2013-05-15T13:36:24-05:00 2012-06-30 381357951 PLANTE & MORAN PLLC 65 EAST STATE STREET SUITE 600 COLUMBUS OH 43215 990 2011-07-01 311534051 HOLZER SENIOR CARE CENTER HOLZ 7404465060 380 COLONIAL DRIVE BIDWELL OH 45614 KENNETH PAYNE 7404465060 2013-05-13 1 BERNIE OSTROWSKI P00366367 6148493000 2011 2016-02-24 21:20:13Z SEE SCHEDULE O TERESA REMY-DETTY 100 JACKSON PIKE GALLIPOLIS OH 45631 9161202 0 X WWW.HOLZER.ORG X 1996 OH HOLZER SENIOR CARE CENTER IS A SKILLED NURSING FACILITY FOR THE CARE AND TREATMENT OF THE SICK, DISABLED, AND INJURED, PROVIDING CARING AND QUALITY SERVICES TOWARD THE ENHANCEMENT OF PHYSICAL AND MENTAL WELL-BEING WITHOUT REGARD TO THE PERSON'S FINANCIAL RESOURCES. 8 0 327 0 0 0 14944 0 9159765 9059058 9402 6039 97033 96105 9281144 9161202 3287 0 0 0 5352142 5185603 0 0 0 3361409 3422659 8716838 8608262 564306 552940 15660599 15866274 9237997 8890732 6422602 6975542 X WE WILL ENCOURAGE WELLNESS AND STRIVE TO IMPROVE THE HEALTH STATUS OF THE PEOPLE AND COMMUNITIES WE SERVE. 0 0 6308847 0 9059058 SEE SCHEDULE OHOLZER SENIOR CARE CENTER IS A SEVENTY (70) BED FACILITY, GUIDED BY THE VISION OF QUALITY CARE AND OPTIMUM OUTCOME. IT IS COMMITTED TO IDENTIFY, UNDERSTAND AND RESPOND TO THE NEEDS OF THE RESIDENTS. HOLZER SENIOR CARE CENTER OFFERS:* A MEDICAL DIRECTOR* SKILLED NURSING CARE 24 HOURS PER DAY* REHABILITATION THERAPIES INCLUDING: PHYSICAL THERAPIES, OCCUPATIONAL THERAPIES, SPEECH THERAPY* SHORT AND LONG TERM PLACEMENT OF RESIDENTS* SOCIAL AND THERAPEUTIC ACTIVITIES* PROGRAM FOR HOSPICE PATIENTS* CHAPLAINCY SERVICES* DIETARY SERVICES WITH A QUALIFIED DIETITIAN* PERSONAL CARE (BEAUTICIAN & BARBER SERVICES)* ALL INCLUSIVE ROOM RATE* CABLE TVMEDICAL SUPPORT: HOLZER SENIOR CARE CENTER IS UNDER THE DIRECT SUPERVISION OF A MEDICAL DIRECTOR, WHO HELPS PROVIDE THE LATEST IN HIGH ACUITY CARE. RESIDENTS OF HOLZER SENIOR CARE CENTER MAY USE THE SERVICES OF THE CENTER'S MEDICAL DIRECTOR, OR CONTINUE UNDER THE DIRECT CARE OF THEIR OWN PHYSICIAN. A TRAINED STAFF, COMMITTED TO THE HIGHEST STANDARD IN CARING FOR THE RESIDENTS OF HOLZER SENIOR CARE CENTER IS ON DUTY TWENTY FOUR HOURS A DAY, EVERY DAY.REHABILITATION SERVICES: A COMPLETE RANGE OF REHABILITATION SERVICES IS OFFERED AT HOLZER SENIOR CARE CENTER, CONDUCTED BY REGISTERED THERAPISTS. PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPIES ARE AVAILABLE TO PROVIDE THE MOST THOROUGH REHABILITATION CARE TO RESIDENTS. A RESTORATIVE NURSING CARE PROGRAM IS AN ONGOING SERVICE TO THE CENTER RESIDENTS. THE