TY 2011 Form 990

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) SR MARYBETH CULNAN OSF BOARD MEMBER	1.0	X			0	0	0
(2) ANDREW J BAGNALL PRESIDENT & CEO	40.0	X	X		0	216,973	78,509
(3) STUART W BROTZ BOARD MEMBER	1.0	X			0	0	0
(4) TIMOTHY KELLNER BOARD MEMBER	1.0	X			0	0	0
(5) DAVID VAN DE WATER JD LLM CHAIRPERSON	1.0	X	X		0	0	0
(6) WILLIAM L TRAGER MD BOARD MEMBER	1.0	X			0	0	0
(7) SR BERNADINE GUTOWSKI OSF SECRETARY	1.0	X			0	0	0
(8) S MARK BETTAG MD BOARD MEMBER	1.0	X			0	0	0
(9) MICHAEL A LANSER EDD VICE CHAIRPERSON	1.0	X	X		0	0	0
(10) CHRISTOPHER L LARSON MD BOARD MEMBER	1.0	X			0	0	0
(11) PETER F BEMIS BOARD MEMBER	1.0	X			0	0	0
(12) ANN m CARR TREASURER	.25		X		0	225,813	215,561
(13) THERESE PANDL DIVISIONAL CEO	15.0		X		0	575,727	192,393
(14) GREG SIMIA DIVISION CFO	15.0		X		0	216,664	12,283
(15) BARBARA HOCKING COO/CNO	40.0		X		203,134	0	7,002
(16) ANDREA M ANGOTTI PHARMACIST	40.0			X	126,441	0	17,308
(17) SUSAN M WHEELER DIRECTOR OF PHARMACY	40.0			X	129,265	0	19,060

(A) Name and business address	(B) Description of services	(C) Compensation
Prevea health services 2710 EXECUTIVE DRIVE GREEN BAY,WI54304	physician services	9,357,400
St vincent hospital 835 S VAN BUREN GREEN BAY,WI543013256	physician services	7,581,994
St mary's hospital medical center 1726 SHAWANO AVENUE GREEN BAY,WI54303	physician services	480,348
DIVERSIFIED CLINICAL SERVICES 5220 BELFORT ROAD SUITE 200 JACKSONVILLE,FL32256	WOUND CENTER	467,396
Infinity healthcare inc 111 E WISCONSIN AVENUE SUITE 2000 MILWAUKEE,WI53202	ER AND HYPERBARIC	397,832
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 5

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	210,893
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	19,806,536	12,884,796	6,921,740
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	1,057,934	688,220	369,714
9	Other employee benefits .......	3,860,584	2,511,435	1,349,149
10	Payroll taxes ...........	1,245,373	810,156	435,217
11	Fees for services (non-employees):
a	Management ......	4,004,280	2,604,914	1,399,366
b	Legal .........	311,534	202,663	108,871
c	Accounting ...........	0
d	Lobbying ...........	0
e	Professional fundraising. See Part IV, line 17..	0
f	Investment management fees ......	0
g	Other ..........	14,437,245	11,241,597	3,195,648
12	Advertising and promotion ....	0
13	Office expenses .......	119,415	84,824	34,591
14	Information technology ......	0
15	Royalties ..	0
16	Occupancy ...........	0
17	Travel ............	133,827	115,685	18,142
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	26,931	10,728	16,203
20	Interest ...........	289,163	188,110	101,053
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	3,877,502	2,092,541	1,784,961
23	Insurance ..............	236,870	154,092	82,778
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a	SUPPLIES	8,654,599	8,541,138	113,461
b	BAD DEBT	2,230,789	2,230,789
c	MEDICAID TAX	2,087,901	2,087,901
d	EQUIPMENT RENTAL & MAINTENANCE	1,843,746	1,466,487	377,259
e
f	All other expenses	1,490,794	969,810	520,984
25	Total functional expenses. Add lines 1 through 24f	65,925,916	48,885,886	16,829,137	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	2,674,232	1	5,662,992
2	Savings and temporary cash investments .......	0	2	0
3	Pledges and grants receivable, net .........	0	3	0
4	Accounts receivable, net .........	10,857,930	4	9,269,068
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........	0	5	0
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........	0	6	0
7	Notes and loans receivable, net .............	0	7	0
8	Inventories for sale or use ..............	1,629,830	8	1,560,659
9	Prepaid expenses and deferred charges ............	303,739	9	232,193
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	115,736,473
b	Less: accumulated depreciation. .....	10b	66,598,554	44,365,270	10c	49,137,919
11	Investments—publicly traded securities ..........	44,211,814	11	40,116,535
12	Investments—other securities. See Part IV, line 11 ......	0	12	0
13	Investments—program-related. See Part IV, line 11 ..	1,252,082	13	1,237,191
14	Intangible assets .........	0	14	0
15	Other assets. See Part IV, line 11 ...........	2,174,177	15	1,589,967
16	Total assets. Add lines 1 through 15 (must equal line 34)...	107,469,074	16	108,806,524
	17	Accounts payable and accrued expenses .	5,332,843	17	6,108,031
18	Grants payable ..........	0	18	0
19	Deferred revenue ..........	0	19	266,636
20	Tax-exempt bond liabilities ..........	16,755,524	20	16,333,920
21	Escrow or custodial account liability. Complete Part IV of Schedule D..	0	21	0
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..	0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....	0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....	9,919,729	25	20,704,830
26	Total liabilities. Add lines 17 through 25.....	32,008,096	26	43,413,417
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	67,628,899	27	57,687,975
28	Temporarily restricted net assets .....	6,201,864	28	6,064,167
29	Permanently restricted net assets .....	1,630,215	29	1,640,965
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	75,460,978	33	65,393,107
34	Total liabilities and net assets/fund balances .....	107,469,074	34	108,806,524

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the the supported organization? ................

11g(i)

(ii) a family member of a person described in (i) above? ......................

11g(ii)

(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of support?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2011

Page 2

Part II

Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3..
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public Support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year(or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (See instructions.) ..................

First Five Years If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2011. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2010. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2011. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2011

Page 3

Part III

Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public Support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) 2011	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13	Total support (Add lines 9, 10c, 11 and 12.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2010 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2010 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2011. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2010. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2011

Page 4

Part IV

Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2011

Name of organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year. ......................... Arrow Bullet

Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on Part I, line 2, of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 2

Name of organization St Nicholas Hospital of the Hospital Sisters of the Third Order of St Francis
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part I	Contributors (see Instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 3

Name of organization St Nicholas Hospital of the Hospital Sisters of the Third Order of St Francis
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)
Part II	Noncash Property (see Instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions).	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Page 4

Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Name of organization
St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

$
Use duplicate copies of Part III if additional space is needed

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2011)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below.
SchCMd Bullet

Attach to Form 990 or Form 990-EZ. SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public
Inspection

If the organization answered “Yes” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
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Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
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Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
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Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
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Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, line 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2011

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2008	(b) 2009	(c) 2010	(d) 2011	(e) Total

2a	Lobbying non-taxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2011

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each “Yes” response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Yes

7,546

Total. Add lines 1c through 1i ...............................

7,546

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2 are answered “No” OR (b) Part III-A, line 3 is answered “Yes”.

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, Part II-A; line 5; and Part ll-B, line 1.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
Description of other lobbying activities	Schedule C, part II B, QUestion 1I	ST.NICHOLAS HOSPITAL ("THE HOSPITAL") IS A MEMBER OF THE CATHOLIC HEALTH ASSOCIATION ("CHA"), THE wisconsin HEALTH ASSOCIATION ("WHA"), THE NATIONAL ASSOCIATION FOR HOME CARE AND HOSPICE, AND THE AMERICAN HEALTH ASSOCIATION ("AHA"). AS A MEMBER OF THESE ORGANIZATIONS, THE HOSPITAL PAYS DUES, WITH PART OF THESE DUES BEING ATTRIBUTABLE TO LOBBYING FEES PAID BY THE ORGANIZATIONS. THE AMOUNT LISTED ABOVE IS THE AMOUNT ATTRIBUTABLE TO THE HOSPITAL FROM ITS DUES PAID.

Schedule C (Form 990 or 990EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .......
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) ...
4	Aggregate value at end of year .......

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................

Yes No

In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958), relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 52283D

Schedule D (Form 990) 2011

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIV.

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current Year	(b)Prior Year	(c)Two Years Back	(d)Three Years Back	(e)Four Years Back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses ...
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the year end balance (line 1g) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIV the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	1,407,040		1,407,040
b	Buildings ................	68,881,658	35,816,589	33,065,069
c	Leasehold improvements ............	283,176	13,179	269,997
d	Equipment ................	42,704,819	28,900,951	13,803,868
e	Other .................	2,459,780	1,867,835	591,945
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				49,137,919

Schedule D (Form 990) 2011

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Book value
Federal Income Taxes		0
ACCRUED BENEFIT LIABILITIES		13,099,380
CAPITAL LEASE		5,063,994
INTEREST RATE SWAP SETTLEMENT		1,987,015
ESTIMATED SELF-INSURANCE LIAB		265,300
OTHER LONG TERM LIABILITIES		289,141




Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		20,704,830
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2011

Page 4

Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1	Total revenue (Form 990, Part VIII, column (A), line 12) ....................	1
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3
4	Net unrealized gains (losses) on investments ..........................	4
5	Donated services and use of facilities .............................	5
6	Investment expenses ...................................	6
7	Prior period adjustments ..................................	7
8	Other (Describe in Part XIV.) .................................	8
9	Total adjustments (net). Add lines 4 through 8 .........................	9
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10

Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......		1
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIV.) ............	2d
e	Add lines 2a through 2d .....................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIV.) ...........	4b
c	Add lines 4a and 4b.......................		4c
5	Total Revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......		5

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............		1
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIV.) ............	2d
e	Add lines 2a through 2d......................		2e
3	Subtract line 2e from line 1.....................		3
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIV.) ............	4b
c	Add lines 4a and 4b.......................		4c
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......		5

Part XIV

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
ASC SUBTOPIC 740-10	SCHEDULE D, PART X, LINE 2	HSHS has adopted ASC Subtopic 740-10, Accounting for Uncertainty in Income Taxes - an Interpretation of FASB Statement No. 109. ASC Subtopic 740-10 addresses the determination of how tax benefits claimed or expected to be claimed on a tax return should be recorded in the consolidated financial statements. Under ASC Subtopic 740-10, the Obligated Group must recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest benefit that has a greater than 50% likelihood of being realized upon ultimate settlement. ASC Subtopic 740-10 also provides guidance on derecognition, classification, interest and penalties on income taxes, and accounting in interim periods, and requires increased disclosures. As of June 30, 2012 and 2011, the Obligated Group does not have a liability for unrecognized tax benefits.

Schedule D (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H (Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a....

Yes

If "Yes," was it a written policy? .......................

Yes

If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.

Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities

Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.

Did the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care?

If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other 225 %

Did the organization use FPG to determine eligibility for providing discounted care? If "Yes," indicate which of the

following was the family income limit for eligibility for discounted care: ............

Yes

200% 250% 300% 350% 400% Other

If the organization did not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? ..............

Yes

Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? ............................

Yes

If "Yes," did the organization's financial assistance expenses exceed the budgeted amount?......

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care?...............

Did the organization prepare a community benefit report during the tax year?...........

Yes

If "Yes," did the organization make it available to the public? ...............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Financial Assistance and Certain Other Community Benefits at Cost

	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Financial Assistance at cost (from Worksheet 1) ..		1,346,287		1,346,287	2.120 %
b Medicaid (from Worksheet 3, column a) .....	1,978	10,574,440	5,577,561	4,996,879	7.870 %
c Costs of other means-tested government programs (from Worksheet 3, column b) .
dTotal Financial Assistance and Means-Tested Government Programs .....	1,978	11,920,727	5,577,561	6,343,166	9.990 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	6,067	239,926	7,379	232,547	0.370 %
f Health professions education (from Worksheet 5) ..
g Subsidized health services (from Worksheet 6) ..	105	590,906	379,931	210,975	0.330 %
h Research (from Worksheet 7)
i Cash and in-kind contributions for community benefit (from Worksheet 8) ....
jTotal Other Benefits ...	6,172	830,832	387,310	443,522	0.700 %
kTotal. Add lines 7d and 7j. ..	8,150	12,751,559	5,964,871	6,786,688	10.690 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2011

Schedule H (Form 990) 2011

Page

Part II

Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.

