2011-11-14T09:02:56-06:00 2010-12-31 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2010-01-01 390806828 MEMORIAL HOSPITAL INC MEMO 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 SCOTT POLENZ 7157433101 2011-11-07 1 HOLLY POKRANDT CPA 7158323407 2011-10-31 2010 2016-02-24 21:20:13Z SCOTT POLENZ 216 SUNSET PLACE NEILLSVILLE WI 54456 23513822 0 X WWW.MEMORIALMEDCENTER.ORG X 1954 WI MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY, AND SAFETY, FINANCE, COMMUNITY, AND GROWTH...ONE PATIENT AT A TIME. MEMORIAL HOSPITAL, INC. PROVIDES SERVICES THROUGH THE 25-BED CRITICAL ACCESS HOSPITAL, HOME HEALTH AGENCY, ASSISTED LIVING, AS WELL AS 3 RURAL HEALTH CLINICS IN NEILLSVILLE, LOYAL, AND GREENWOOD. TO FULFILL COMMUNITY NEEDS, MEMORIAL HOSPITAL, INC. FACILITATES EDUCATIONAL SEMINARS AND SUPPORT GROUPS LED BY MEDICAL AND PROFESSIONAL STAFF AT GREATLY REDUCED-RATES; PROVIDES FREE HEALTH SCREENINGS AT GIVEN TIMES THROUGHOUT THE YEAR; STAFF BOOTHS AT COMMUNITY EVENTS; SERVES AS AN EDUCATION SITE FOR STUDENTS IN HIGH SCHOOL, TECHNICAL COLLEGE, AND UNIVERSITIES; AS WELL AS OTHER NEEDS AS DETERMINED. MEMORIAL HOSPITAL, INC. ALSO ADMINISTERS A CHARITY CARE PROGRAM HELPING TO ENSURE AFFORDABLE ACCESS TO HEALTHCARE 11 9 333 80 362415 -194353 98892 68077 24629230 22288934 119621 629306 70688 380707 24918431 23367024 0 0 0 0 16266485 14673153 0 0 0 7969573 7143353 24236058 21816506 682373 1550518 15062770 16588627 4304575 4241300 10758195 12347327 X TO PROVIDE THE COMMUNITIES WE SERVE THE BEST EXPERIENCE IN HEALTH CARE, EDUCATION, AND PREVENTION, SUPPORTED BY OUR PILLARS OF PEOPLE, SERVICE, QUALITY AND SAFETY, FINANCE, COMMUNITY, AND GROWTH, ONE PATIENT AT A TIME. 1 1 12749181 17897333 HOSPITAL INPATIENT SERVICES IN 2010 INCLUDED 1,249 ACUTE CARE PATIENT DAYS, 288 OBSERVATION DAYS, AND 609 SWING BED PATIENT DAYS.EMERGENCY ROOM VISITS TOTALLED 2,926 AND SURGERIES AND PROCEDURES TOTALLED 1,222 IN 2010.OTHER HOSPITAL SERVICES PROVIDED IN 2010 INCLUDED BUT WERE NOT LIMITED TO PHYSICAL THERAPY, RADIOLOGY, LABORATORY, CARDIAC REHABILITATION, SPEECH THERAPY, RESPIRATORY THERAPY, OCCUPATIONAL THERAPY, DIABETIC EDUCATION, AND HOME HEALTH SERVICES. 4991556 3431608 A TOTAL OF 26,372 CLINIC VISITS OCCURRED IN 2010 AT THE THREE CLINICS LOCATED IN NEILLSVILLE, LOYAL, AND GREENWOOD. 1040549 765081 THE HEALTH AND REHAB UNIT PROVIDED 4,330 DAYS OF SKILLED NURSING CARE AND THE ASSISTED LIVING PROVIDED A HOME FOR 10 RESIDENTS BY YEAR END. 18781286 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 16 0 1 333 1 1 1 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 1 1 1 0 WI X KELLY MOEN MEMORIAL HOSPITAL INC 7157433101 216 SUNSET PLACE NEILLSVILLE WI 54456 ALLAN HOESLY 1.00 X 600 0 0 DR ARMANDO PACIS 32.00 X 260043 0 22127 DR GRACE CRUZ-APOLINARIO 40.00 X 467903 0 31409 JEANETTE STEINER 1.00 X 500 0 0 RICK SZYMANSKI 1.00 X 600 0 0 ROBERT BARTH 1.00 X 550 0 0 WENDY SIGURDSON 1.00 X 500 0 0 TREVOR WUETHRICH 1.00 X 400 0 0 KEVIN GRAP 1.00 X 550 0 0 TIM RUETH 1.00 X 0 0 0 DOROTHY WELSH 1.00 X 250 0 0 DR TIM MEYER 36.00 X 371123 0 13468 SCOTT POLENZ 64.00 X 174671 0 34139 KELLY MOEN 47.00 X 98880 0 37449 SHARON LOANEY-BERGSHOLM 46.00 X 98255 0 25781 DR JIM STANGA 40.00 X 276571 0 31409 DR LOUIS A BENOIST 32.00 X 292315 0 12843 DR MAX OLESEVICH 62.00 X 332364 0 26909 DRDAVID PAUSTIAN 40.00 X 613094 0 17627 DR AMY COULTHARD 48.00 X 238006 0 4683 3227175 0 257844 14 0 1 0 TOM SILBERNAGEL W5844 