WIDE RANGE OF SPECIALIZED THERAPY PROGRAMS ENABLES MANY RESIDENTS TO RESUME THEIR FORMER LIFESTYLES AS THEY BECOME MORE INDEPENDENT.NUTRITIONAL SERVICES: RESIDENTS AT HOLZER SENIOR CARE CENTER ENJOY NUTRITIONAL AND APPETIZING MEALS IN A COMFORTABLE AND ATTRACTIVE DINING SETTING. A REGISTERED DIETITIAN WHO SPECIALIZES IN MEETING EACH RESIDENT'S NEEDS PLANS THE MENUS. BED SIDE SERVICE IS AVAILABLE FOR THOSE RESIDENTS WHO ARE UNABLE TO GO TO THE DINING ROOM FOR THEIR MEALS. FAMILY AND FRIENDS WHO WISH TO DINE WITH THEIR LOVED ONES MAY ALSO PURCHASE A MEAL FOR A NOMINAL FEE.SOCIAL AND RECREATIONAL ACTIVITIES: THE OVERALL ACTIVITY PROGRAM AT HOLZER SENIOR CARE CENTER IS THERAPEUTICALLY DESIGNED BY A QUALIFIED AND EXPERIENCED ACTIVITIES COORDINATOR, WHO GIVES SPECIAL ATTENTION TO THE PHYSICAL, MENTAL, SPIRITUAL, AND SOCIAL NEEDS OF EACH RESIDENT. THERE IS SOMETHING FOR EVERYONE. AMONG THE MOST POPULAR EVENTS ARE THE GAMES, CRAFTS, SING-ALONGS, RELIGIOUS SERVICES, PICNICS, AND COMMUNITY OUTINGS. EACH RESIDENT IS ENCOURAGED TO PARTICIPATE IN WHATEVER ACTIVITIES PROVIDE THE MOST FULFILLMENT AND BEST SERVES HIS OR HER PERSONAL NEEDS.ACCOMMODATIONS: A COMFORTABLE HOME-LIKE SETTING CAN PLAY A MAJOR ROLE IN RESTORING HEALTH AND WELL-BEING. THE ROOMS AT HOLZER SENIOR CARE CENTER ARE SPACIOUS AND SUNNY WITH WINDOWS THAT BRING IN AN ABUNDANCE OF NATURAL LIGHT. RESIDENTS ARE ENCOURAGED TO DECORATE THEIR ROOMS WITH FAVORITE PERSONAL BELONGINGS, SUCH AS QUILTS, PILLOWS, AND PICTURES. THE ROOM RATE AT HOLZER SENIOR CARE CENTER IS AN ALL-INCLUSIVE RATE. NO ADDITIONAL CHARGES ARE MADE FOR PERSONAL GROOMING ITEMS OR LAUNDRY SERVICES. THE ATTRACTIVE SOLARIUM AREAS ARE ALWAYS AVAILABLE FOR THE ENJOYMENT OF THE RESIDENTS, THEIR FAMILIES AND FRIENDS. QUALITY OF LIFE: EVERY MEMBER OF THE STAFF AT HOLZER SENIOR CARE CENTER IS COMMITTED TO ADDRESSING AND MEETING THE NEEDS OF EACH RESIDENT ON A PERSONAL BASIS. THEY RESPECT EVERY RESIDENT'S RIGHT TO PRIVACY, DIGNITY AND TREATMENT AS AN INDIVIDUAL.DURING THE YEAR, HOLZER SENIOR CARE SERVED 25,417 PATIENT DAYS AND ASSISTED LIVING SERVED 31,755 PATIENT DAYS. 6308847 1 0 0 0 0 0 0 0 0 0 1 0 0 1 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 1 1 1 1 0 0 1 7 0 1 327 1 0 0 0 0 0 0 0 0 0 0 X 8 0 0 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 OH X WILLIAM CRABTREE 7402880192 190 WATER ST SUITE 4 JACKSON OH 45640 X STEVE CHAPMAN CPA 1.00 X X 0 15500 0 ALAN STOCKMEISTER 1.00 X X 0 16000 0 RYAN SMITH 1.00 X X 0 16000 0 BRENT SAUNDERS 1.00 X 0 