		(b) Persons served (optional)	(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development
3	Community support	60	1,246	1,246
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy	222	3,355	3,355	0.010 %
8	Workforce development
9	Other
10	Total	282	4,601	4,601	0.010 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense........

2,230,789

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy .....

Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

20,146,711

Enter Medicare allowable costs of care relating to payments on line 5.....

31,497,127

Subtract line 6 from line 5. This is the surplus or (shortfall)........

-11,350,416

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Did the organization have a written debt collection policy during the tax year? ..........

Yes

If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI.......................

Yes

Part IV

Management Companies and Joint Ventures

(see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership%	(e) Physicians' profit % or stock ownership %
1orange cross	ambulance services	50.000 %	0 %	0 %
2sheboygan surg cntr	outpatient surgery center	50.000 %	0 %	50.000 %
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2011

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	St Nicholas Hospital	X	X	X

Schedule H (Form 990) 2011

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Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)

St Nicholas Hospital

Name of Hospital Facility:

Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2011)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1	Yes
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet the community health needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20 11
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3	Yes
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4	Yes
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5	Yes
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Participation in the development of a community-wide community benefit plan
	d	Participation in the execution of a community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the Needs Assessment
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs. ....		7		No
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explained eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care?...........		9	Yes
	If "Yes," indicate the FPG family income limit for eligibility for free care: 225.% If "No," explain in Part VI the criteria the hospital facility used.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care?.................		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 300.% If "No," explain in Part VI the criteria the hospital facility used.
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
	a	Income level
	b	Asset level
	c	Medical indigency
	d	Insurance status
	e	Uninsured discount
	f	Medicaid/Medicare
	g	State regulation
	h	Other (describe in Part VI)
12	Explained the method for applying for financial assistance?...................		12	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted on the hospital facility’s web site
	b	The policy was attached to all billing invoices
	c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
	d	The policy was posted in the hospital facility’s admissions offices
	e	The policy was provided, in writing, to patients upon admission to the hospital facility
	f	The policy was available upon request
	g	Other (describe in Part VI)
Billing and Collections
14	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained actions the hospital facility may take upon non-payment?.......		14	Yes
15	Check all of the following collection actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
16	Did the hospital facility or an authorized third party perform any of the following actions during the tax year before making reasonable efforts to determine the patient’s eligibility under the facility’s FAP?..........		16		No
	If “Yes,” check all actions in which the hospital facility or a third party engaged:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other similar actions (describe in Part VI)
17	Indicate which efforts the hospital facility made before initiating any of the actions checked in line 16 (check all that apply):
	a	Notified patients of the financial assistance policy upon admission
	b	Notified patients of the financial assistance policy prior to discharge
	c	Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
	d	Documented its determination of whether patients were eligible for financial assistance under the hospital facility’s financial assistance policy
	e	Other (describe in Part VI)

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
				Yes	No
18	Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........		18	Yes
	If “No,” indicate why:
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility’s policy was not in writing
	c	The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
	d	Other (describe in Part VI)
Individuals Eligible for Financial Assistance
19	Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
	a	The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged
	b	The hospital facility used the average of it's three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged
	c	The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged
	d	Other (describe in Part VI)
20	Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?.........		20		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its FAP-eligible patients an amount equal to the gross charge for any services provided to that patient?...............................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2011

Page

Part VFacility Information (continued)

