Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2012
Open to Public Inspection
A For the 2012 calendar year, or tax year beginning 09-01-2012 , 2012, and ending 08-31-2013
BCheck if applicable:
CName of organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
103 ROSE HILL DRIVE
 
Room/suite
City or town, state or country, and ZIP + 4
SOUTH BOSTON, VA24592
D Employer identification number

54-6074529
E Telephone number

G Gross receipts $ 13,300,338
F Name and address of principal officer:
CHRIS A LUMSDEN
2204 WILBORN AVENUE
SOUTH BOSTON,VA24592
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.THEWOODVIEW.ORG
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet  
K Form of organization:
 
L Year of formation: 1967
M State of legal domicile: VA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: TO PROVIDE THE HIGHEST QUALITY OF CARE TO THE INDIVIDUALS REQUIRING LONG TERM CARE SERVICES.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 5
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 3
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ...... 5 223
6 Total number of volunteers (estimate if necessary) ............. 6 93
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 752,525 650,000
9 Program service revenue (Part VIII, line 2g) ......... 10,783,158 12,300,900
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 166,274 292,517
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 53,977 56,921
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 11,755,934 13,300,338
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 315,000
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) 7,273,574 7,978,860
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 4,156,409 4,269,836
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 11,429,983 12,563,696
19 Revenue less expenses. Subtract line 18 from line 12....... 325,951 736,642
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 9,694,172 13,453,665
21 Total liabilities (Part X, line 26)............. 2,586,112 2,526,384
22 Net assets or fund balances. Subtract line 21 from line 20..... 7,108,060 10,927,281
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ............
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2012)
Form 990 (2012)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III ...............
1
Briefly describe the organization’s mission: THE MISSION OF HALIFAX REGIONAL LONG TERM CARE, INC. IS TO PROVIDE THE HIGHEST QUALITY OF CARE TO THE INDIVIDUALS REQUIRING LONG TERM CARE SERVICES, RESULTING IN THE HIGHEST ACHIEVABLE QUALITY OF LIFE. FOR MORE INFORMATION, SEE SCHEDULE O.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ......................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ............................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 10,960,825 including grants of $ 315,000 ) (Revenue $ 12,300,900 )
THIS ORGANIZATION, DOING BUSINESS AS THE WOODVIEW AND SEASONS AT THE WOODVIEW, IS COMPOSED OF A 180-BED DUALLY CERTIFIED (MEDICAID AND MEDICARE) NURSING FACILITY, (THE WOODVIEW), PROVIDING PERSONAL SERVICES, HEALTH CARE SERVICES AND REHABILITATION SERVICES; AND AN 18-BED LICENSED ASSISTED LIVING NEIGHBORHOOD (SEASONS AT THE WOODVIEW), FOR INDIVIDUALS WITH ALZHEIMER'S DISEASE OR A RELATED DEMENTIA. FOR MORE INFORMATION, SEE SCHEDULE O.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet10,960,825
Form 990 (2012)
Form 990 (2012)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment........................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part IClick to see attachment..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If “Yes,” complete Schedule C, Part IIClick to see attachment........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C,
Part IIIClick to see attachment............................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part IClick to see attachment........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If “Yes,” complete Schedule D, Part IIClick to see attachment...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III Click to see attachment....................
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,” complete Schedule D, Part IVClick to see attachment..............
9
Yes
 
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part VClick to see attachment......
10
 
No
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10?
If “Yes,” complete Schedule D, Part VI.Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIClick to see attachment.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IXClick to see attachment............
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part XClick to see attachment.........................
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI and XII Click to see attachment.................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E....
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?.....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the United States? If “Yes,” complete Schedule F, Parts II and IV
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the United States? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I (see instructions)....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If “Yes,” complete Schedule H....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
 
 
Form 990 (2012)
Form 990 (2012)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II... Click to see attachment
21
Yes
 
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........ Click to see attachment
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, line 3, 4, or 5 about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I........
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I...................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highest compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II..........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV ..........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV.....................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If “Yes,” complete Schedule L, Part IV...
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M.............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Part II, III, or IV, and Part V, line 1........................ Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2012)
Form 990 (2012)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V ...............
Yes
No
1a
Enter the number reported in Box 3 of Form 1096 Enter -0- if not applicable ..
1a
37
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
223
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions)
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)?..........................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes,” to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions?...
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?............................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?............................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?............
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?..........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?.......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year. ....................
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2012)
Form 990 (2012)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI ...............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year .....................
1a
5
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent ...................
1b
3
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? ...........................
4
Yes
 
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
 
No
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done.......................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
 