ROLLING HILLS DRIVE NEILLSVILLE WI 54456 CRNA SERVICES 440681 CMDI PO BOX 158 MILACA MN 56353 CT SERVICES 295800 SHARED MEDICAL SERVICES INC PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 165505 KEN WEIS ELECTRIC PO BOX 605 MARSHFIELD WI 54449 ELECTRICIAN SERVICES 136520 4 33154 34923 68077 HOSPITAL REVENUE 621990 17897333 17897333 CLINIC REVENUE 621110 3431608 3431608 NURSING HOME AND ASSIS 623000 765081 765081 194912 194912 22288934 72814 72814 18292 18292 18292 18292 703290 146798 556492 556492 556492 DIET,MAINT,HSKG,LNDRY 722230 362415 362415 362415 23367024 22094022 362415 842510 1639198 1290109 349089 9831893 8439182 1392711 308248 264584 43664 2222396 1936525 285871 671418 572237 99181 111733 111733 62295 62295 1465857 1423531 42326 122932 1498 121434 2982859 2707190 275669 473564 473564 9237 9237 94711 65618 29093 693405 693405 257408 96255 161153 BAD DEBT 670878 670878 ADMIN HOSPITAL TAX EXPE 82382 82382 DUES AND LICENSES 61001 61001 NURSING HOME ASSESSMENT 31500 31500 RECRUITMENT AND MOVING 23591 23591 21816506 18781286 3035220 0 3063958 4469532 2280027 2350895 2284605 2053995 528 459855 382552 250067 191113 14072063 8384024 5506306 5688039 1217424 1452501 15062770 16588627 2016740 2107087 547 1475000 1210000 402066 296737 410769 626929 4304575 4241300 X 10743475 12347327 14720 0 10758195 12347327 15062770 16588627 X 1550518 38614 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2181 2181 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF THE ANNUAL DUES ($1,581) PAID TO THE WISCONSIN HOSPITAL ASSOCIATION WAS USED FOR LOBBYING EXPENDITURES AND A PORTION OF ANNUAL DUES PAID TO THE RURAL WISCONSIN HEALTH COOPERATIVE ($600) WAS USED FOR LOBBYING EXPENDITURES. 20673 20673 10704020 5874818 4829202 3081503 2316651 764852 265867 192555 73312 5688039 UNAMORTIZED BOND ISSUE COSTS 23053 INVESTMENT IN CENTRAL MN DIAGNOSTIC, INC. 373715 DEFERRED COMPENSATION PLAN ASSETS 635733 AMOUNTS RECEIVABLE FROM THIRD-PARTY REIUMBURSEMENT PROGRAMS 420000 1452501 DEFERRED COMPENSATION LIABILITY 626929 626929 23367024 21816506 1550518 38614 38614 1589132 23405638 38614 38614 23367024 0 23367024 21816506 0 21816506 0 21816506 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE FACILITY IS A TAX-EXEMPT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE FACILITY IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SIMILAR STATE OF WISCONSIN TAX LAWS. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE FACILITY DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE FACILITY'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX WHEN INCURRED. AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2010 AND 2009, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTERST RELATED TO TAX PENALTIES RECORDED BY THE FACILITY IN THE FINANCIAL STATEMENTS. THE FACILITY RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS IN 2010 AND 2009. FEDERAL RETURNS FOR THE YEARS 2007 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 1 X 49.000000000000 1 X 1 1 1 0 1 1 198089 198089 0.00940 2055 3860832 2468184 1392648 0.06590 2055 4058921 2468184 1590737 0.07530 54254 2045 52209 0.00250 116001 116001 0.00550 2662368 1649042 1013326 0.04790 75737 75737 0.00360 2908360 1651087 1257273 0.05950 2055 6967281 4119271 2848010 0.13480 190 190 0.00000 95 95 0.00000 5168 5168 0.00020 11882 11882 0.00060 17335 17335 0.00080 0 364479 145790 4223104 4272193 -49089 X 1 1 1 1 MEMORIAL HOSPITAL INC