Section C. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2011

Page

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 3, 4, 5c, 6i, 7, 9, 10, 11h, 13g, 15e, 16e, 17e, 18d, 19d, 20, and 21.
2	Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Identifier	ReturnReference	Explanation
PART I, LINE 3C		Not applicable, as the organization does follow FPG to determine eligibility for providing charity and discounted care to low-income uninsured and underinsured individuals.
PART I, LINE 6A		The Hospital's community benefit report can be accessed at www.stnicholashospital.org.
PART I, LINE 7, COLUMN (F)		THE PERCENTAGE OF CHARITY CARE AND CERTAIN OTHER BENEFITS AT COST AS A PERCENT OF TOTAL EXPENSES LESS BAD DEBT IS 10.69%. THE AMOUNT OF BAD DEBT REMOVED WHEN CALCULATING PART I, LINE 7, COLUMN (F) WAS 2,230,789.
PART I, LINE 7		Charity care is reported on St. Nicholas Hospital's fiscal year 2012 audited financial statements. Charity care is processed through patient billing and identified through the use of charity care billing codes. The total charity care dollar amount is then reduced to cost by applying the Hospital's cost to charge ratio as calculated on IRS Schedule H-Worksheet J.
Part II		The community building activities are identified and reported in St. Nicholas Hospital's community benefit reports. The activities consist primarily of participating in and supporting the work of community groups to advance community awareness about health issues.
Part III, Line 4		The Hospital strongly believes that its charity care, and the related community benefit obtained from such care, is understated because some patients who potentially qualify for charity care do not wish to apply for it. In addition, some care is not classified as charity because of missing documentation on patient resources. Thus, the Hospital's bad debt includes a portion that could be classified as charity care if application for such care was sought and/or completed. Currently, the Hospital is implementing processes, procedures, and systems to more effectively determine charity care that will reduce a patient's documentation requirements and ease the patient's emotional burden in applying for charity care. This will provide a more accurate reporting of charity care services provided by the Hospital in the future. The Hospital computes the cost of bad debt by multiplying the ratio of patient care cost to charges to the total charges written off as bad debt expense. The patient care cost is determined by reducing the total Hospital annual operating expenses by bad debt expenses, Medicaid provider taxes, and community benefit expense. This adjusted patient care operating cost is then divided by the total gross patient charges to calculate the ratio of patient care cost to charges.
Part III, Line 8		The Hospital continually strives to provide excellent patient care in the most cost effective manner. Nonetheless, the Medicare program, in many cases, does not provide payment that covers the full cost of the care provided. Since the mission of the Hospital is to respond to community need, hospital management continually advocates for improved Medicare payment so that the cost of quality care to those patients is not compromised and is fairly subsidized by all payers. While this shortfall in Medicare payments is not classified as community benefit by the IRS, it is an important contribution made by the Hospital to the health and well being of the community. St. Nicholas Hospital's mission is to serve all patients with the highest possible quality and efficiency, regardless of financial reimbursement. The Hospital computes the unpaid costs of providing care to Medicare patients by comparing the cost of the services to the reimbursement received from Medicare during the year. The cost of Medicare services is calculated by applying the ratio of patient care cost to charges to the annual Medicare charges. The patient care cost is determined by reducing the total annual operating expense by bad debt expenses, Medicaid provider taxes, and community benefit expense. The difference between the reimbursement received and the calculated cost of the services is reported as the Medicare shortfall. While the Medicare shortfall is not recognized as a community benefit, St. Nicholas Hospital reports this information within the Community Benefit footnote of the audited financial statements.
Part III, Line 9b		Every effort is made prior to, during, and after provision of medical services to determine whether a patient is eligible for charity/community care and to assist the patient in completing the application and providing adequate documentation. If the patient qualified for charity/community care for the full balance of their account, the entire amount is written off to charity/community care for a portion of their account balance, that portion is written off to charity/community care, with the patient being responsible for the remainder of the balance. Additionally, reasonable effort will be made to obtain third-party or government payer reimbursement on behalf of the patient. If those efforts are not fruitful, an offer will be extended to the patient to make installment payments on their balance. Only at such point that the patient defaults on installment payments or refuses to cooperate with the Hospital's efforts to be reimbursed will the account be sent to collections. For additional information, see response to question VI, 3.
Part V-B, Line 3		The community needs assessment was a collaborative, multi-stage process which included St. Nicholas Hospital, the Sheboygan County Health Division of Public Health, and community partners. Two complementary community engagement sessions occurred: * A Community Health Needs Forum sponsored by St. Nicholas Hospital. As described in the companion brochure which is also posted on the Hospital's website, this Forum included presentations and engagement by a group broadly representative of the community. * The Community Health Improvement Call to Action event sponsored by the Sheboygan County Division of Public Health and Healthy Sheboygan County 2020 (HSC 2020). HSC 2020 is a coalition of community and health-related organizations. This event also entailed broad community participation, including representation from St. Nicholas Hospital. In both of the above sessions, participants developed priorities for community-wide action based on the 2009 Community Health Needs Assessment conducted by the Sheboygan County Division of Public Health, updated data from the 2010 census, and more current publicly reported public health statistics. This Health Assessment utilized the health focus framework of Healthiest Wisconsin 2020 to gather Sheboygan County data and key findings. Major Needs and How Priorities Were Established At the May 2011 St. Nicholas Hospital Community Health Needs Forum, approximately 70 community leaders participated in the event with representation from business, non-profit agencies, healthcare, education, public health and safety, and elected officials. The objective of the Forum was to obtain community input to identify and prioritize health issues that the Hospital is best positioned to address in partnership with other organizations in the community. This event included a presentation by Jean Beinemann, RN, Program Supervisor from the Sheboygan County Division of Public Health on the 2009 Sheboygan County Community Health Needs Assessment, updated data from the 2010 census, and more current publicly reported public health statistics. The larger group was broken down into nine subgroups to rate and rank the health needs using two documents developed for this process to assess the needs against three criteria: (a) magnitude of problem; (b) seriousness of the consequences; and (c) feasibility of correcting. These documents included a Problem Importance Worksheet for each of the identified 12 key focus areas identified in the Sheboygan County Health Needs Assessment, and a Problem Prioritization Worksheet to rank the problems identified in the Problem Importance Worksheet. A similar process was used at the June 2011 Call to Action event sponsored by the Health Department and HSC 2020. This event included about 60 representatives from government, not-for-profit, healthcare, education, public safety, and business. The group reviewed health data in relation to the Healthy People 2020 and Healthiest Wisconsin 2020 framework. They discussed health needs in small groups. Priorities were established using the "dot method", whereby each participant can attribute an allocated number of votes to the needs that they identify as most important. The two priority-setting forums had slightly different but complementary purposes. Results from the Call to Action event were incorporated into the Sheboygan County Community Health Improvement Plan. This plan includes extensive involvement from St. Nicholas Hospital staff members, who serve on several implementing committees. The St. Nicholas Hospital forum also sought community input to set priorities, but with a focus on needs that the Hospital is best positioned to help address and to help support the development of the implementation strategy. The St. Nicholas Hospital forum identified five priority health issues: 1. Oral health. 2. Physical activity. 3. Adequate, appropriate, and safe food and nutrition (tie). 4. Unhealthy drug and alcohol use (tie). 5. Tobacco use and exposure. In addition (though not formally identified as a separate priority), each issue includes health literacy as a component. The Sheboygan County/HSC 2020 event also identified five top priorities: 1. Oral/dental health issues. 2. Mental health issues. 3. Improvement of health literacy. 4. AODA and tobacco use issues. 5. Obesity. The next step for St. Nicholas Hospital was to identify commonality between the identified issues which emerged as a result of the community engagement sessions. The priorities identified at both of the community engagement sessions shared many commonalities. Oral Health emerged as the top health issue at both sessions. Some of the priorities could be grouped together, including: physical activity; adequate, appropriate and safe food and nutrition; and obesity. AODA, including tobacco use, was also highlighted as a top community concern. Mental health was not identified as one of the top five priorities at the St. Nicholas Hospital forum, but it was identified as the sixth community health priority. Health Care Facilities and Resources within the Community There are two acute care hospitals in Sheboygan County-St. Nicholas Hospital and Aurora Sheboygan Medical Center. Both provide inpatient, outpatient, and emergency care. In addition, Aurora Sheboygan Memorial provides mental health and AODA treatment programs. In 2012, a community health clinic and a community dental clinic were started to serve the health care needs of low income individuals within the community. Sheboygan County Community Health Needs Forum Sponsored by St. Nicholas Hospital May 6, 2011 Attendee List * Ann Wondergem, Sheboygan & Plymouth Area United Way ** * Dr. Clifford Martin, Prevea Sheboygan Women's Care * Beverly Randall, Mental Health America ** * Marty Folan, St. Nicholas Hospital * Katy Pruitt, Safe Harbor ** * Dr. Al Hardersen, UW-Sheboygan * Tanya Smith, St. Nicholas Hospital * Steve Stauber, Friends of St. Nicholas Hospital * Heidi Selberg, HSHS Division-Eastern Wisconsin * Jean Beinemann, Sheboygan County Division of Public Health * * Sue Wheeler, St. Nicholas Hospital * Aly Flaskrud, Willowdale Nursing and Rehabilitation Center * Brian Charlier, Prevea Health * Andy Bagnall, St. Nicholas Hospital * Dr. Donald Gore, Sheboygan Orthopaedic Associates * Sherri Samuels-Fuerst, Sargento Foods, Inc. * Chris Jensema, HSHS Division-Eastern Wisconsin * Judy Halverson, Partners of St. Nicholas Hospital * Mary Schueller, HSHS Division-Eastern Wisconsin * Annette Selk, Public Health Nurse, Sheboygan County Division of Public Health * * Joseph Leibham, Wisconsin State Senate * Jeanette Miller, Partners of St. Nicholas Hospital * Nancy Jusky, Sheboygan & Plymouth Area United Way ** * Eve Kovacs, Partners of St. Nicholas Hospital * Mary Jo Tittl, Family Resource Center ** * Beth Millin, St. Nicholas Hospital * Jill Niemczyk, Northeastern Wisconsin Area Health Education Center * Mark Radtke, Wind Mill Slatwall Products * Jody Moesch Ebeling, Public Health Nurse, Sheboygan County Division of Public Health * * Dale Hippensteel, Health Officer, Sheboygan County Division of Public Health * * Kristin Blanchard, Sheboygan County Interfaith Organization ** * Susie Runaas, St. Nicholas Hospital * Amy Betke, Public Health Nurse, Sheboygan County Division of Public Health * * Carrie Bender, Rockline Industries * Steve Neisius, Rockline Industries * Jean McMurray, Aurora Health Care * Wendy Elgin, BridgePoint Health ** * Jan Mulhern, St. Nicholas Hospital * Michelle Niemi-Prange, Sheboygan Progressive Care Center * Dawn Kind, Prairie States Enterprises * Mary Paluchniak, St. Nicholas Hospital * Cynthia Bertsch, St. Nicholas Hospital * Xue Yang, St. Nicholas Hospital * Kaitlin Swanson, HSHS Division-Eastern Wisconsin * Virginia Thomas, Sheboygan Area Community Clinics, Inc. ** * Alejandra Klemme, Catholic Charities ** * Phil Duket, Family Resource Center ** * Chasong Yang, Hmong Mutual Assistance Association ** * Dr. David Wyatt Seal, Medical College of Wisconsin * Ryan Perkins, St. Nicholas Hospital * Jenny Pernat, St. Nicholas Hospital * Marlene Mielke, Regional Representative for U.S. Senator Herbert Kohl * Terri Boxrucker, Public Health Nurse,Sheboygan County Division of Public Health * * Connie Bitter, Friends of St. Nicholas Hospital and Bemis Manufacturing * Mike Klein, Bemis Manufacturing * Robert Weber, D.D.S. * Dr. Gregory Grose, Prevea Sheboygan Urology * Jessica Muchowski, Willowdale Nursing and Rehabilitation Center * Cindy Musial, The Gathering Place ** * Nichol Fidlin, Prevea Health * Mel Blanke, Sheboygan Area Community Clinics, Inc. ** * John Koehler, Sheboygan Area School District * Joann Wieland, Sheboygan & Plymouth Area United Way ** * John Wenig, Friends of St. Nicholas Hospital * Lorraine Pashley, St. Nicholas Hospital * Thomas Eggebrecht, Sheboygan County Health and Human Services Department ** * Check Butler, Sheboygan City Fire Department * Public health representative ** Representative of minority, underserve
Needs Assessment		The Community Health Needs and associated implementation strategy will be used to guide the Hospital's efforts in FY2013. For prior years, the Hospital employed a number of methods to assess health care needs. For example, the Hospital has a community advisory committee that is representative of the community that the Hospital serves. The committee meets regularly to discuss hospital services and the ability of the Hospital to meet community health care needs. Agendas are purposely organized to include time for feedback from members on what they are hearing in the community. In addition, Hospital colleagues represent the Hospital on a wide variety of community groups. Through this representation, the Hospital becomes aware of emerging needs, and as a result, is able to offer or support screening and education programs that addresses these needs. St. Nicholas Hospital's Community Needs Assessment is published on its website. The link is http://www.stnicholashospital.org/communityHealthNeeds.html.
Patient Education of Eligibility for Assistance		St. Nicholas Hospital posts its charity care policy and application on its website. In addition, charity care applications are available and prominently displayed in waiting rooms and registration areas. The Hospital's financial counselors are available to meet with patients on site before or at the time of service to assist in identifying whether or not they are eligible for government aid or financial assistance. The financial counselors assist patients in applying for programs for which they may be eligible. After patients receive their health care service(s), the Hospital's customer service representatives are also trained to assist patients in applying for various government programs or for the Hospital's charity care program. In addition, the Hospital's collectors are trained to provide this assistance as well. Lastly, the Hospital has contracted with an outside organization to perform active outreach with patients, who may need additional assistance or advocacy to apply for benefits, appeal denials, or who need transportation to government agencies to apply for benefits.
Community Information		Sheboygan County is primarily an urban county. Sheboygan County is one of 72 Wisconsin counties, and is located in eastern Wisconsin. The population of approximately 115,000 is primarily Caucasian. However, there are an estimated 5,600 Hispanic residents (over 200% increase since 1990) and nearly 5,000 Asian residents (over 100% increase since 1990). The percent of people age 65 and over exceeds state and national levels. According to the Wisconsin Department of Health Services, 5% of residents are below the federal poverty level, and another 9% have incomes of less than 200% of the federal poverty level. About 3% of the population receives Medicaid assistance. Other notable findings on community needs include: * There are no dental providers in Sheboygan County that accept new patients if their source of payment is Medicaid. * 66% of the Sheboygan County adults are overweight or obese. * 33% of Sheboygan County adults have hypertension. * 22% of Sheboygan County adults have diabetes, which includes 2,460 undiagnosed adults. * Estimated 19% of Sheboygan County individuals over age 20 and older are pre-diabetic.