306199 3531 TERESA REMY DETTY 40.00 X X 0 167104 9024 WILLIAM CRABTREE 40.00 X X 0 90674 4280 THOMAS TOPE 1.00 X 0 188527 0 PAT CONNERS 1.00 X 0 356206 0 PETE DETTY 40.00 X 56793 0 2750 TERESA COFFEE 40.00 X 71328 0 0 PEGGY WILLIAMS 40.00 X 71422 0 2600 KENNETH PAYNE 1.00 X 0 260363 0 DR WAYNE MUNRO 40.00 X 0 576417 0 TIM HACKWORTH 40.00 X 0 63529 3014 199543 2056519 25199 0 0 1 0 UNITED HEALTHCARE 9200 WORTHINGTON ROAD WESTERVILLE OH 43082 HEALTH COVERAGE 478779 REHABCARE GROUP PO BOX 503534 ST LOUIS MO 63150 THERAPY 446215 SKILLED CARE PHARMACY 6175 HI-TEK COURT MASON OH 45040 PHARMACY SERVICES 131975 3 PROGRAM SERVICES 623000 8386980 8386980 RESIDENT MEALS 623000 597828 597828 ADMISSION FEES 623000 74250 74250 9059058 6039 6039 MEALS & VENDING 623000 37043 37043 PHONE INCOME 623000 25808 25808 CABLE TV INCOME 623000 21543 21543 11711 11711 96105 9161202 9059058 0 102144 204926 204926 3855356 2968624 886732 1204 927 277 818346 630126 188220 305771 235444 70327 197883 197883 3227 3227 40691 40691 355118 273441 81677 75752 75752 991285 763289 227996 158 122 36 403223 310482 92741 15686 15686 368276 283573 84703 441393 339873 101520 117483 90462 27021 OHIO BED TAX 278535 278535 RESIDENT SERVICES 78488 78488 BAD DEBT EXPENSE 31361 31361 EMPLOYEE EXPENSES 16031 16031 8069 8069 8608262 6308847 2299415 0 1500 1500 979752 1447733 449607 323231 10000 10000 68933 49587 13339815 5219045 8331129 8120770 203260 204106 4432080 4432080 1184338 1277267 15660599 15866274 1102719 1021280 7107853 6769967 1027425 1099485 9237997 8890732 X 6422602 6975542 6422602 6975542 15660599 15866274 552940 0 X X 0 1 1 X 0 X 40600 14944 55544 8033379 8836134 8985906 9159765 9059058 44074242 8033379 8836134 9026506 9174709 9059058 44129786 0 0 0 44129786 63135 40554 52466 9402 6039 171596 63135 40554 52466 9402 6039 171596 126466 -14923 93098 97033 96105 397779 8222980 8861765 9172070 9281144 9161202 44699161 0.98730 0.98310 0.00380 0.00480 X SCHEDULE A, PART II, LINE 12, EXPLANATION OF OTHER INCOME: GUEST MEALS BARBER & BEAUTY SERVICES VENDING MACHINES PHONE INCOME CABLE TV INCOME MISCELLANEOUS 542107 542107 9388407 3994440 5393967 772801 126739 646062 1893870 1032323 861547 742630 65543 677087 8120770 BOND ISSUE COSTS 77563 INTERCOMPANY RECEIVABLE 582831 ASSETS LIMITED AS TO USE 616873 1277267 COST REPORT SETTLEMENT PAYABLE 1141 INTERCOMPANY PAYABLE 1098344 1099485 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE SYSTEM AND RECOGNIZE A TAX LIABILITY IF THE SYSTEM HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE INTERNAL REVENUE SERVICE OR OTHER APPLICABLE TAXING AUTHORITIES. MANAGEMENT HAS ANALYZED TAX POSITIONS TAKEN BY THE SYSTEM AND HAS CONCLUDED THAT AS OF JUNE 30, 2012, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE SYSTEM IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE SYSTEM FILES FEDERAL AND STATE TAX RETURNS AND BELIEVES IT IS NO LONGER SUBJECT TO FEDERAL, STATE, OR LOCAL INCOME TAX EXAMINATIONS BY TAX AUTHORITIES FOR THE YEARS BEFORE FISCAL YEAR 2009. 1 1 0 0 0 0 0 0 0 BRENT SAUNDERS 0 306199 0 0 0 0 0 3531 0 0 0 309730 0 0 TERESA REMY DETTY 0 167104 0 0 0 0 0 9024 0 0 0 176128 0 0 THOMAS TOPE 0 0 0 0 0 188527 0 0 0 0 0 188527 0 0 PAT CONNERS 0 356206 0 0 0 0 0 0 0 0 0 356206 0 0 KENNETH PAYNE 0 206813 0 53550 0 0 0 0 0 0 0 260363 0 0 DR WAYNE MUNRO 0 576417 0 0 0 0 0 0 0 0 0 576417 0 0 PART I, LINES 4A-B SCHEDULE J, PART I, LINE 4A: DURING THE CALENDAR YEAR, THOMAS TOPE RECEIVED SEVERANCE PAY IN THE AMOUNT OF $188,527. UNDER THE TERMS OF THE SEVERANCE AGREEMENT MR. TOPE WILL RECEIVE 100% OF BASE SALARY AND OTHER BENEFITS AS OF THE TERMINATION DATE, 7/1/09, THROUGH 1/1/11. HE WILL ALSO BE ENTITLED TO AN ANNUAL AUTO ALLOWANCE, PARTICIPATION IN THE HOSPITAL'S GROUP LIFE INSURANCE PLAN, QUARTERLY PAYMENTS DIRECTLY FROM THE HOSPITAL TO MR. TOPE IN AN AMOUNT EQUAL TO THE 457(F) CONTRIBUTION, AND OTHER PENSION PLAN PAYMENTS DIRECTLY FROM THE HOSPITAL TO MR. TOPE BASED ON THE MAXIMUM DEFFERAL ALLOWED. FOLLOWING THIS 18 MONTH PERIOD, MR. TOPE WILL ALSO RECEIVE AN AMOUNT EQUAL TO 22 WEEKS OF BASE SALARY, PLUS 4 WEEKS OF BASE SALARY AS ADDITIONAL RETIREMENT CONSIDERATION (BASED ON THE SALARY IN EFFECT AT THE TERMINATION DATE). SCHEDULE J, PART I, LINE 4B: BRENT SAUNDERS PARTICIPATED IN A 457(F) PLAN AND HAD CONTRIBUTIONS OF $134,623. THESE CONTRIBUTIONS WERE RECEIVED IN 2012 (MARCH AND JUNE). SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: COMPENSATION PAID TO THE ORGANIZATION'S CEO IS ESTABLISHED BY A RELATED ORGANIZATION AND INCLUDES USE OF AN INDEPENDENT COMPENSATION CONSULTANT, A WRITTEN EMPLOYMENT CONTRACT, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION A, LINE 6 HOLZER HEALTH SYSTEM IS THE SOLE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B HOLZER SENIOR CARE CENTER'S DECISIONS THAT ARE MADE BY THEIR BOARD OF DIRECTORS CAN BE OVERRULED BY HOLZER HEALTH SYSTEM'S BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE CONTROLLER AND THE CFO OF HOLZER HEALTH SYSTEM REVIEW FORM 990. A COPY WILL BE