216 SUNSET PLACE NEILLSVILLE WI 54456

X X X X 3 PROVIDER BASED RURAL HEALTH CLINICS, 1 HOME HEALTH AGENCY NOT REQUIRED 1 6 MEMORIAL MEDICAL CENTER

216 SUNSET PLACE NEILLSVILLE WI 54456

PROVIDER BASED RURAL HEALTH CLINIC NEILLSVILLE MEMORIAL HOME

216 SUNSET PLACE NEILLSVILLE WI 54456

SKILLED NURSING FACILITY LOYAL CLINIC - MEMORIAL MEDICAL CENTER

502 EAST ELM STREET LOYAL WI 54446

PROVIDER BASED RURAL HEALTH CLINIC GREENWOOD FAMILY MEDICAL CENTER

201 SOUTH MAIN GREENWOOD WI 54437

PROVIDER BASED RURAL HEALTH CLINIC MEMORIAL MEDICAL CENTER

216 SUNSET PLACE NEILLSVILLE WI 54456

HOME HEALTH AGENCY SUNSET GARDENS

216 SUNSET PLACE NEILLSVILLE WI 54456

ASSISTED LIVING FACILITY PART I, LINE 7: THE CALCULATED PERCENT OF TOTAL EXPENSES EXCLUDES BAD DEBT EXPENSE. THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICES REVENUES. THIS COST TO CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATAGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. (THE TESTING METHODOLOGY FOR SUBSIDIZED HEALTH SERVICES IN PART I LINE 7G OF SCHEDULE H IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. THIS ALLOCATION METHOD AND PRINCIPLES OF ALLOCATION WERE USED TO DERIVE A SPECIFIC AMOUNT OF COST FOR THE VARIOUS PROGRAMS AND COST CENTERS OPERATED BY THE ORGANIZATION.) PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 670878. PART II: COMMUNITY BUILDING ACTIVITIES PROMOTE THE HEALTH OF THE COMMUNITY SERVED BY THE HOSPITAL THROUGH COLLABORATION WITH OTHER LOCAL ORGANIZATIONS TO PROVIDE INFORMATION TO THE COMMUNITY REGARDING VARIOUS ISSUES THAT AFFECT HEALTH SUCH AS CAR SEAT SAFETY, GUN SAFETY, STRESS MANAGEMENT, MALE CHRONIC DISEASE MANAGEMENT, AND PREVENTATIVE SERVICES. PART III, LINE 4: THE COST TO CHARGE RATIO WAS CALCULATED USING THE MEDICARE COST REPORT.PATIENT RECEIVABLES AND CREDIT POLICYPATIENT ACCOUNTS RECEIVABLE ARE UNCOLLATERALIZED PATIENT OBLIGATIONS THAT ARE STATED AT THE AMOUNT MANAGEMENT EXPECTS TO COLLECT FROM OUTSTANDING BALANCES. THESE OBLIGATIONS ARE PRIMARILY FROM LOCAL RESIDENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THE FACILITY BILLS THIRD-PARTY PAYORS ON THE PATIENTS' BEHALF, OR IF A PATIENT IS UNINSURED, THE PATIENT IS BILLED DIRECTLY. ONCE CLAIMS ARE SETTLED WITH THE PRIMARY PAYOR, ANY SECONDARY INSURANCE IS BILLED, AND PATIENTS ARE BILLED FOR COPAY AND DEDUCTIBLE AMOUNTS THAT ARE THE PATIENTS' RESPONSIBILITY. PAYMENTS ON PATIENT ACCOUNTS RECEIVABLE ARE APPLIED TO THE SPECIFIC CLAIM IDENTIFIED ON THE REMITTANCE ADVICE OR STATEMENTTHE FACILITY DOES HAVE A POLICY TO CHARGE INTEREST ON ACCOUNTS NEEDING EXTENDED PAYMENT BEYOND ONE YEAR. THE FACILITY WILL SET UP LONG-TERM PAYMENT PLANS FOR THESE TYPE OF ACCOUNTS. THESE PATIENTS SIGN AN AGREEMENT WITH THE HOSPITAL TO REPAY THE BALANCE IN APPROXIMATELY TWO YEARS AND WILL BE ASSESSED INTEREST AT A RATE OF 0.833% PER MONTH OR 10% ANNUAL INTEREST ON THE BALANCES