Promotion of Community Health		St. Nicholas Hospital offers hope to the community in the tradition of the Hospital Sisters of St. Francis. As a healing ministry of the Catholic Church and an affiliate of the Hospital Sisters Health System (HSHS), St. Nicholas Hospital is committed to delivering high quality, compassionate, and cost-effective health care services to all. The hospital was founded over 120 years ago to bring a healing presence to the community and to improve the health of the community, especially for people who are sick, poor, and disadvantaged. Because of the Hospital's purpose and tradition, it is organized to promote the health of Sheboygan County, Wisconsin, and surrounding areas. The Hospital is governed by a Board of Directors, of which the majority is comprised of persons who reside in the organization's primary service area and who are neither employees nor contractors of the hospital (nor family members thereof). The Board insures that St. Nicholas Hospital is responding to community need. During the last fiscal year, for example, the Board reviewed the Community Health Needs Assessment and approved an implementation strategy for addressing selected needs. In addition, the Hospital Advisory Council, Friends of St. Nicholas Foundation, and the Partners of St. Nicholas Hospital (whose volunteer members assist in many areas of the Hospital) provide the Hospital with additional connections to and insights into the larger community and its health care needs. Also consistent with its exempt purpose, St. Nicholas Hospital has an open medical staff with privileges available to all qualified physicians in the area. In addition, the Hospital operates an emergency department that is open 24 hours to all persons regardless of their ability to pay. As a not-for-profit hospital, St. Nicholas Hospital reinvests surplus funds into the mission of the organization and health of the community, rather than distributing them as profits to shareholders or individuals. Funds not committed to ongoing operations are generally used to upgrade facilities, secure new technologies, improve patient care, and support initiatives designed to promote health and insure access for all. For example, St. Nicholas Hospital is currently working with its parent organization, Hospital Sisters Health System, to continuously enhance quality and improve coordination of care both inside the Hospital and with a growing number of physician partners. Supported by investments in information technology, this "care integration" strategy is designed to better coordinate care, improve health outcomes, create new efficiencies, and help insure that patients (especially those with chronic conditions) get well and stay well. For example, the new Epic electronic medical record system enables providers to connect with their patients' medical record from wherever they are, as well as, allows emergency physicians access to patient medical records from any facility that has implemented Epic. This reduces duplicate testing, puts critical health information at providers' fingertips, helps better manage chronic conditions, and improves patient safety. A Heart Failure Clinic has been established to assist heart failure patients with maintaining good health and staying out of the hospital by incorporating diet, exercise and other wellness information into the long-term care plan. This growing program has shown success in reducing readmissions, which is especially helpful for those with limited financial resources. St. Nicholas Hospital provides significant resources to access for patients who cannot afford care, along with other community benefits. In fiscal year 2012, St. Nicholas provided $6.8 million in community benefit services, including charity care at cost, unpaid costs of Medicaid and other public programs, and a range of diverse programs designed to enhance access and improve community health. During this period, St. Nicholas provided $15.3 million (at cost) in excess of Medicare payments for health care services. Responding to Community Need The range of benefits provided by St. Nicholas Hospital flows from its mission and long-standing commitment to the community. In many cases, these programs would be unlikely to exist without the leadership role played by St. Nicholas Hospital, and these programs often relieve a burden that would otherwise be carried by the government. St. Nicholas Hospital's active participation with the local Hmong and Hispanic organizations has brought screenings and education to locations and venues, which are nonthreatening to members of those populations. In doing so, the Hospital has reached out to more than 350 members of these communities. The Hospital has been able to identify critical health conditions, and to encourage and promote ongoing proactive health care. Another example of community benefit at St. Nicholas Hospital is the Hope After Loss Organization (HALOTM), which provides support to families that experience loss of life during pregnancy. This program serves the entire community, at no cost to participants, whether their loss occurred at St. Nicholas Hospital or another facility. Over 100 individuals attended HALO support programs. Community benefits at St. Nicholas Hospital also include multiple programs aimed at health promotion. * St. Nicholas Hospital actively participates in "Healthy Sheboygan County 2020". This collaborative group is made up local health care organizations. The group's primary focus is to improve the lives of people in Sheboygan County. St. Nicholas Hospital staff members help the AODA Committee with a County-wide Medication Drop Off, as well as educational presentations. * The Sheboygan County Activity & Nutrition (SCAN) receives assistance through the Hospital's participation in the Employee Health & Fitness Day, Family Health & Fitness Day, and local health fairs. * St. Nicholas Hospital is a supporting co-sponsor of the Community Clinic being developed to address the need to increase access to health care for the un- and underinsured in Sheboygan County. In addition to the financial support, St. Nicholas Hospital has dedicated staff to assist with this important community benefit effort. * Free monthly screenings and health education for the Hmong Mutual Assistance Association. * Support groups free of charge for heart, renal, and stroke patients, as well as grief counseling for adults and children. * Free monthly blood pressure screenings at dozens of locations throughout the county. * Free use of hospital conference and meeting rooms for area not-for-profit organizations. * Provide a house with financial support and in-kind services for Sheboygan County Interfaith Organization and their Bridgeway House, which provides temporary housing for homeless women and children and families transitioning out of domestic abuse situations. * More than 100 families took advantage of child care seat safety checks by certified technicians open to the public free of charge. The checks include education on the need for regular use of safety seats, and the importance of proper installation and of child restraints. * Free bike helmet fittings and bike helmets at cost. The helmet fittings are open to the public. More than 200 helmets were provided through Emergency Department walk in sessions, and over 300 helmets were provided through bike rodeos and other special events. * More than 900 individuals attended foot clinics for the elderly and individuals with diabetes. The clinics assist with care that can be difficult primarily related to degenerative health conditions, as well as, provide regular specialized care for diabetics. * Breast cancer screenings, at cost, for the underserved, including special services and translation for women from the local Hispanic community. * Financial support and in-kind services for Sheboygan County Interfaith Organization, Family Resource Center, Safe Harbor Domestic Abuse Shelter, Big Brothers/Big Sisters, and area churches and schools, which reaches thousands in need within the greater Sheboygan County area; * Food drives for local food pantries. * School supply and clothing drives for area schools.
Affiliated Health Care System		St. Nicholas Hospital of the Hospital is an affiliate of Hospital Sisters Health System (HSHS), a health care ministry that includes 13 hospitals, scores of community-based health centers and clinics, and more than 2,000 physician partners across Illinois and Wisconsin. The Mission of HSHS is to reveal and embody Christ's healing love for all people through our high quality Franciscan health care ministry. We live our Mission by healing those who seek our care, as well as through our Community Benefit initiatives. Working collaboratively with others in the 12 communities we serve, our Community Benefit efforts are successfully expanding access to care, improving the health status of residents, and furthering medical education and knowledge. Across HSHS, we collectively provided $174.2 million in Community Benefits (or 9.7% of total hospital expenses) in FY2012. Included in this amount was $43.1 million provided for Charity Care and $97.9 million for unreimbursed care provided under the Medicaid program. In addition, HSHS hospitals committed significant resources to care for Medicare patients. The cost of providing services to primarily elderly beneficiaries of the Medicare program - in excess of governmental and managed care contract payments - was $168.4 million. HSHS hospitals also recorded $106.6 million in uncollectible accounts. Beyond the dollars invested in our Community Benefit programs, HSHS also continues to reinvest any surplus revenue from operations and investments into new medical technology, facility infrastructure and health care services in our communities. By doing do, we ensure we are able to meet the ongoing demand for high quality, efficient and easily accessible health care. Recognizing that the health care delivery model in the U.S. is evolving, HSHS remains focused on implementing our Care Integration strategy. Care Integration coordinates the delivery of care around the needs of each patient. During FY2012, we made significant progress with this strategy as we further implemented interoperable health information technologies, expanded the number of Medical Homes, and strengthened our alignment with physicians. Greater access to care As a Franciscan health care ministry, HSHS is deeply committed to serving those who are most in need. We not only provide care to every patient who walks through our doors, but also reach out beyond the walls of our hospitals and clinics to care for the individual. Our efforts to ensure residents in the communities we serve receive the right care at the right time often involve partnering with others to achieve this goal. Across our two-state system, there are numerous examples of HSHS collaborating with other organizations to enhance access to care for those in need. In western Wisconsin, St. Joseph's Hospital in Chippewa Falls works closely with the Chippewa Health Improvement Partnership (CHIP) to support the Open Door Clinic. The free medical clinic provides health care for those without insurance coverage. This past year, the clinic received a total of 2,216 patient visits, a 25% increase from the prior year. With more than 150 individuals volunteering, the clinic provided over 6,500 hours (including 700 physician hours and 1,500 nursing hours) of service to individuals. The Open Door Clinic is an example of HSHS providing leadership and support to a community-based program designed to meet the needs of those less fortunate. In northeastern Wisconsin, St. Vincent Hospital in Green Bay supports patient care for the uninsured at the NEW Community Clinic by paying a nurse's salary and offering free and discounted laboratory and radiology services. More than 70% of patients who use the clinic report the care they received helped keep them out of the Emergency Department. St. Nicholas Hospital in Sheboygan proactively reaches out to local Hmong and Hispanic organizations to ensure these populations can participate in free screenings and health education programs. Through this ongoing outreach initiative, St. Nicholas engaged more than 350 people last year, and in many cases was able to identify critical health conditions early and provide appropriate follow-up care. A Woman's Place at St. Mary's Hospital Medical Center in Green Bay reaches out to Hispanic neighbors to provide health and wellness education, health screenings, resources and referral services. Last year A Woman's Place touched the lives of more than 7,000 women through health screenings, educational events, classes and its resource center. In southeast Illinois, area residents can get help filling a prescription through the long-term collaboration between St. Anthony's Memorial Hospital in Effingham and Catholic Charities. Last year, St. Anthony's helped underwrite the cost of prescription medications for more than 430 residents. In southwest Illinois, St. Joseph's Hospital in Highland recognized many rural residents did not have a reliable means of transportation and partnered with generous individuals in the community to offer a free transportation service. The "Friends' Van," fully supported by the Friends of St. Joseph's Hospital, provides free rides to medical, dental and other personal appointments within a 20-mile radius of Highland. In FY2012, the Friends Van transported 2,050 individuals for a total of 12,561 miles. In addition to programs such as these, HSHS makes sure that those who need financial assistance for care receive it. Our Charity Care program covers 100% of hospital charges for individuals and families who earn less than 200% of the federal poverty level. HSHS Charity Care programs have a sliding scale, in some instances providing up to a 60% discount on charges for those earning up to 600% of the federal poverty level. Counselors are available in our hospitals to explain our charity care policies to patients, provide them with assistance in filling out a simple application form, or help them enroll in publicly funded health care programs. Better community health As part of our mission to embody Christ's healing love, we understand that we have a responsibility to improve the overall quality of life in our communities by supporting initiatives that promote health and wellness. We recognize we are most successful when we work together with a wide array of public and private organizations that share our commitment to improving lives. By doing so, we maximize our efforts and reduce the duplication of services. HSHS hospitals also understand we need to listen closely to the residents of the communities we serve to ensure the health care needs of all are being met. To that end, each of our 13 hospitals completed Community Health Needs Assessments (CHNA) during FY2012. The information gathered from these assessments is being used to help us develop new, and enhance existing, programs and services that best address the needs of the community. Among the many priority needs identified from the CHNAs include metabolic and cardiovascular disease management, adequate food and nutrition, and mental health. HSHS hospitals are addressing these and other needs by proactively offering educational opportunities, preventative screenings, and new or enhanced clinical services. To address metabolic disease management, St. Francis Hospital in Litchfield, Illinois, partners with Montgomery County Health Department to provide screening for diabetes and renal disease. St. Francis Hospital teams up with Macoupin County Health Department to provide Diabetes Self-Management classes. St. Joseph's Hospital in Breese, Illinois coordinates several community education seminars and health fairs on cardiovascular disease and healthy eating each year. Over 3,000 residents participated in these health events last year. Recognizing the importance of proper food and nutrition to overall health, St. John's Hospital in Springfield initiated the Destination Dinner program which teaches families how to cook healthy, from-scratch meals, and eat together as a family. Families meet quarterly to learn new cooking skills. They also learn how to prepare a meal for a family of four on a budget of $8.00. In addition to raising awareness about how to eat healthy on a limited budget, the program brings families together around the dinner table, which research shows promotes healthy relationships, increased academic performance and decreased risk for substance abuse and risky sexual behavior. Sacred Heart Hospital in Eau Claire, Wisconsin addressed the need for access to mental health services for children and adolescents by opening an outpatient behavioral health clinic. Sacred Heart has also adopted screening tools for behavioral and mental health risk factors for use at affiliated clinics. The goal is to better identify mental health issues and provide earlier intervention. Sacred Heart Hospital is also working with the Chippewa Valley Free Clinic (CVFC) to develop expanded provider coverage for CVFC patients who require mental health servi
STATE FILING OF COMMUNITY BENEFIT REPORT	990 SCHEDULE H, PART VI	WI,

