursing home and restorative facility ME 501(c)(3) Line 10 Covenant Health Inc 0 St Joseph Ambulatory Care Inc 360 Broadway Bangor ME 04402 222480373 Physician practice ME 501(c)(3) Line 10 St Joseph Healthcare Foundation 0 St Joseph Healthcare Foundation 360 Broadway Bangor ME 04402 222480149 Healthcare foundation ME 501(c)(3) Line 10 Covenant Health Inc 0 St Joseph Hospital 360 Broadway Bangor ME 04402 010212435 Hospital and health care facility ME 501(c)(3) Line 3 St Joseph Healthcare Foundation 0 St Joseph Manor Health Care 215 Thatcher Street Brockton MA 02302 042565937 Nursing home and restorative facility MA 501(c)(3) Line 10 Covenant Health Inc 0 St Joseph's Hospital of Nashua NH Inc 172 Kinsley Street Nashua NH 03061 020222215 Hospital and health care facility NH 501(c)(3) Line 3 Covenant Health Inc 0 St Mary's D'Youville Pavilion PO Box 7291 Lewiston ME 04243 010211558 Nursing home and restorative facility ME 501(c)(3) Line 10 St Mary's Health System 0 St Mary's Health System PO Box 7291 Lewiston ME 04243 222504349 Hospital and health care facility ME 501(c)(3) Line 12a, I Covenant Health Inc 0 St Mary's Regional Medical Center PO Box 7291 Lewiston ME 04243 010211551 Hospital and health care facility ME 501(c)(3) Line 3 St Mary's Health System 0 St Mary's Residences PO Box 7291 Lewiston ME 04243 222504356 Low income housing ME 501(c)(3) Line 10 St Mary's Health System 0 St Mary's Villa Nursing Home Inc 675 St Marys Villa Road Moscow PA 18444 232057177 Nursing home and restorative facility PA 501(c)(3) Line 10 Covenant Health Inc 0 The Surgicenter at St Joseph Hospital Inc 172 Kinsley Street Nashua NH 03061 020222215 Healthcare and surgery center NH 501(c)(3) Line 10 St Joseph Hospital of Nashua NH Inc 0 Youville Hospital and Rehabiliation Center Inc 1575 Cambridge Street Cambridge MA 02138 043239563 Hospital and health care facility MA 501(c)(3) Line 10 Youville Lifecare Inc 0 Youville House Inc 1573 Cambridge Street Cambridge MA 02138 043239593 Assisted living services MA 501(c)(3) Line 10 Youville Lifecare Inc 0 Youville Lifecare Inc 1575 Cambridge Street Cambridge MA 02138 042103582 Hospital and health care facility MA 501(c)(3) Line 10 Covenant Health Inc 0 Youville Place 10 Pelham Road Lexington MA 02421 043297834 Assisted living services MA 501(c)(3) Line 10 Covenant Health Inc 0 Campus Holding PO Box 7291 Lewiston ME 04240 010406049 Holding company ME N/A C 0 Covenant Health Insurance LTD PO Box 69 Grand Cayman CJ KY1-1102 043360127 Self-insurance company CJ N/A C 0 GNM Corporation 172 Kinsley Street Nashua NH 03060 020400550 Real estate holding company NH N/A C 0 SJ Physicians Services 172 Kinsley Street Nashua NH 03060 020522234 Physician practice NH N/A C 0 St Joseph Corporate Services Inc 172 Kinsley Street Nashua NH 03060 020405197 Holding company NH N/A C 0 Strauss Incorporated 360 Broadway Bangor ME 04402 010391369 Repairs and transcriptions ME N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 Part IV, Identification of Related Organizations Taxable as Corp or Trust Name of Related Organization: St. Joseph Corporate Services, Inc. Direct Controlling Entity: St. Joseph's Hospital of Nashua, NH Inc.