2012-08-09T14:43:56-05:00 2011-12-31 421206169 Gronewold Bell Kyhnn & Co PC 1910 E 7th St Atlantic IA 50022 990 2011-01-01 421101835 SHENANDOAH MEDICAL CENTER SHEN 7122461230 300 PERSHING AVENUE SHENANDOAH IA 51601 KAREN COLE 7122461230 2012-08-09 1 Christopher J Nelson P00075202 7122431800 2011 2016-02-24 21:20:13Z KAREN COLE 300 PERSHING AVENUE SHENANDOAH IA 51601 28002790 0 X www.shenandoahmedcenter.com X 1978 IA TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF SHENANDOAH & SURROUNDING COMMUNITIES WITHOUT REGARD FOR ABILITY TO PAY AND WITHOUT DISCRIMINATION. 10 10 311 40 14358 -8492 304392 243254 23169561 26805621 147338 93695 224620 229026 23845911 27371596 0 0 0 0 12387739 13802419 0 0 54621 10229176 12222591 22616915 26025010 1228996 1346586 24175853 25598581 2534453 2662721 21641400 22935860 TO PROVIDE A COMPLETE CONTINUUM OF HEALTHCARE SERVICES TO THE PEOPLE OF SHENANDOAH & SURROUNDING COMMUNITIES WITHOUT REGARD FOR ABILITY TO PAY AND WITHOUT DISCRIMINATION 0 0 24389867 27113984 SHENANDOAH MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL WITH 25 ACUTE BEDS AND A 61 BED ASSISTED LIVING AND INTERMEDIATE CARE NURSING FACILITY. THE HOSPITAL PROVIDES ACUTE AND ANCILLARY SERVICES TO INDIVIDUALS IN AN INPATIENT AND OUTPATIENT SETTING. IN ADDITION, THE HOSPITAL PROVIDES RENTAL SPACE FOR A PHYSICIAN CLINIC AND A CANCER AND DIALYSIS TREATMENT CENTER. DURING 2011, THE HOSPITAL PROVIDED 1,748 DAYS OF ACUTE CARE, 833 DAYS OF SKILLED NURSING CARE, 224 NURSERY DAYS, AND 80,536 OUTPATIENT OCCASIONS OF SERVICE. THE NURSING FACILITY PROVIDED 2,591 ASSISTED LIVING DAYS AND 14,503 INTERMEDIATE CARE DAYS OF SERVICE. 24389867 1 1 0 0 0 0 0 0 0 1 1 1 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 17 0 1 311 1 1 1 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 IA X SANDRA CHESSHIRE 7122461230 SHENANDOAH MEDICAL CENTER 300 SHENANDOAH IA 51601 MARY JO CARRELL 3.00 X X 0 0 0 DAVE LASHIER 3.00 X X 0 0 0 KENNETH DEBAERE 3.00 X X 0 0 0 PAM MCGARGILL 3.00 X 0 0 0 GREG RITCHEY 3.00 X 0 0 0 DEB ISTAS 3.00 X 0 0 0 JON LEHNER 3.00 X 0 0 0 TIM AUGUSTINE 3.00 X 0 0 0 FLOYD JONES DO 3.00 X 0 0 0 ED KLOBERDANZ 3.00 X 0 0 0 SUSAN MCGOUGH 40.00 X 206013 0 14219 SANDRA CHESSHIRE 40.00 X 145605 0 14505 DAVE LEIGHTON 40.00 X 116381 0 16619 SUBIR RAY MD 40.00 X 597011 0 16866 SCOTT R KING 40.00 X 324822 0 23839 WAYNE JOHNSON 40.00 X 181996 0 7144 JOHN BOWERY MD 40.00 X 149089 0 19676 VICTOR BYCROFT 40.00 X 119915 0 12423 1840832 0 125291 8 0 1 0 ACUTE CARE 1609 N ANKENY BLVD ANKENY IA 50023 ER PHYSICIAN STAFFING 790762 UNMC