Schedule H (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....

Yes

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....

Yes

Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ...............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? ........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

Schedule J (Form 990) 2011

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1) ANDREW J BAGNALL	(i) (ii)	0 205,068	0 0	0 11,905	0 54,984	0 24,649	0 296,606	0 16,031
(2) ANN m CARR	(i) (ii)	0 180,382	0 0	0 45,431	0 197,622	0 18,652	0 442,087	0 15,440
(3) THERESE PANDL	(i) (ii)	0 559,242	0 0	0 16,485	0 169,750	0 27,306	0 772,783	0 58,540
(4) GREG SIMIA	(i) (ii)	0 166,664	0 50,000	0 0	0 0	0 12,664	0 229,328	0 0
(5) BARBARA HOCKING	(i) (ii)	203,134 0	0 0	0 0	0 0	7,759 0	210,893 0	0 0

Schedule J (Form 990) 2011

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation
Social Club Dues	Schedule J, Part I, Line 1a	St. Nicholas paid social club dues on Andrew Bagnall's behalf during the year. The fair market value was included in his reportable compensation for the year.
therese pandl	schedule j, part i, line 4b	Therese pandl participated in a SERP plan during the year in the amount of $114,915.
ann m. carr	schedule j, part i, line 4b	ann m. carr participated in a SERP plan during the year in the amount of $33,655.
andrew bagnall	schedule j, part i, line 4b	andrew bagnall participated in a SERP plan during the year in the amount of $37,044.

Schedule J (Form 990) 2011

Additional Data

Software ID:
Software Version:

- TIN:

Schedule L
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Transactions with Interested Persons

Complete if the organization answered
"Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c,
or Form 990-EZ, Part V lines 38a or 40b.
MediumBullet

Attach to Form 990 or Form 990-EZ. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Part I

Excess Benefit Transactions (section 501(c)(3) and section 501 (c)(4) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.

1(a) Name of disqualified person	(b) Description of transaction	(c) Corrected?
1(a) Name of disqualified person	(b) Description of transaction	Yes	No

Enter the amount of tax imposed on the organization managers or disqualified persons during the year under section 4958. ......................... Bullet Image

Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ....... Bullet Image

Part II

Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 26, or Form 990-EZ, Part V, line 38a.

(a) Name of interested person and purpose	(b) Loan to or from the organization?		(c)Original principal amount	(d)Balance due	(e) In default?		(f) Approved by board or committee?		(g)Written agreement?
(a) Name of interested person and purpose	To	From	(c)Original principal amount	(d)Balance due	Yes	No	Yes	No	Yes	No
(1) THERESE PANDL mortgage extension		X	250,000	274,484		No	Yes		Yes
(2) THERESE PANDL stock purchase		X	4,125	4,125		No	Yes		Yes




Total ............... $				278,609

Part III

Grants or Assistance Benefitting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.

(a) Name of interested person	(b)Relationship between interested person and the organization	(c)Amount of grant or type of assistance

For Privacy Act and Paperwork Reduction Act Notice, see the
Instructions for Form 990 or 990-EZ.

Cat. No. 50056A

Schedule L (Form 990 or 990-EZ) 2011

Page 2

Part IV

Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.

(a) Name of interested person	(b) Relationship between interested person and the organization	(c) Amount of transaction	(d) Description of transaction	(e) Sharing of organization's revenues?
(a) Name of interested person		(c) Amount of transaction	(d) Description of transaction	Yes	No
(1) Barbara Hocking	Temporary Placement	186,879	Director of Surgery placement		No

Part V

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule L (see instructions).

Identifier	Return Reference	Explanation
Loans to/from interested persons	Schedule L, Part II	All loans involving interested persons are compliant with the organization's conflict of interest policy. any transactions requiring board approval are reviewed by an independent board prior to being approved.
business transactions involving interested persons	schedule l, part iv	All business transactions involving interested persons are compliant with the organization's conflict of interest policy. any transactions requiring board approval are reviewed by an independent board prior to being approved.