No
If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization:
MediumBulletSTEWART R NELSON2204 WILBORN AVESOUTH BOSTONVA24592 (434) 517-3183
Form 990 (2012)
Form 990 (2012)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII ...............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(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
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) DAVID H WHITE JR........................................................................
CHAIRMAN
 1.00
.......................5.00 		X   X       0 0 0
(2) J AUBREY HOUGHTON........................................................................
TREASURER (THROUGH 6/30/13)
 1.00
.......................5.00 		X   X       0 0 0
(3) CAROL C THOMAS........................................................................
VICE CHAIRMAN
 1.00
.......................5.00 		X   X       0 0 0
(4) HABIB BASSIL MD........................................................................
SECRETARY (THROUGH 6/30/13)
 1.00
.......................5.00 		X   X       0 78,750 0
(5) JAMES PRIEST DDS........................................................................
BOARD MEMBER
 1.00
.......................5.00 		X           0 0 0
(6) CHRIS A LUMSDEN........................................................................
CEO(THRU 6/30)/PRES/SEC(EFF 7/1/13)
 2.00
.......................38.00 		X   X       12,870 380,785 21,110
(7) ROBERT A BROERMANN........................................................................
TREASURER (EFF 7/1/13)
 1.00
.......................54.00 		X   X       0 0 0
(8) STEWART R NELSON........................................................................
CHIEF FINANCIAL OFFICER
 2.00
.......................38.00 		    X       8,668 250,735 4,655
(9) THOMAS S KLUGE........................................................................
CHIEF OPERATING OFFICER
 2.00
.......................38.00 		      X     7,639 216,131 14,338
(10) CONNIE ZAMORA........................................................................
DIR OF LONG-TERM CARE SERVICES
 40.00
.......................   		        X   120,346 0 17,105














Form 990 (2012)
Form 990 (2012)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(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
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;


