PHYSICIANS PO BOX 30014 OMAHA NE 68103 LAB REFERENCE FEES 262218 STAFF CARE PO BOX 281923 ATLANTA GA 30384 PHYSICIAN STAFFING 247377 DENNIS CUMMINGS 13951 W 115TH ST OLATHE KS 66062 CRNA SERVICES 222217 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI AND PET SCAN FEES 173020 8 74332 168922 243254 NET PATIENT SERVICE RE 621110 26805621 26805621 26805621 166588 166588 264598 69894 194704 194704 194704 482696 5711 537220 24080 -54524 -18369 -72893 -72893 SHENANDOAH AMBULANCE S 621910 19964 19964 CATERING OF MEALS 722320 14358 14358 34322 27371596 27113984 14358 0 467999 261986 206013 11011656 10369538 596993 45125 294918 273080 20630 1208 1261556 1168443 88246 4867 766290 709267 53602 3421 11541 11541 63567 63567 1848464 1831355 17109 12987 12987 1247730 1247730 SUPPLIES 5922289 5425495 496794 BAD DEBTS 2247628 2247628 PURCHASED SERVICES 760195 734168 26027 SUPPORT SHEN HEALTHCARE 66628 66628 41562 41562 26025010 24389867 1580522 54621 1846389 2270920 315999 318384 23035 3334085 4643227 619421 714538 255007 243250 24296837 16326271 8647080 7970566 8688964 7578451 0 445873 1859245 24175853 25598581 1606834 2017612 14619 13109 840000 73000 632000 2534453 2662721 X 20512593 21806064 878179 874110 250628 255686 21641400 22935860 24175853 25598581 X 1346586 -52126 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8688964 58208 1168721 7578451 8857784 601102 769922 8688964 6608058 1274933 974793 8857784 7318227 770144 -1480313 6608058 0.85090 0.03370 0.11530 0 0 92822 92822 11852331 7712881 4139450 11366030 7948439 3417591 985654 664951 320703 7970566 OTHER RECEIVABLES 57434 DUE FROM AFFILIATES 49325 OTHER ASSETS 1742 CONSTRUCTION IN PROGRESS 1533533 EQUITY IN SHENANDOAH AMBULANCE SERVICE 217211 1859245 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 632000 632000 27371596 26025010 1346586 -49126 -3000 -52126 1294460 27322470 -49126 -49126 27371596 0 27371596 26028010 3000 3000 26025010 0 26025010 Part XI, Line 8 - Other Adjustments: USE OF TEMP RESTRICTED FUNDS -3000. Part XIII, Line 2d - Other Adjustments: USE OF TEMP RESTRICTED FUNDS 1 1 X 1 X 1 X 1 1 0 1 1 228624 228624 0.00880 2294496 1803767 490729 0.01890 2523120 1803767 719353 0.02770 14 2540 270273 183539 86734 0.00330 10 32510 10040934 8807266 1233668 0.04740 4 6150 14856 14856 0.00060 28 41200 10326063 8990805 1335258 0.05130 28 41200 12849183 10794572 2054611 0.07900 1 916 916 0.00000 1 3210 3210 0.00010 2 484 17708 17708 0.00070 1 60 237 237 0.00000 5 544 22071 22071 0.00080 1 1290401 7128778 7143918 -15140 X 1 1 1 1 SHENANDOAH MEDICAL CENTER