Schedule L (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2011

Open to Public
Inspection

Name of the organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Identifier	Return Reference	Explanation
Organization's Mission	FORM 990 PART III, LINE 1	ST. NICHOLAS HOSPITAL IS DEDICATED TO SUFFERING HUMANITY FOR HIS SAKE, AND IS COMMITTED TO PROVIDING HIGH QUALITY, COMPASSIONATE CARE WITHOUT REGARD FOR RACE, CREED, OR ABILITY TO PAY. The hospital's CORE VALUES OF RESPECT, CARE, COMPETENCE AND JOY ARE LIVED BY ALL WHO serve HERE, AND FELT BY ALL WHO receive healthcare services at St. nicholas Hospital. STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS FORM 990 PART III, LINE 4A THE COMMUNITY BENEFIT CONTRIBUTION OF ST. NICHOLAS HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS INCLUDES PROGRAMS AND ACTIVITIES THAT IMPROVE ACCESS TO HEALTH CARE AND IMPROVE HEALTH IN the community the hospital serves. IN ORDER TO PORTRAY THE FULL BREADTH OF this CONTRIBUTION, the hospital's COMMUNITY BENEFIT INFORMATION IS DESCRIBED BELOW: SECTION 1: QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT - DESCRIBES THE HOSPITAL'S COMMUNITY BENEFIT MISSION, HOW THE MISSION IS TRANSLATED INTO A PROACTIVE APPROACH DESIGNED TO MEET COMMUNITY HEALTH NEEDS, HOW THE HOSPITAL MEETS TAX-EXEMPT REQUIREMENTS, AND A DESCRIPTION OF COMMUNITY BENEFIT PROGRAMS AND SERVICES THAT HIGHLIGHT THE HOSPITAL'S IMPACT ON COMMUNITY HEALTH. SECTION 2: QUANTITATIVE DESCRIPTION OF COMMUNITY BENEFIT - DESCRIBES THE HOSPITAL'S COMMUNITY BENEFIT CONTRIBUTION IN FINANCIAL TERMS PRESENTING THE level OF CHARITY CARE, THE UNPAID SHORTFALL FROM GOVERNMENT HEALTH CARE FOR THE INDIGENT, AND THE NET EXPENSE OF COMMUNITY BENEFIT SERVICES. SECTION 1 - QUALITATIVE DESCRIPTION OF COMMUNITY BENEFIT 1. ORGANIZATIONAL COMMITMENT TO PROVIDING COMMUNITY BENEFIT A. DESCRIBE HOSPITAL'S MISSION AND PRIMARY EXEMPT PURPOSE. (IF APPLICABLE, IDENTIFY HOSPITAL'S STATUS AS A CRITICAL ACCESS HOSPITAL, SOLE COMMUNITY HOSPITAL, DISPROPORTIONATE SHARE HOSPITAL, OR RELATED STATUS.) THE MISSION OF ST. NICHOLAS HOSPITAL IS TO CARRY FORWARD THE HEALING MINISTRY OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS AS PART OF THE HEALTH MINISTRY OF THE ROMAN CATHOLIC CHURCH. ST. NICHOLAS HOSPITAL IS DEDICATED TO SUFFERING HUMANITY FOR HIS SAKE AND IS COMMITTED TO PROVIDING HIGH QUALITY, COMPASSIONATE CARE WITHOUT REGARD FOR RACE, CREED, OR ABILITY TO PAY. the hospital's CORE VALUES OF RESPECT, CARE, COMPETENCE, AND JOY ARE LIVED BY ALL WHO serve HERE, AND FELT BY ALL WHO receive healthcare services at St. nicholas hospital. B. SUMMARIZE HOSPITAL'S APPROACH TO PROVIDING COMMUNITY BENEFIT. THIS SUMMARY INCLUDEs THE FOLLOWING INFORMATION: GEOGRAPHIC AREA AND TARGET POPULATIONS. ST. NICHOLAS HOSPITAL'S SERVICE AREA INCLUDES SHEBOYGAN COUNTY AND PARTS OF OZAUKEE, FOND DU LAC, MANITOWOC, AND CALUMET COUNTIES WITH A TOTAL POPULATION OF APPROXIMATELY 140,000. MUCH OF THIS AREA IS RURAL AND CONSISTS OF SMALL FAMILY FARMS. IMMIGRANT COMMUNITIES HAVE expanded SUBSTANTIALLY IN RECENT YEARS, PARTICULARLY HISPANICS FROM MEXICO AND LATIN AMERICA, HMONGS FROM SOUTHEAST ASIA, AND EASTERN EUROPEANS. IT IS ESTIMATED THAT OVER 10% OF THE United States POPULATION IS UNINSURED. IN ADDITION TO MEDICAID, WISCONSIN HAS BADGERCARE, which WAS INTRODUCED IN 1999. THE NEW BADGERCARE PLUS PROGRAM REACHED MAXIMUM ENROLLMENT LEVELS THREE MONTHS AFTER ITS inception. THE STATE WAS FORCED TO CAP ENROLLMENT FOR CHILDLESS ADULTS IN ITS BADGERCARE PLUS CORE PROGRAM AFTER 33,000 ADULTS HAD ENROLLED IN THE FIRST FEW MONTHS OF THE PROGRAM. MAJOR TRENDS, NEEDS, AND PROBLEMS IN THE COMMUNITY; AS NOTED ABOVE, JOB LOSSES including THE LOSS OF INSURANCE and expansion of IMMIGRANT COMMUNITIES IN RECENT YEARS have created new issues and needs in the community. LANGUAGE AND CULTURAL BARRIERS CAN HAMPER COMMUNICATIONS. NUTRITION AND LIFESTYLE CHOICES HAVE LED TO RISING RATES OF DIABETES, CARDIOVASCULAR DISEASE, OBESITY, and other health issues AMONG ALL POPULATIONS. MAJOR STRATEGIES TO ADDRESS IDENTIFIED NEEDS AND PROBLEMS; UTILIZING DATA COLLECTED BY THE STATE OF WISCONSIN, THE COUNTY DEPARTMENT OF PUBLIC HEALTH, THE NORTHEASTERN WISCONSIN AREA HEALTH EDUCATION CENTER, AND OTHER AREA HEALTHCARE PROVIDERS, ST. NICHOLAS HOSPITAL MONITORS CHANGES IN POPULATION, DISEASE INDICATORS, ETC., AND DEVELOPS A BROAD RANGE OF PROGRAMS TO ADDRESS UNMET HEALTHCARE NEEDS. THE MAJORITY OF THESE PROGRAMS ARE PROVIDED FREE OF CHARGE OR AT/BELOW COST. COMMUNITY ORGANIZATIONS COLLABORATING WITH THE HOSPITAL TO IMPROVE COMMUNITY HEALTH, EXPAND ACCESS TO HEALTH CARE, OR IN OTHER WAYS BENEFIT THE COMMUNITY; ST. NICHOLAS HOSPITAL WAS A FOUNDING MEMBER OF "HEALTHY SHEBOYGAN COUNTY 2020" ("HSC 2020"), A COLLABORATIVE EFFORT TO IMPROVE THE LIVES OF PEOPLE IN sheboygan COUNTY. PARTNERS IN THIS EFFORT INCLUDE THE PUBLIC HEALTH DEPARTMENT, AURORA HEALTH CARE, THE MENTAL HEALTH ASSOCIATION, FAMILY RESOURCE CENTER, SALVATION ARMY, AND PRAIRIE STATES ENTERPRISES. OUTREACH PROGRAMS ARE CURRENTLY FOCUSED ON OBESITY/INACTIVITY, ALCOHOL AND OTHER DRUG ABUSE PREVENTION, AND MENTAL HEALTH ISSUES, PARTICULARLY SUICIDE PREVENTION. HSC 2020 IS CURRENTLY IN A LONG-RANGE PLANNING PROCESS (FUNDED BY A GRANT FROM THE LOCAL UNITED WAY agency) which is focusing on THE NEED TO INCREASE ACCESS TO HEALTHCARE FOR THE UN- AND UNDERINSURED IN sheboygan COUNTY. st. nicholas HOSPITAL HAS DEDICATED STAFF TO ASSIST with THE COMMUNITY BENEFIT EFFORT. THE HOSPITAL'S COMMUNITY EDUCATION AND OUTREACH DEPARTMENTS ARE STAFFED BY NURSES, SCREENERS, AND EDUCATORS, WHO ARE TRAINED AND DEDICATED TO BRINGING HEALTH EDUCATION AND SERVICES TO THE COMMUNITY, PARTICULARLY FOR THE POOR AND ETHNIC MINORITIES. AN INTERPRETER SERVICE IS AVAILABLE TO ASSIST WITH LANGUAGE BARRIERS FOR ANY POPULATION. C. DESCRIBE THE HOSPITAL'S FINANCIAL ASSISTANCE POLICIES OR PROGRAMS (E.G. CHARITY CARE, DISCOUNTING) FOR LOW-INCOME PERSONS AND HOW those policies and programs ARE COMMUNICATED TO THE PUBLIC. AS A CATHOLIC ORGANIZATION, ST. NICHOLAS HOSPITAL IS RESPECTFUL OF THE DIGNITY OF EVERY PERSON, AND PROVIDES SERVICES IN A COURTEOUS MANNER REGARDLESS OF FINANCIAL STATUS. WE OFFER FINANCIAL ASSISTANCE TO THOSE PATIENTS IN NEED. however, GUIDELINES HAVE BEEN ESTABLISHED TO ENSURE THAT THE HOSPITAL'S LIMITED RESOURCES ARE USED TO TREAT PATIENTS WHO ARE TRULY UNABLE TO PAY AND ARE NOT CONSUMED BY THOSE UNWILLING TO PAY OR WHO HAVE ALTERNATE PAY SOURCES. PATIENT ACCOUNT SPECIALISTS HELP PEOPLE EXPLORE OPTIONS FOR FINANCIAL ASSISTANCE AND THEN, if necessary, OFFER st. nicholas hospital's CHARITY CARE PROGRAM. UPON APPLICATION, AND IF THE GUIDELINES ARE MET, THE HOSPITAL WILL PROVIDE Charity care OF 25% - 100%, BASED ON THE MINIMUM ANNUAL INCOME GUIDELINES ESTABLISHED BY THE U.S. DEPARTMENT OF HEALTH AND SOCIAL SERVICES. DISCOUNTS ARE ALSO AVAILABLE FOR PATIENTS WHO MAY BE UN- OR UNDERINSURED, BUT WHO FALL OUTSIDE THE CHARITY CARE PROGRAM GUIDELINES. FINANCIAL ASSISTANCE INFORMATION IS AVAILABLE AT ADMITTING/REGISTRATION, THE CASHIER OFFICE, AND EMERGENCY DEPARTMENT.
STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS CONTINUED	FORM 990 PART III, LINE 4A	2. ORGANIZATIONAL DESCRIPTION FOR TAX EXEMPTION INDICATE WHETHER THE HOSPITAL: OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY; ST. NICHOLAS HOSPITAL OPERATES A LEVEL III TRAUMA CENTER/EMERGENCY DEPARTMENT THAT IS OPEN 24/7 AND STAFFED BY board-CERTIFIED EMERGENCY MEDICINE PHYSICIAN SPECIALISTS. STAFF MEMBERS ARE CERTIFIED IN ADVANCED CARDIAC LIFE SUPPORT, PEDIATRIC ADVANCED LIFE SUPPORT, AND TRAUMA. LIKE ALL HOSPITAL SERVICES, EMERGENCY CARE IS PROVIDED REGARDLESS OF RACE, CREED, OR ABILITY TO PAY, AND FINANCIAL ASSISTANCE IS AVAILABLE AFTER CARE IS PROVIDED FOR THOSE IN NEED. HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA; st. nicholas hospital's MEDICAL STAFF IS OPEN TO ALL AREA PHYSICIANS who ARE PROPERLY CREDENTIALED. HAS A GOVERNING BODY IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE A MAJORITY; ST. NICHOLAS HOSPITAL'S BOARD OF DIRECTORS IS COMPRISED OF HOSPITAL SISTERS HEALTH SYSTEM EXECUTIVES AS WELL AS REPRESENTATIVES FROM the surrounding GEOGRAPHIC AREA. st. nicholas hospital's ADVISORY COUNCIL IS COMPRISED OF 19 MEN AND WOMEN REPRESENTING A BROAD RANGE OF AREA BUSINESS AND PHYSICIAN INTERESTS AS WELL AS LOCAL FAITH COMMUNITIES AND SOCIAL SERVICE AGENCIES. ENGAGES IN MEDICAL OR SCIENTIFIC RESEARCH PROGRAMS; THE HOSPITAL HAS CONDUCTED SOME LIMITED MEDICAL/SCIENTIFIC RESEARCH PROGRAMS, I.E. DRUG TRIALS, ONLY UNDER CAREFUL MEDICAL STAFF/ INSTITUTIONAL REVIEW BOARD SUPERVISION. ENGAGES IN THE TRAINING AND EDUCATION OF HEALTH CARE PROFESSIONALS; ST. NICHOLAS HOSPITAL PROVIDES EDUCATIONAL TRAINING AND SUPERVISED HANDS-ON EXPERIENCE FOR INTERNS AND EXTERNS FROM AREA COLLEGES AND TECHNICAL COLLEGEs. PARTICIPATES IN MEDICAID, MEDICARE, CHAMPUS, TRICARE, AND/OR OTHER GOVERNMENT-SPONSORED HEALTH CARE PROGRAMS; ST. NICHOLAS HOSPITAL PARTICIPATES IN MEDICAID, MEDICARE, CHAMPUS, tricare, AND OTHER GOVERNMENT-SPONSORED HEALTHCARE PROGRAMS. 3. DESCRIPTION OF COMMUNITY BENEFIT PROGRAMS A. DESCRIBE AND HIGHLIGHT ONE OR MORE PROGRAMS THAT HAVE CLEARLY MET AN IDENTIFIED COMMUNITY HEALTH NEED. FREE MONTHLY SCREENINGS AND HEALTH EDUCATION FOR THE HMONG MUTUAL ASSISTANCE ASSOCIATION AND THE HISPANIC CONGREGATION AT ST. CLEMENT PARISH, INCLUDING CULTURALLY APPROPRIATE NUTRITION EDUCATION; PROVIDING TWO HOUSES, INCLUDING UTILITIES, FREE OF CHARGE TO THE SHEBOYGAN SAFE HARBOR AGENCY FOR USE AS DOMESTIC ABUSE SHELTERS; PROVIDING ATHLETIC TRAINERS TO THE SHEBOYGAN AREA SCHOOL DISTRICT FOR LOCAL HIGH SCHOOL SPORTING EVENTS; PROVIDING free of charge SUPPORT GROUPS FOR HEART, RENAL, AND STROKE PATIENTS, AS WELL AS GRIEF support groups FOR ADULTS AND CHILDREN; FREE MONTHLY BLOOD PRESSURE SCREENINGS AT DOZENS OF LOCATIONS THROUGHOUT THE COUNTY; FREE USE OF HOSPITAL CONFERENCE AND MEETING ROOMS FOR AREA NOT-FOR-PROFIT ORGANIZATIONS; PROVIDING THREE HOMES WITH FINANCIAL SUPPORT AND IN-KIND SERVICES FOR the SHEBOYGAN COUNTY INTERFAITH ORGANIZATION ("SCIO") AND BRIDGEWAY AND BEYOND. this program PROVIDES TEMPORARY HOUSING FOR HOMELESS WOMEN AND CHILDREN, AND FAMILIES TRANSITIONING OUT OF DOMESTIC ABUSE SITUATIONS; CHILD CAR SEAT SAFETY CHECKS BY CERTIFIED TECHNICIANS OPEN TO THE PUBLIC FREE OF CHARGE; FREE PRENATAL CARE PROGRAM FOR THE POOR; FREE BIKE HELMET FITTINGS AND HELMETS are available for purchase AT COST. OPEN TO THE PUBLIC BREAST CANCER SCREENINGS AT COST FOR THE UNDERSERVED, INCLUDING SPECIAL SERVICES AND TRANSLATION FOR WOMEN OF THE LOCAL HISPANIC COMMUNITY; FREE ADVANCE DIRECTIVE EDUCATION IN LOCAL CHURCHES AND OTHER VENUES TO ASSIST THE PUBLIC WITH END-OF-LIFE PLANNING; PARTNER WITH THE PUBLIC HEALTH DEPARTMENT TO OFFER FREE CHILDBIRTH EDUCATION IN SPANISH; PROVIDING FINANCIAL SUPPORT AND IN-KIND SERVICES FOR SCIO, FAMILY RESOURCE CENTER, SAFE HARBOR DOMESTIC ABUSE SHELTER, BIG BROTHERS/BIG SISTERS, AND AREA CHURCHES AND SCHOOLS; PROVIDE SAFE SHARPS DISPOSAL FREE OF CHARGE TO THE PUBLIC; ANNUAL ASSESSMENT BY THE STATE OF WISCONSIN TO FUND WISCONSINCARE THAT SERVES THE UNINSURED; FOOD DRIVES FOR AREA FOOD PANTRIES; SCHOOL SUPPLY AND CLOTHING DRIVES FOR AREA SCHOOLS; SENDING THE HEALTHEXPRESS vehicle INTO THE COMMUNITY THROUGHOUT THE YEAR TO PROVIDE FREE SCREENINGS AND HEALTH EDUCATION; 4. LINKS TO ADDITIONAL COMMUNITY BENEFIT INFORMATION A. PLEASE VISIT st. nicholas hospital's WEBSITE (WWW.STNICHOLASHOSPITAL.ORG) FOR ADDITIONAL INFORMATION ABOUT OUR HOSPITAL PROVIDED SERVICES AND OUR 2011 COMMUNITY BENEFIT REPORT: SECTION 2 - QUANTIFIABLE COMMUNITY BENEFIT THIS SECTION INCLUDES A LIST OF THE TYPES OF PROGRAMS AND SERVICES THAT COULD BE INCLUDED AS COMMUNITY BENEFIT ACTIVITIES. SEE WWW.CHAUSA.ORG/COMMUNITYBENEFIT/COUNTING FOR MORE DETAILS ABOUT THESE PROGRAMS AND SERVICES. THE FINANCIAL INFORMATION IN THIS REPORT WAS PREPARED IN ACCORDANCE WITH THE CATHOLIC HEALTH ASSOCIATION'S ("CHA") COMMUNITY BENEFIT REPORTING GUIDELINES. st. nicholas hospital's REPORT FOLLOWS THESE ("CHA") RECOMMENDATIONS: - REPORT CHARITY CARE AT COST, NOT CHARGES. - DOes NOT INCLUDE BAD DEBT, CONTRACTUAL ALLOWANCES, AND QUICK PAY DISCOUNTS AS PART OF CHARITY CARE EXPENSE. - DO NOT COUNT MEDICARE SHORTFALL AS A COMMUNITY BENEFIT. - REPORT THE NET EXPENSE FOR COMMUNITY BENEFIT SERVICES, I.E., THE TOTAL COMMUNITY BENEFIT EXPENSE MINUS ANY ASSOCIATED REVENUE FROM PATIENTS, PAYERS, AND OTHER EXTERNAL SOURCES. THE CHA REPORTING GUIDELINES REFLECT A CONSERVATIVE APPROACH TO REPORTING QUANTIFIABLE COMMUNITY BENEFIT. THE GOAL OF THE REPORTING GUIDELINES IS TO PRODUCE COMMUNITY BENEFIT FINANCIAL REPORTS THAT REFLECT TRUE COSTS AND THAT DESCRIBE COMMUNITY BENEFIT ACTIVITIES THAT INCREASE ACCESS TO HEALTH CARE AND IMPROVE COMMUNITY HEALTH. FOR FISCAL YEAR ENDED JUNE 30, 2012, 1) CHARITY CARE - AT COST DO NOT INCLUDE BAD DEBT. $ 1,346,287 2) GOVERNMENT SPONSORED HEALTH CARE - NET EXPENSE $ 4,996,879 UNPAID COST OF PUBLIC INDIGENT CARE PROGRAMS (INCLUDES MEDICAID, SCHIP, OTHER SAFETY NET PROGRAMS; DOES NOT INCLUDE MEDICARE SHORTFALL) 3) COMMUNITY BENEFIT PROGRAMS - NET EXPENSE $ 443,522 SPECIFIC EXPENSES MAY BE ITEMIZED AS APPROPRIATE. TOTAL QUANTIFIABLE COMMUNITY BENEFIT $ 6,786,688 OTHER EXAMPLES OF COMMUNITY BENEFIT PROGRAM NET EXPENSES OTHER PROGRAM SERVICES FORM 990, PART IV, LINE 4D ST. NICHOLAS HOSPITAL PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT MEDICAL SERVICES TO THE COMMUNITY. BESIDES THE THREE LARGEST PROGRAM SERVICES IDENTIFIED IN PART III, ST NICHOLAS HOSPITAL PROVIDES ADDITIONAL SERVICES INCLUDING WOMENS' AND INFANT SERVICES, WOUND CARE, RADIATION THERAPY, ORTHOPEDIC SERVICES, RENAL DIALYSIS, SLEEP CENTER SERVICES, AND A VARIETY OF ADDITIONAL MEDICAL SERVICES. st. nicholas hospital PROVIDEs AN ARRAY OF COMMUNITY HEALTH SERVICES INCLUDING, BUT NOT EXCLUSIVE TO THE FOLLOWING, DIABETIC SCREENINGS, FLU SHOTS, foot clinics, AND A VARIETY OF COMMUNITY EDUCATION CLASSES. IN ADDITION, ST. NICHOLAS HOSPITAL PARTNERS WITH SEVERAL PHYSICIAN GROUPS AND OTHER JOINT VENTURES THAT PROVIDE NEEDED MEDICAL SERVICES TO THE COMMUNITY.
Tax Exempt Bonds	Form 990 Part IV, Question 4	St. Nicholas Hospital HOLDS A LIABILITY ON ITS BOOKS FOR TAX-EXEMPT BONDS, WHICH IS AN ALLOCATION FROM ITS SOLE CORPORATE MEMBER, HOSPITAL SISTERS SERVICES, INC. ("HSSI"). AS A RESULT, THIS QUESTION WAS ANSWERED NO, AND SCHEDULE K WILL BE COMPLETED ON THE HSSI FORM 990.