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 149,523 926,401 57,208
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet1
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual ..............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
FUNCTIONAL PATHWAYS LLC614 MABRY HOOD ROAD STE 301KNOXVILLETN37932 CONTRACT LABOR 659,701
PHARM SAVE INC2545 JETPORT ROADKINSTONNC28504 CONSULTING 219,950
VIRGINIA HOSPITAL LAUNDRY1601 OLIVER HILL WAYRICHMONDVA232191233 LAUNDRY SERVICES 156,585
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet3
Form 990 (2012)
Form 990 (2012)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response to any question in this Part VIII ..............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d 650,000
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines
1a-1f:$ 		 
h Total. Add lines 1a-1f.......MediumBullet 650,000
Program Service Revenue Business Code
2a NET PATIENT SERVICE REVENUE 623000 12,255,024 12,255,024    
b BARBER & BEAUTY SHOP REVENUE 812900 45,876 45,876    
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 12,300,900
Other Revenue 3 Investment income (including dividends, interest, and other similar amounts).......MediumBullet 292,517     292,517
4 Income from investment of tax-exempt bond proceeds..MediumBullet        
5 Royalties...........MediumBullet        
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss)    
d Net rental income or (loss).......MediumBullet        
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses    
c Gain or (loss)    
d Net gain or (loss)..........MediumBullet        
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..MediumBullet      
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...MediumBullet        
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..MediumBullet        
Miscellaneous Revenue Business Code
11a CAFE & VENDING 722210 54,960     54,960
b MISCELLANEOUS 900099 1,961     1,961
c            
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 56,921
12 Total revenue. See Instructions......MediumBullet 13,300,338 12,300,900 0 349,438
Form 990 (2012)
Form 990 (2012)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response to any question in this Part IX ...............
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 21 315,000 315,000
2 Grants and other assistance to individuals in the United States. See Part IV, line 22    
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16    
4 Benefits paid to or for members    
5 Compensation of current officers, directors, trustees, and key employees .... 54,744   54,744  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....        
7 Other salaries and wages 5,694,958 5,028,904 666,054  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 346,946 305,312 41,634  
9 Other employee benefits ....... 1,474,611 1,297,658 176,953  
10 Payroll taxes ........... 407,601 359,137 48,464  
11 Fees for services (non-employees):        
a Management ......        
b Legal ......... 42,757   42,757  
c Accounting ........... 26,928   26,928  
d Lobbying ...........        
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ......        
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........ 1,211,514 1,118,524 92,990  
12 Advertising and promotion .... 17,390   17,390  
13 Office expenses ....... 662,249 603,725 58,524  
14 Information technology ...... 17,782 17,782    
15 Royalties ..        
16 Occupancy ........... 231,020 231,020    
17 Travel ............ 3,882 3,004 878  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ......        
19 Conferences, conventions, and meetings ....        
20 Interest ...........        
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization ..... 497,398 497,398    
23 Insurance .............. 200,103   200,103  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MEDICAL SUPPLIES 1,076,289 1,076,289    
b MISCELLANEOUS 182,568 21,858 160,710  
c BAD DEBTS 63,248 63,248    
d EDUCATION 21,262 19,594 1,668  
e All other expenses 15,446 2,372 13,074  
25 Total functional expenses. Add lines 1 through 24e 12,563,696 10,960,825 1,602,871 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 MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2012)
Form 990 (2012)
Page 11
Part X Balance Sheet Check if Schedule O contains a response to any question in this Part X ...............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing ............. 839,789 1 1,194,657
2 Savings and temporary cash investments ......... 142,551 2 183,153
3 Pledges and grants receivable, net ...........   3  
4 Accounts receivable, net ............. 970,513 4 946,440
5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L ..................
  5  
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
  6  
7 Notes and loans receivable, net .............   7  
8 Inventories for sale or use .............. 40,181 8 45,115
9 Prepaid expenses and deferred charges .......... 38,049 9 135,733
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 7,076,898
b Less: accumulated depreciation ..... 10b 87,192 3,800,562 10c 6,989,706
11 Investments—publicly traded securities .......... 3,617,005 11 3,831,070
12 Investments—other securities. See Part IV, line 11 .....   12  
13 Investments—program-related. See Part IV, line 11 .....   13  
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ........... 245,522 15 127,791
16 Total assets. Add lines 1 through 15 (must equal line 34)...... 9,694,172 16 13,453,665
Liabilities 17 Accounts payable and accrued expenses ......... 1,219,148 17 1,170,272
18 Grants payable .................   18  
19 Deferred revenue ................   19  
20 Tax-exempt bond liabilities .............   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 109,837 21 69,817
22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L..........   22  
23 Secured mortgages and notes payable to unrelated third parties ..   23  
24 Unsecured notes and loans payable to unrelated third parties ....   24  
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.................... 1,257,127 25 1,286,295
26 Total liabilities. Add lines 17 through 25......... 2,586,112 26 2,526,384
Net Assets or Fund Balance Organizations that follow SFAS 117 (ASC 958), check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets .............. 7,108,060 27 10,927,281
28 Temporarily restricted net assets ...........   28  
29 Permanently restricted net assets ...........   29  
Organizations that do not follow SFAS 117 (ASC 958), check here MediumBullet 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 ........... 7,108,060 33 10,927,281
34 Total liabilities and net assets/fund balances ........ 9,694,172 34 13,453,665
Form 990 (2012)
Form 990 (2012)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI ...............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
13,300,338
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
12,563,696
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
736,642
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
7,108,060
5
Net unrealized gains (losses) on investments ...............
5
-80,319
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
3,162,898
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B))
10
10,927,281
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII ..............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If “Yes,” to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits
3b
 
 
Form 990 (2012)
Form 990, Special Condition Description:
Special Condition Description
Additional Data


Software ID:  
Software Version:  
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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Employer identification number

54-6074529
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.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
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.)
10
11
e
f
g
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization? ................
11g(i)
 
No
(ii) A family member of a person described in (i) above? ......................
11g(ii)
 
No
(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
No
h
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) (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 monetary support
Yes No Yes No Yes No
(A) HALIFAX REGIONAL HOSPITAL INC
  		540648699 3 Yes           0
Total                 0

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..            
11 Total support (Add lines 7 through 10).            
12
12
 
13
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
14
14
 
15
15
 
16a
b
17a
b
18
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) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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) right arrow (a) 2008 (b) 2009 (c) 2010 (d) 2011 (e) 2012 (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.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information. Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2012

Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990, 990-EZ,
or 990-PF)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors
Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
OMB No. 1545-0047
2012
Name of the organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Employer identification number

54-6074529
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ





Form 990-PF




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
Special Rules
......................... 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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 2
Name of organization
HALIFAX REGIONAL LONG TERM CARE INC
  		Employer identification number

54-6074529
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


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 

     
 
   

$  


(Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 3
Name of organization
HALIFAX REGIONAL LONG TERM CARE INC
  		Employer identification number

54-6074529
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) (2012)

Schedule B (Form 990, 990-EZ, or 990-PF) (2012)
Page 4
Name of organization
HALIFAX REGIONAL LONG TERM CARE INC
  		Employer identification number

54-6074529
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 (c) Use 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 (c) Use 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 (c) Use 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 (c) Use 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) (2012)

Additional Data


Software ID:  
Software Version:  
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
2012
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.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet 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
Round Bullet 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.
Round Bullet 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, Part V, line 35c (Proxy Tax), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Employer identification number

54-6074529
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV.
2
Political expenditures ....................................SchCMd Bullet
$  
3
Volunteer hours ........................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 .........SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 ......SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............
4a
Was a correction made? .........................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ...................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b..SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ..........................
5
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 Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.
Cat. No. 50084S
Schedule C (Form 990 or 990-EZ) 2012

Schedule C (Form 990 or 990-EZ) 2012
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 SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(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? ......................................