PROVIDED TO ALL BOARD MEMBERS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST STATEMENTS ARE COMPLETED ANNUALLY BY ALL OFFICERS, BOARD MEMBERS, AND EMPLOYEES, AND ARE REVIEWED BY THE CONFLICT OF INTEREST REVIEW COMMITTEE. MEMBERS OF THE BOARD ARE AWARE THAT THEY SHOULD DISCLOSE CONFLICTS WHEN THEY ARISE, AND MEMBERS ABSTAIN FROM PARTICIPATING IN DISCUSSIONS OR VOTING ON MATTERS WHERE A CONFLICT IS PRESENT. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF OFFICERS IS BASED ON EXPERIENCE AND MARKET VALUE AS EVIDENCED BY COMPARABILITY DATA AND IS APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD. OFFICER COMPENSATION DECISIONS THAT ARE MADE ARE DOCUMENTED IN THE EXECUTIVE COMMITTEE MEETING MINUTES. THE PROCESS WAS LAST UPDATED DECEMBER 2012. FORM 990, PART VI, SECTION C, LINE 18 FORM 1023 AND 990 ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PAGE 7, PART VII: THE FOLLOWING TRUSTEES AND OFFICERS DEVOTED TIME TO RELATED ORGANIZATIONS: ALAN STOCKMEISTER 1-2 HOURS BRENT SAUNDERS 40-50 HOURS KENNETH PAYNE 40-50 HOURS NIRMAL DUTTA 1-2 HOURS RYAN SMITH 1-2 HOURS STEVEN CHAPMAN 1-2 HOURS THOMAS TOPE 1-2 HOURS WAYNE MUNRO 40-50 HOURS FORM 990, PART XI, LINE 2C: THE AUDIT OVERSIGHT PROCESS AND THE PROCESS OF SELECTION OF AN INDEPENDENT ACCOUNTANT HAVE NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PAGE 1, LINE C: DOING BUSINESS AS: HOLZER ASSISTED LIVING - GALLIPOLIS HOLZER ASSISTED LIVING - JACKSON GALLIA HEALTH PARTNERS LLC 300 BRIARWOOD DR GALLIPOLIS OH 45631 311534051 ASSISTED LIVING OH 2152767 6200676 HOLZER SENIOR CARE CENTER JACKSON HEALTH PARTNERS LLC 101 MARKHAM DRIVE JACKSON OH 45640 311534051 ASSISTED LIVING OH 1785626 5110476 HOLZER SENIOR CARE CENTER HOLZER HEALTH SYSTEM 100 JACKSON PIKE GALLIPOLIS OH 45631 311156690 MANAGEMENT SERVICES OH 501(C)(3) LINE 11A, I N/A 0 HOLZER HOSPITAL FOUNDATION 100 JACKSON PIKE GALLIPOLIS OH 45631 314379491 HEALTH CARE OH 501(C)(3) LINE 3 HOLZER HEALTH SYSTEM 1 HOLZER MEDICAL CENTER - JACKSON 100 JACKSON PIKE GALLIPOLIS OH 45631 311724085 HEALTH CARE OH 501(C)(3) LINE 3 HOLZER HEALTH SYSTEM 1 HOLZER FOUNDATION 100 JACKSON PIKE GALLIPOLIS OH 45631 310927482 CONTINUING ADVANCEMENT OF HEALTH AND MEDICAL CARE OH 501(C)(3) LINE 7 HOLZER HEALTH SYSTEM 1 HOLZER CARDIOVASCULAR LLC 90 JACKSON PIKE GALLIPOLIS OH 45631 311780671 MEDICAL OH N/A HOLZER VANGUARD INC 100 JACKSON PIKE GALLIPOLIS OH 45631 311192567 STOCK HOLDING COMPANY OH N/A C 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 NONE GREATER THAN 50000