OUTSTANDING.THE CARRYING AMOUNTS OF PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A CHARGE TO GROSS PATIENT SERVICE REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE.PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS.THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE PART III, LINE 8: THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT EXPENSE BECAUSE SERVICES PROVIDED TO MEDICARE BENEFICIARIES ARE TYPICALLY PROVIDED TO ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UNINSURED PATIENTS ARE GIVEN THE OPPORTUNITY TO FILL OUT AN APPLICATION FOR CHARITY CARE AT THE TIME OF ADMISSION AND ALL PATIENTS ARE ASKED TO FILL OUT A CHARITY CARE APPLICATION DURING THE COLLECTION PROCESS PRIOR TO SENDING TO ANY ACCOUNTS TO A COLLECTION AGENCY. IF THE PAPERWORK IS NOT RECEIVED, THE ACCOUNT IS HANDLED THROUGH THE NORMAL COLLECTION PROCESS. PART VI, LINE 2: DURING 2009 MEMORIAL HOSPITAL, INC ENTERED INTO A FORMAL COMMUNITY NEEDS ASSESSMENT WITH CLARK COUNTY IN ORDER TO SPECIFICALLY ADDRESS PUBLIC HEALTH, WIC, SCHOOLS, ORGANIZATIONS ADVOCATING FOR THE ELDERLY ETC. AND MAINTAIN MEMBERSHIPS IN OTHER COMMUNITY ORGANIZATIONS TO STAY IN TOUCH WITH THE COMMUNITY. ALSO DURING 2009 MEMORIAL HOSPITAL, INC STARTED A COMMUNITY HEALTH COUNCIL THAT MEETS QUARTERLY. THIS COUNCIL IS COMPRISED OF APPROX 30 COMMUNITY MEMBERS REPRESENTING OUR FULL SERVICE AREA. THE PURPOSE OF THIS GROUP IS TO GAIN DIRECT INPUT FROM COMMUNITY MEMBERS ON UNMET HEALTH NEEDS AND POSSIBLE SOLUTIONS TO FILL GAPS. PART VI, LINE 3: ALL PATIENTS WHO REGISTER WITH NO INSURANCE ARE SENT A PRIVATE PAY LETTER NOTIFYING THEM TO CONTACT A FINANCIAL SERVICES REPRESENTATIVE AT MEMORIAL HOSPITAL, INC. IF THEY NEED HELP IN PAYING THEIR BILL. THE FINANCIAL SERVICES REPRESENTATIVE THEN DISCUSSES THE OPTIONS AVAILABLE TO THE PATIENT. PART VI, LINE 4: MEMORIAL HOSPITAL, INC SERVES IN A COUNTY IN WHICH 54% OF THE POPULATION EARNS LESS THAN 200% OF THE FEDERAL POVERTY LEVEL AND 31% OF THE POPULATION ARE UNINSURED. THE COMMUNITY HAS A HIGH POPLULATION OF ELDERLY AND AMISH/MENNONITE. TRANSPORTATION IS HIGHLY UNDER-DEVELOPED AND UNAVAILABLE. THE COUNTY IS DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA AND MEDICALLY UNDERSERVED AREA. MEMORIAL HOSPITAL, INC SERVES ROUGHLY A 25 MILE RADIUS WITH A POPULATION TOTAL OF 15,000. PART VI, LINE 6: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR HOSPITAL PROVIDES CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, HOME CARE, INFUSION SERVICES, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH AND AUDIOLOGY, SURGICAL SERVICES, AND WOMENS HEALTH SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X X X 0 1 0 0 0 0 0 0 0 DR ARMANDO PACIS 166989 0 91759 0 1295 0 4500 0 17627 0 282170 0 0 0 DR GRACE CRUZ-APOLINARIO 179646 0 288104 0 153 0 4500 0 26909 0 499312 0 0 0 DR TIM MEYER 181994 0 189027 0 102 0 4500 0 8968 0 384591 0 0 0 SCOTT POLENZ 