300 PERSHING AVE SHENANDOAH IA 51601

X X X X SHENANDOAH MEDICAL CENTER 1 1 1 200.000000000000 1 200.000000000000 1 X X X X X X X 1 1 X 1 X 1 X X 1 X 0 0 8 ELM HEIGHTS CARE CENTER

1204 SOUTH ELM SHENANDOAH IA 51601

NURSING HOME SHENANDOAH MEDICAL CENTER

300 PARK AVE SHENANDOAH IA 51601

MEDICAL CLINIC SHENANDOAH MEDICAL CENTER

315 PERSHING SHENANDOAH IA 51601

RENTAL FOR CRNA FREMONT COUNTY MEDICAL CENTER

802 ILLINOIS ST FREMONT IA 52561

SIDNEY CLINIC FREMONT COUNTY MEDICAL CENTER

804 ILLINOIS ST FREMONT IA 52561

DENTAL OFFICE RENTAL SHENANDOAH MEDICAL CENTER

2 JACK FOSTER DR SHENANDOAH IA 51601

WELLNESS CENTER SHENANDOAH MEDICAL CENTER

317 PERSHING AVE SHENANDOAH IA 51601

RENTAL HOME ALEGENT HEALTH CLINIC

527 IOWA AVE ESSEX IA 51638

ESSEX CLINIC Part III, Line 4: PATIENT ACCOUNTS RECEIVABLE IS REPORTED AT ITS ESTIMATED NET REALIZABLE VALUE. THE CHANGE IN THE ESTIMATED ALLOWANCE FOR BAD DEBTS PLUS THE BAD DEBT ACCOUNTS WRITTEN OFF LESS RECOVERIES OF BAD DEBTS EQUALS THE BAD DEBT EXPENSE. THE BAD DEBT EXPENSE AT COST WAS ESTIMATED BASED ON THE HOSPITAL'S OVERALL COST COMPARED TO GROSS REVENUES. Part III, Line 8: THE MEDICARE SHORTFALL SHOULD BE CONSIDERED A COMMUNITY BENEFIT BECAUSE IT REPRESENTS UNCOMPENSATED CARE PROVIDED TO INDIVIDUALS IN THE SHENANDOAH OR SURROUNDING COMMUNITIES. IT HAS BEEN DETERMINED BASED ON THE OVERALL MEDICARE ALLOWABLE COST AS A PERCENT OF TOTAL CHARGES, APPLIED TO THE TOTAL MEDICARE CHARGES. SHENANDOAH MEDICAL CENTER Part V, Section B, Line 19d: THE INDIVIDUALS WHO DID NOT HAVE INSURANCE ARE GIVEN A 15% UNINSURED DISCOUNT 1 Shenandoah Healthcare Foundation 300 Park Ave Shenandoah IA 51601 421471184 501c(3) 66628 Cost Foundation operating expenses Assist the Foundation in generating assets used to support healthcare in the Shenandoah community. 1 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Shenandoah Medical Center's oversees the operating expenses of the Foundation. 1 X 1 0 0 0 0 0 0 0 0 SUSAN MCGOUGH 141991 0 15000 0 49022 0 9622 0 4597 0 220232 0 0 0 SANDRA CHESSHIRE 144443 0 0 0 1162 0 6669 0 7836 0 160110 0 0 0 SUBIR RAY MD 464308 0 131077 0 1626 0 6181 0 10685 0 613877 0 0 0 SCOTT R KING 241931 0 80863 0 2028 0 12116 0 11723 0 348661 0 0 0 WAYNE JOHNSON 174908 0 5000 0 2088 0 0 0 7144 0 189140 0 0 0 JOHN BOWERY MD 147018 0 0 0 2071 0 7953 0 11723 0 168765 0 0 0 Part I, Line 4a Susan McGough will receive a total amount of $195,083.46 from a severance package where at September 8, 2012, the severance payments will be complete. From September 16, 2011 through December 17, 2011, the last pay period of 2011, Susan received $47,593.35. From the first pay period of calendar year 2012 starting December 18, 2011 through September 8, 2012, Susan will receive $147,490.11. Form 990, Part VI, Section B, line 11 REVIEWED BY CEO, CFO AND GOVERNING BOARD. Form 990, Part VI, Section B, line 12c ENFORCED BY CEO AND COMPLIANCE OFFICER. Form 990, Part VI, Section B, line 15 BOARD OF DIRECTORS AUTHORIZATION. Form 990, Part VI, Section C, line 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE FOR PUBLIC INSPECTION UPON REQUEST OF THE ORGANIZATION. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -49126. USE OF TEMP RESTRICTED FUNDS -3000. Total to Form 990, Part XI, Line 5: -52126.