RIGHTS OF MEMBERS TO ELECT GOVERNING BODY	FORM 990 PART VI, LINES 6 & 7A	THE SENIOR GOVERNING BODY OF ST. NICHOLAS HOSPITAL (THE "CORPORATION") IS THE MEMBER OF THE CORPORATION, WHICH IS HOSPITAL SISTERS SERVICES, INC. ("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. PURSUANT TO SECTION 2.3 OF THE CORPORATION'S BYLAWS, HSSI HAS THE RIGHT TO APPOINT AND REMOVE THE CORPORATION'S BOARD OF DIRECTORS, CHAIRPERSON OF THE BOARD, AND PRESIDENT.
MEMBER RESERVED POWERS	FORM 990 PART VI, LINE 7B	Responsibility for the policy and operations of St. Nicholas Hospital (the "Corporation") is vested in its Board of Directors, except with respect to specific powers reserved in the Corporation's Bylaws to the Corporation's Member, Hospital Sisters Services, Inc. ("HSSI"), an Illinois not for profit corporation exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code. The member of HSSI is Hospital Sisters Health System ("HSHS"), an Illinois not for profit corporation exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code. The members of HSHS are the individual sisters who, from time to time, are the duly elected Provincial Superior and Provincial Councilors, respectively of the American Province of the Hospital Sisters of St. Francis ("American Province"). The American Province is the United States organization of the Congregation of the Hospital Sisters of the Third Order Regular of St. Francis, a religious institute of the Roman Catholic Church. The governance and operations of the Corporation are subject to HSSI's right to exercise these reserved powers with respect to the Corporation and organizations of which the Corporation is either, directly or indirectly, a controlling member or a controlling shareholder ("Affiliates"). HSSI's right to exercise certain of these reserved powers is, in turn, subject to the approval of HSHS and HSHS' members. The reserved powers include all rights granted to HSSI by law and the right to: (a) Adopt, approve amendments to, or amend any statement of philosophy, mission, mission integration or values, or any name, logo, or mark of the Corporation or of any Affiliate; (b) Adopt, approve amendments to, or amend the Articles of Incorporation of the Corporation or of any Affiliate; (c) Adopt, approve amendments to, or amend the Bylaws of the Corporation or of any Affiliate; (d) Appoint and remove the Board of Directors, any one or more of the Directors of the Corporation or of any Affiliate, and the Chairperson and President of the Corporation or of any Affiliate; (e) Approve the recommendation of the Board of Directors to appoint or remove the Board of Directors, any one or more Directors of the Corporation or of any Affiliate, or the Chairperson and President of the Corporation or of any Affiliate. (f) With respect to the Corporation or any Affiliate, approve the purchase, sale, alienation, exchange, lease, or encumbrance of any real property of the Corporation or of any Affiliate, which property has a value in excess of limits set from time to time by HSSI; (g) Approve the operating and capital budgets of the Corporation or of any Affiliate, and any deviations by the Corporation or of any Affiliate from such budgets in an amount or percentage specified by HSSI from time to time; (h) Approve the strategic plan and goals of the Corporation or of any Affiliate; (i) Approve the sale of substantially all of the assets of the Corporation or of any Affiliate; (j) Approve the merger or dissolution of the Corporation or of any Affiliate; (k) Adopt or amend the plan for ministry education and governance for the Corporation and its Affiliates; (l) Approve the Corporation's Mission Accountability Reports and those of any Affiliate; (m) Approve the financial policies and procedures of the Corporation or of any Affiliate, and approve any deviations from such policies and procedures by the Corporation or any Affiliate; and (n) Adopt policies to implement the Reserved Powers of HSSI.
FORM 990 REVIEW PROCESS	FORM 990 PART VI, LINE 11B	The hospital employs KPMG to assist in the overall review and electronic submission of its Form 990. KPMG provides guidance in identifying critical errors in the return submission, and feedback on quantitative and qualitative responses. Additionally, the hospital CFO performs a thorough review of the return and reviews it with the hospital CEO and/or senior leaders before presenting it in its entirety to the hospital Board for questioning and review prior to the return's signing and submission to the IRS.
CONFLICT OF INTEREST POLICY	FORM 990 PART VI, LINE 12C	The organization is subject to the corporate compliance program and conflict of interest policy ("policy") of Hospital Sisters Health System, an Illinois not for profit corporation exempt from federal taxation under section 501(c)(3) of the internal revenue code. the current CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY was effective JANUARY 2009 TO MANAGE CONFLICTS OF INTEREST USING A SYSTEM-WIDE PROTOCOL FOR DISCLOSURE STATEMENTS. IN ACCORDANCE WITH the organizaton's CONFLICT OF INTEREST POLICY, ALL COVERED PERSONS HAVE A DUTY TO COMPLY WITH THE CONFLICT OF INTEREST POLICY FOR ANY CONTRACT, TRANSACTION, RELATIONSHIP, OR ACTIVITY CONTEMPLATED, ENTERED INTO, OR CONDUCTED AT HSHS OR ITS AFFILIATES. THE POLICY DEFINES COVERED PERSONS AS BOARD MEMBERS, BOARD COMMITTEE MEMBERS, OFFICERS, BOARD DESIGNEES, SENIOR MANAGEMENT, MEMBERS OF ANY COMMITTEE THAT OVERSEES THE APPROVAL OF PHARMACEUTICALS AND MEDICAL DEVICES, and ANY OTHER INDIVIDUAL WHO HOLDS A POSITION OF TRUST. ON AN ANNUAL BASIS, HSHS DISCLOSES A COPY OF THE CONFLICT OF INTEREST POLICY (AND ALL CORRESPONDING PROCEDURES, GUIDELINES, FORMS, AND TOOLS) TO ALL COVERED PERSONS, AND ADVISES ALL COVERED PERSONS IN WRITING OF ANY SUBSTANTIVE CHANGES TO THIS POLICY AND SUCH RELATED MATERIALS. COVERED PERSONS ARE REQUIRED TO REVIEW AND COMPLETE THE CORRESPONDING CONFLICT OF INTEREST STATEMENT. THE SYSTEM OFFICE VICE PRESIDENT - SYSTEM RESPONSIBILITY, VICE PRESIDENT - RISK & COMPLIANCE, OR MEMBERS OF THE AUDIT AND INTEGRITY COMMITTEE ("COMMITTEE") ARE AVAILABLE TO ANSWER ANY QUESTIONS A COVERED PERSON MAY HAVE. IN ADDITION, IF AT ANY TIME AFTER SUBMITTING AN ANNUAL CONFLICT OF INTEREST STATEMENT, A COVERED PERSON BECOMES AWARE OF AN INTEREST THAT HE OR SHE WOULD HAVE HAD TO DISCLOSE AT THE ANNUAL INTERVAL, THE COVERED PERSON IS REQUIRED to PROMPTLY DISCLOSE such INTEREST TO THE COMMITTEE USING THE HSHS CONFLICT OF INTEREST DISCLOSURE STATEMENT. COMPLETED CONFLICT OF INTEREST STATEMENTS ARE SUBMITTED TO THE COMMITTEE, WHICH IS RESPONSIBLE FOR IDENTIFYING, ASSESSING, AND MANAGING CONFLICTS OF INTEREST, which ARISE IN THE COURSE OF CONDUCTING THE AFFAIRS OF HSHS AND ITS AFFILIATES. IF THE COMMITTEE DETERMINES THAT A CONFLICT OF INTEREST EXISTS, THE CONFLICT OF INTEREST POLICY REQUIRES HSHS NOT TO ENGAGE IN, OR ENTER INTO, A PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY UNLESS THE COMMITTEE OR, WHERE NECESSARY, THE BOARD OF DIRECTORS (ACTING THROUGH ITS DISINTERESTED MEMBERS), HAS INVESTIGATED ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY IN THE ABSENCE OF ALTERNATIVES THAT ARE IN THE BEST INTERESTS OF HSHS, the committee HAS DETERMINED: 1. THAT, REGARDLESS OF WHETHER THE COVERED PERSON PARTICIPATES IN THE IMPLEMENTATION OF THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY; 2. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS IN THE BEST INTERESTS OF HSHS; 3. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS FAIR AND REASONABLE FROM THE PERSPECTIVE OF HSHS; AND 4. HSHS CANNOT OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. IN DETERMINING WHETHER A CONTRACT, TRANSACTION, OR ARRANGEMENT IS FAIR AND REASONABLE TO HSHS, THE COMMITTEE SHALL CONSIDER, WHERE APPLICABLE: 1. APPRAISALS OR OTHER INDEPENDENT VALUATIONS OF THE FAIR MARKET VALUE OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT; 2. INFORMATION REGARDING COMPARABLE CONTRACTS, TRANSACTIONS, OR ARRANGEMENTS BETWEEN UNRELATED PARTIES; 3. OFFERS FROM COMPARABLE COMPETING ENTITIES; AND/OR 4. STUDIES OF COMPARABLE COMPENSATION ARRANGEMENTS. IN ANY CASE IN WHICH THE COMMITTEE FINDS, AFTER TAKING THE STEPS DESCRIBED ABOVE, THAT HSHS SHOULD PARTICIPATE IN A PROPOSED TRANSACTION OR ARRANGEMENT DESPITE THE EXISTENCE OF A CONFLICT OF INTEREST, THE COMMITTEE SHALL DEVELOP, IMPLEMENT, MONITOR, AND ENFORCE COMPLIANCE WITH, A CONFLICT MANAGEMENT PLAN FOR MANAGING THE CONFLICT OF INTEREST AS IT CONSIDERS NECESSARY FOR SUCH FINDINGS TO REMAIN VALID THROUGHOUT THE LIFE OF THE CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY. ALL CONFLICT MANAGEMENT PLANS SHALL: 1. STATE THAT THE COMMITTEE WILL OVERSEE, MONITOR, AND ENFORCE COMPLIANCE WITH THE PLAN THROUGHOUT THE COURSE OF THE STUDY, AND SPECIFY MEANS FOR DOING SO, INCLUDING, WITHOUT LIMITATION, THAT THE APPROPRIATE INDIVIDUALS MUST PROVIDE THE COMMITTEE WITH WRITTEN REPORTS PERTAINING TO COMPLIANCE WITH THE CONFLICT MANAGEMENT PLAN, THAT THE COMMITTEE SHALL HAVE THE RIGHT TO AUDIT THE STUDY FOR SUCH COMPLIANCE, AND THE RIGHT TO IMPOSE SANCTIONS FOR NON-COMPLIANCE; 2. STATE THAT THE PLAN MUST BE SHARED WITH COVERED PERSON WHOSE INTERESTS IT WAS DEVELOPED TO MANAGE; 3. STATE THAT THE PLAN MUST BE SHARED WITH, AND PERIODIC REPORTS ON COMPLIANCE WITH THE PLAN MUST BE PROVIDED TO, THE BOARD, SENIOR MANAGEMENT, AND/OR GOVERNMENT AGENCIES; AND 4. PROVIDE FOR SUCH OTHER MANAGEMENT STEPS AND MECHANISMS THE COMMITTEE CONSIDERS NECESSARY AND APPROPRIATE. IN ADDITION TO THE COMMITTEE, THE SYSTEM OFFICE VICE PRESIDENTS OF SYSTEM RESPONSIBILITY AND RISK & COMPLIANCE MAY RETAIN SUCH INDEPENDENT ADVISORS OR EXPERTS AS DEEMED NECESSARY TO ASSIST IN MAKING ITS DETERMINATIONS AND DECISIONS. IF THE COMMITTEE DETERMINES THAT THE CONTEMPLATED TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY CANNOT PROCEED DUE TO A CONFLICT OF INTEREST, THE COMMITTEE SHALL INFORM THE APPLICABLE COVERED PERSON OR DECISION-MAKING BODY OF SUCH DETERMINATION WITHIN ONE WEEK OF THE COMMITTEE MEETING AT WHICH THE CONTEMPLATED TRANSACTION WAS DISCUSSED. THE COMMITTEE SHALL DOCUMENT ITS REJECTION OF THE CONTEMPLATED TRANSACTION IN THE COMMITTEE'S MEETING MINUTES.
WHISTLEBLOWER POLICY	FORM 990 PART VI, LINE 13	Provisions within the Corporate Compliance Program and Conflict of Interest Policy provide protections for whistleblower type activities.
COMPENSATION PROCESS	FORM 990 PART VI, LINE 15	The Compensation Committee ("Committee") is comprised of independent members of the Board of Directors. The Committee develops a compensation philosophy for the System and all affiliates. The Committee selects and hires the independent compensation consultant to develop comparability data and advise the Committee during its deliberations regarding all elements of total compensation for all disqualified individuals. Integrated Healthcare Strategies ("IHS"), the consultants utilized by the Committee, use data from multiple tax-exempt peer group sources to determine salary ranges, incentive opportunity ranges, and benefits for the disqualified individuals. IHS then assists the Committee in preparing contemporaneous documentation of all actions. Each Committee meeting is conducted with the intent to create a rebuttable presumption of reasonableness for all elements of executive total compensation for the disqualified individuals. The Chairman makes this declaration and also inquires if there are any conflicts of interest by any attendees. Any conflicts are disclosed and the Committee then acts in a manner to avoid any conflicted individual participating in any manner where a conflict might exist. At the end of the meeting, the Committee prepares contemporaneous minutes that record all actions taken during the meeting. Joint Ventures FORM 990 PART VI, LINE 16B Hospital Sisters Health System adopted a Joint Venture Compliance Program policy effective on January 1, 2012 for all system hospitals, including St. Nicholas Hospital. The overall purpose of the policy is to provide practical guidelines for ethical business conduct, to achieve compliance, and to detect and prevent violations of applicable laws. The policy requires St. Nicholas Hospital, and all HSHS hospitals, to evaluate their participation in joint venture arrangements, including under applicable federal tax laws, and to safeguard St. Nicholas hospitals tax exempt status with respect to any joint venture arrangements.
DOCUMENTS AVAILABLE TO THE PUBLIC	FORM 990 PART VI, LINE 19	Board-approved financial statements are made available to the public upon request. The governing documents and conflict of interest policy are not made available to the general public at this time.
POOLED INVESTMENT ACCOUNT	FORM 990 PART X, LINE 11	St. Nicholas Hospital's cash reserves are invested in a pooled investment account. Participation in the pooled fund is limited to the 501(C)(3) Hospitals and related health services organizations sponsored by the Hospital Sisters Health System. The pooled account consists of cash, and equity and debt securities that are publicly traded. In accordance with the provisions of SFAS No. 124 "Accounting for certain investments held by Not-For-Profit Organizations," investments in equity securities with readily determinable values, and all investments in debt securities, are reported at fair value on the Balance Sheet. Income, realized and unrealized gains and losses are pooled and allocated to the participants. Individual components of assets and revenue are not identified to the participants.
OTHER CHANGES IN NET ASSETS	FORM 990, PART XI, LINE 5	unrealized losses from investments (1,454,036) change in fair value of interest rate swaps (1,104,687) unrealized losses on investments at foundation (570,455) increase in temporarily restricted net assets 332,687 increase in permanently restricted net assets 10,750 contributions reported on foundation (321,523) transfer to related organization (716,000) pension changes other than net periodic cost (5,107,819) ----------- (8,931,083) ===========
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:SR. MARYBETH CULNAN, OSF TITLE:BOARD MEMBER HOURS:59
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:ANN m. CARR TITLE:TREASURER HOURS:60
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:THERESE PANDL TITLE:DIVISIONAL CEO HOURS:45
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:GREG SIMIA TITLE:DIVISION CFO HOURS:45