160772 0 13746 0 153 0 4500 0 29639 0 208810 0 0 0 DR JIM STANGA 136046 0 140372 0 153 0 4500 0 26909 0 307980 0 0 0 DR LOUIS A BENOIST 143146 0 123819 0 25350 0 4500 0 8343 0 305158 0 0 0 DR MAX OLESEVICH 314929 0 17343 0 92 0 0 0 26909 0 359273 0 0 0 DRDAVID PAUSTIAN 217188 0 395766 0 140 0 0 0 17627 0 630721 0 0 0 DR AMY COULTHARD 157729 0 80195 0 82 0 2412 0 2271 0 242689 0 0 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 DURING NOVEMBER OF 2010, WE OPENED AN ASSISTED LIVING FACILITY OFFERING A PLACE FOR INDIVIDUALS THAT WERE NOT YET READY FOR THE NURSING HOME BUT COULD NOT LIVE INDEPENDENTLY ANYMORE. CHANGES IN PROGRAM SERVICES FORM 990, PART III, LINE 3 AFTER MANY YEARS OF PROVIDING SKILLED NURSING AND LONG-TERM CARE SERVICES TO THE COMMUNITY, MEMORIAL HOSPITAL,INC SOLD ITS NURSING HOME OPERATIONS TO AN UNRELATED PARTY ON MARCH 31, 2010. THE ORGANIZATION OPERATED THE NURSING HOME AS A DEPARTMENT OF THE HOSPITAL FOR MANY YEARS UNDER WHICH REIMBURSEMENT, PRIMARILY FROM THE WISCONSIN MEDICAID PROGRAM, DID NOT COVER THE COSTS OF PROVIDING THIS TYPE OF CARE TO RESIDENTS. THE ORGANIZATION RECOGNIZED THAT LONG-TERM CARE SERVICES IN THE FORM OF A SKILLED NURSING HOME WERE STILL AN ESSENTIAL SERVICE TO PROVIDE IN THE COMMUNITY; HOWEVER THE ORGANIZATION COULD NO LONGER AFFORD TO SUSTAIN THESE LOSSES WITH ITS HOSPITAL OPERATIONS, SO AN OUTSIDE BUYER WAS FOUND. THE NEW NURSING HOME OPERATOR CONTINUES TO OPERATE THE SKILLED NURSING FACILITY IN A HIGH QUALITY AND COST EFFICIENT MANNER. THE NEW OWNER IS REIMBURSED UNDER A DIFFERENT MODEL WHICH DOES NOT HAVE ALLOCATION ISSUES UNDER THE MEDICARE COST REPORTING GUIDELINES. FORM 990, PART VI, SECTION B, LINE 11 THE CFO DETAIL REVIEWS THE FORM BEFORE SUBMISSION. ALSO, BEFORE THE 2010 RETURN WAS FILED, A PRELIMINARY COPY THAT EXCLUDED INDIVIDUAL SALARY INFORMATION WAS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW AND COMMENTS. THE BOARD OF DIRECTORS APPROVED AT THEIR NOVEMBER 2011 MEETING. FORM 990, PART VI, SECTION B, LINE 15 A COMMITTEE OF THE BOARD OF DIRECTORS HAS BEEN DESIGNATED TO REVIEW ALL EXECUTIVE PAY CHANGES. MARKET DATA IS PROVIDED TO THE COMMITTEE IN THEIR EVALUATION OF PAY CHANGES. COMPARABILITY DATA WAS USED AND THE RESULTS OF ANY EXECUTIVE PAY CHANGES WERE DOCUMENTED. NO ONE WITH A CONFLICT OF INTEREST WAS INCLUDED IN THE DECISION MAKING OF EXECUTIVE COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS ARE AVAILABLE UPON REQUEST. DOCUMENTS ARE ALSO DISCUSSED AT COMMUNITY MEETINGS AND EMPLOYEE FORUMS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 38,614. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE SELECTION OF AN INDEPENDENT AUDITOR AND MANAGEMENT OVERSEES THE AUDIT PROCESS. THIS PROCESS HAS NOT CHANGED IN 2010. COUNTRY VIEW INC 216 SUNSET PLACE NEILLSVILLE WI 54456 391411586 HUD HOUSING WI 501(C)(3) 9 N/A 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0