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2011

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2011

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital
Sisters of the Third Order of St Francis

Employer identification number

39-0808480

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)

(a) Name, address, and EIN of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity
(1) KIARA CLINICAL INTEGRATION NETWORK LLC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 26-1417684	HEALTHCARE	IL	0	0	HSSI
(2) PHYSICIAN CLINICAL INTEGRATION NETWORK L 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1668647	HEALTHCARE	IL	0	0	KCIN
(3) SPRINGFIELD HEALTH PARTNERS LLC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1364419	HEALTHCARE	IL	0	0	HSHS MG

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) HOSPITAL SISTERS OF ST FRANCIS FDTN 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1186514	HEALTHCARE	IL	501(C)(3)	11A	NA		No
(2) HOSPITAL SISTERS HEALTH SYSTEM 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1058692	HEALTHCARE	IL	501(C)(3)	11A	NA		No
(3) HOSPITAL SISTERS SERVICES INC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1163402	HEALTHCARE	IL	501(C)(3)	11A	NA		No
(4) HSHS HEALTH CARE PLAN TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1137724	HEALTHCARE	IL	501(C)(9)	N/A	NA		No
(5) HOSPITAL SISTERS HEALTHCARE - WEST INC 2661 COUNTY HIGHWAY I CHIPPEWA FALLS,WI54729 51-0157933	HEALTHCARE	WI	501(C)(3)	11A	NA		No
(6) SACRED HEART HOSPITAL 900 WEST CLAIREMONT AVENUE EAU CLAIRE,WI54701 39-0807060	HEALTHCARE	WI	501(C)(3)	3	NA		No
(7) ST NICHOLAS HOSPITAL 3100 SUPERIOR AVENUE SHEBOYGAN,WI53081 39-0808480	HEALTHCARE	WI	501(C)(3)	3	NA		No
(8) ST ELIZABETH'S HOSPITAL 211 SOUTH THIRD STREET BELLEVILLE,IL62220 37-0663567	HEALTHCARE	IL	501(C)(3)	3	NA		No
(9) ST JOHN'S HOSPITAL 800 EAST CARPENTER STREET SPRINGFIELD,IL62769 37-0661238	HEALTHCARE	IL	501(C)(3)	3	NA		No
(10) ST FRANCIS HOSPITAL 1215 FRANCISCAN DRIVE LITCHFIELD,IL62056 37-0661236	HEALTHCARE	IL	501(C)(3)	3	NA		No
(11) ST JOSEPH'S HOSPITAL 9515 HOLY CROSS LANE BREESE,IL62230 37-1208459	HEALTHCARE	IL	501(C)(3)	3	NA		No
(12) ST JOSEPH'S HOSPITAL 1515 MAIN STREET HIGHLAND,IL62249 37-0663568	HEALTHCARE	IL	501(C)(3)	3	NA		No
(13) ST JOSEPH'S HOSPITAL 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS,WI54729 39-0810545	HEALTHCARE	WI	501(C)(3)	3	NA		No
(14) ST MARY'S HOSPITAL 1800 E LAKE SHORE DRIVE DECATUR,IL62521 36-2169181	HEALTHCARE	IL	501(C)(3)	3	NA		No
(15) ST MARY'S HOSPITAL 111 SPRING STREET STREATOR,IL61364 36-2169181	HEALTHCARE	IL	501(C)(3)	3	NA		No
(16) ST VINCENT HOSPITAL 835 S VAN BUREN GREEN BAY,WI54301 39-0817529	HEALTHCARE	WI	501(C)(3)	3	NA		No
(17) ST MARY'S HOSPITAL MEDICAL CENTER 1726 SHAWANO AVENUE GREEN BAY,WI54303 39-0818682	HEALTHCARE	WI	501(C)(3)	3	NA		No
(18) HSHS MEDICAL GROUP INC 3215 Executive Park Drive SPRINGFIELD,IL62703 26-3956318	HEALTHCARE	IL	501(C)(3)	11A	NA		No
(19) HSHS WISCONSIN MEDICAL GROUP INC 3215 Executive Park Drive Springfield,IL62703 26-4515959	HEALTHCARE	WI	501(C)(3)	11A	NA		No
(20) HSHS SELF INSURANCE TRUST FUND 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1120626	INSURANCE	IL	501(C)(3)	11A	NA		No
(21) ORANGE CROSS AMBULANCE INC 919 ASHLAND AVE SHEBOYGAN,WI53081 39-1860942	HEALTHCARE	WI	501(C)(3)	9	ST NICHOLAS		No
(22) WISCONSIN UPPER PEN ONC MNGMT SERVICES 835 S VAN BUREN GREEN BAY,WI54301 39-1677100	HEALTHCARE	WI	501(C)(3)	3	ST VINCENT		No
(23) UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE,WI54115 39-1750729	HEALTHCARE	WI	501(C)(3)	9	HSSI		No

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2011

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) MEMORIAL AND ST ELIZABETH'S HEALTHCARE 4000 NORTH ILLINOIS STREET SWANSEA,IL62226 37-1312961	HEALTHCARE	IL	ST ELIZABETH'S	RELATED	0	0		No	0		No	0 %
(2) PRAIRIE HEART INSUTUTE - CARBONDALE LLC 800 EAST CARPENTER STREET SPRINGFIELD,IL62769 37-1321197	HEALTHCARE	IL	ST JOHN'S	RELATED	0	0		No	0		No	0 %
(3) NORTHEAST WISCONSIN RADIATION THERAPY SE 1821 S WEBSTER AVENUE STE 300 GREEN BAY,WI543079047 26-3749065	HEALTHCARE	WI	HSSI	RELATED	0	0		No	0		No	0 %
(4) PAIN CENTER OF WISCONSIN 4131 W LOOMIS ROAD STE 300 GREENFIELD,WI53221 26-3155343	HEALTHCARE	WI	ST VINCENT	RELATED	0	0		No	0		No	0 %
(5) SURGERY CENTER OF SHEBOYGAN LLC 3141 SAEMANN AVE SHEBOYGAN,WI53081 26-0822209	HEALTHCARE	WI	ST NICHOLAS	RELATED	0	0		No	0		No	0 %
(6) PREVEA VENTURES LLC 2710 EXECUTIVE DR GREEN BAY,WI54304 20-3775127	HEALTHCARE	WI	HSSI	RELATED	0	0		No	0		No	0 %
(7) CARPENTER STREET HOTEL LLC 525 NORTH SIXTH STREET SPRINGFIELD,IL62702 36-4128127	HOTEL	IL	LASANTE INC	RELATED	0	0		No	0		No	0 %
(8) SPRINGFIELD URGENT CARE REAL ESTATE LLC PO BOX 19456 SPRINGFIELD,IL627949456 03-0413258	RENT. REAL ES	IL	LASANTE INC	RELATED	0	0		No	0		No	0 %

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)
(1) KIARA INC 4936 LAVERNA RD SPRINGFIELD,IL62707 37-1163401	HEALTHCARE	IL	HSHS	C CORP
(2) LASANTE WISCONSIN INC 4936 LAVERNA RD SPRINGFIELD,IL62707 39-1572196	HEALTHCARE	IL	KIARA INC	C CORP
(3) LASANTE INC 4936 LAVERNA RD SPRINGFIELD,IL62707 37-1163400	HEALTHCARE	IL	KIARA INC	C CORP
(4) PRAIRIE CARDIOVASCULAR 619 EAST MASON STE 4P57 SPRINGFIELD,IL62701 37-1071858	HEALTHCARE	IL	KIARA INC	C CORP
(5) PREVEA HEALTH SERVICES 2710 EXECUTIVE DR GREEN BAY,WI54304 39-1839351	HEALTHCARE	WI	HSSI	C CORP
(6) PREVEA CLINIC INC 2710 EXECUTIVE DR GREEN BAY,WI54304 39-1839349	HEALTHCARE	WI	HSSI	C CORP
(7) PREVEA HEALTH NETWORK 2710 EXECUTIVE DR GREEN BAY,WI54304 39-2000537	HEALTHCARE	WI	HSSI	C CORP
(8) RENAISSANCE QUALITY INSURANCE PO BOX 1159 grand caymans KY1-1102 CJ 98-0669953	INSURANCE	CJ	hssi	c corp

Schedule R (Form 990) 2011

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III or IV.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

Yes

n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved	(d) Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)

Schedule R (Form 990) 2011

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2011

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation
TRANSACTIONS WITH RELATED ENTITIES	FORM 990 SCHEDULE R, PART V LINE 2	The Transactions reported in Question 1 are between related 501(c)(3) public charities and are not reported in this section.

Additional Data

Software ID:
Software Version:

1	Briefly describe the organization’s mission or most significant activities: TO CARRY FORWARD THE HEALING MINISTRY OF THE HOSPITAL SISTERS OF ST. FRANCIS AS PART OF THE HEALTH MINISTRY OF THE ROMAN CATHOLIC CHURCH.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a).....	3	10
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	9
5	Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...	5	552
6	Total number of volunteers (estimate if necessary) ....	6	145
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	129,179
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b	-48,573

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	195,887	321,523
9	Program service revenue (Part VIII, line 2g) .........	65,663,911	60,601,783
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	2,611,371	2,400,003
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	1,100,314	1,254,926
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	69,571,483	64,578,235
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	27,745,134	26,181,320
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	46,455,254	39,744,596
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	74,200,388	65,925,916
19	Revenue less expenses. Subtract line 18 from line 12.......	-4,628,905	-1,347,681
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	107,469,074	108,806,524
21	Total liabilities (Part X, line 26).............	32,008,096	43,413,417
22	Net assets or fund balances. Subtract line 21 from line 20.....	75,460,978	65,393,107

Sign Here

	Signature of officer	Date

	Type or print name and title.


4a	(Code: ) (Expenses $ 5,146,154 including grants of $ ) (Revenue $ 8,239,933 )
	surgical services - See Schedule O - Community Benefit Report

4b	(Code: ) (Expenses $ 3,260,541 including grants of $ ) (Revenue $ 11,107,338 )
	diagnostic imaging - See Schedule O - Community Benefit Report

4c	(Code: ) (Expenses $ 1,539,306 including grants of $ ) (Revenue $ 6,694,524 )
	emergency services - See Schedule O - Community Benefit Report

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 38,939,885 including grants of $ ) (Revenue $ 34,559,988 )
4e	Total program service expenses$ 48,885,886

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	562,652	1,235,177	557,666

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) DOUG PETRY DIAGNOSTIC IMAGING TECH	40.0	X	103,812	0	15,550

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d		321,523
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			321,523
			Business Code
2a	NET PATIENT SERVICE REVENUE		900,099	59,726,004	59,726,004
b	LABORATORY OUTREACH REVENUE		621,500	129,179		129,179
c	OTHER OPERATING REVENUES		900,099	746,600	746,600
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			60,601,783
3	Investment income (including dividends, interest
	and other similar amounts).....			804,138			804,138
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross rents	2,048,442
b	Less: rental expenses	793,516
c	Rental income or (loss)	1,254,926
d	Net rental income or (loss).......			1,254,926			1,254,926
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	1,616,472	20,000
b	Less: cost or other basis and sales expenses		40,607
c	Gain or (loss)	1,616,472	-20,607
d	Net gain or (loss)..........			1,595,865			1,595,865
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0		0
Miscellaneous Revenue			Business Code
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			0
12	Total revenue. See Instructions....			64,578,235	60,472,604	129,179	3,654,929


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			2,674,232	1	5,662,992
2	Savings and temporary cash investments .......			0	2	0
3	Pledges and grants receivable, net .........			0	3	0
4	Accounts receivable, net .........			10,857,930	4	9,269,068
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........			0	5	0
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........			0	6	0
7	Notes and loans receivable, net .............			0	7	0
8	Inventories for sale or use ..............			1,629,830	8	1,560,659
9	Prepaid expenses and deferred charges ............			303,739	9	232,193
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	115,736,473
b	Less: accumulated depreciation. .....	10b	66,598,554	44,365,270	10c	49,137,919
11	Investments—publicly traded securities ..........			44,211,814	11	40,116,535
12	Investments—other securities. See Part IV, line 11 ......			0	12	0
13	Investments—program-related. See Part IV, line 11 ..			1,252,082	13	1,237,191
14	Intangible assets .........			0	14	0
15	Other assets. See Part IV, line 11 ...........			2,174,177	15	1,589,967
16	Total assets. Add lines 1 through 15 (must equal line 34)...			107,469,074	16	108,806,524
17	Accounts payable and accrued expenses .			5,332,843	17	6,108,031
18	Grants payable ..........			0	18	0
19	Deferred revenue ..........			0	19	266,636
20	Tax-exempt bond liabilities ..........			16,755,524	20	16,333,920
21	Escrow or custodial account liability. Complete Part IV of Schedule D..			0	21	0
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..			0	23	0
24	Unsecured notes and loans payable to unrelated third parties ....			0	24	0
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D.....			9,919,729	25	20,704,830
26	Total liabilities. Add lines 17 through 25.....			32,008,096	26	43,413,417
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			67,628,899	27	57,687,975
28	Temporarily restricted net assets .....			6,201,864	28	6,064,167
29	Permanently restricted net assets .....			1,630,215	29	1,640,965
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			75,460,978	33	65,393,107
34	Total liabilities and net assets/fund balances .....			107,469,074	34	108,806,524