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) 2009 (b) 2010 (c) 2011 (d) 2012 (e) Total
             
2a Lobbying nontaxable 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) 2012


Schedule C (Form 990 or 990-EZ) 2012
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)
No
Yes
(b)
Amount
1
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:
a
Volunteers? .........................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....
 
No
c
Media advertisements? ....................................
 
No
 
d
Mailings to members, legislators, or the public? .........................
 
No
 
e
Publications, or published or broadcast statements? .......................
 
No
 
f
Grants to other organizations for lobbying purposes? .......................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? ........
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......
 
No
 
i
Other activities? ..........................
Yes
 
1,254
j
Total. Add lines 1c through 1i ...............................
1,254
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 .................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....
 
d
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
No
1
Were substantially all (90% or more) dues received nondeductible by members? ................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........
3
 
 
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."
1
Dues, assessments and similar amounts from members .....................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).
a
Current year .........................................
2a
 
b
Carryover from last year ....................................
2b
 
c
Total ............................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
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? ................................
4
 
5
Taxable amount of lobbying and political expenditures (see instructions) ..............
5
 
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, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.
Identifier Return Reference Explanation
EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: A PORTION OF DUES PAID TO THE VIRGINIA HEALTH CARE ASSOCIATION IS ATTRIBUTABLE TO LOBBYING EXPENSES.
Schedule C (Form 990 or 990EZ) 2012

Additional Data


Software ID:  
Software Version:  

SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet 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
2012
Open to Public Inspection
Name of the organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Employer identification number

54-6074529
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 ........    
5
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? ............
6
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? ...................................
Part II
Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
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.
Held at the End of the 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  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................
6
Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................
9
In Part XIII, 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.
1a
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 XIII, the text of the footnote to its financial statements that describes these items.
b
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 $  
2
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:
a
Revenues included in Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
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?........
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.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b
If "Yes," explain the arrangement in Part XIII and complete the following table:
Amount
c Beginning balance ................................. 1c  
d Additions during the year .............................. 1d  
e Distributions during the year ............................. 1e  
f Ending balance ................................... 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21? .....................
b
If “Yes,” explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........
Part V
Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.
(a)Current year (b)Prior year b (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 ......          
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet  
b
Permanent endowment SchDMd Bullet  
c
Temporarily restricted endowment SchDMd Bullet  
The percentages in lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) unrelated organizations ........................
3a(i)
 
 
(ii) related organizations ........................
3a(ii)
 
 
b
If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII 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 (a) Cost or other basis (investment) (b)Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .................   1,686,000 1,686,000
b Buildings ................   3,660,200 17,899 3,642,301
c Leasehold improvements ............        
d Equipment ................   1,487,443 63,357 1,424,086
e Other .................   243,255 5,936 237,319
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......SchDMdBullet 6,989,706
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 3
Part VII
Investments—Other 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.)Small Bullet  
Part VIII
Investments—Program 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.)Small Bullet  
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.)...........Small Bullet  
Part X
Other Liabilities. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
Federal income taxes  
DUE TO THIRD PARTY PROGRAMS 147,087
DUE TO AFFILIATES 273,088
PATIENT SECURITY DEPOSITS 183,153
OTHER LONG-TERM LIABILITIES 142,858
ACCRUED PENSION OBLIGATION 539,677
OTHER CURRENT LIABILITIES 432



Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 1,286,295
2. Fin 48 (ASC 740) Footnote. In Part XIII, 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 (ASC 740). Check here if the text of the footnote has been provided in Part XIII .....................................................
Schedule D (Form 990) 2012

Schedule D (Form 990) 2012
Page 4
Part XI 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 XIII.) ............ 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 XIII.) ........... 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 XII 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 XIII.) ............ 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 XIII.) ............ 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 XIII
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, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Identifier Return Reference Explanation
  PART IV, LINE 2B: THE ORGANIZATION SERVES AS CUSTODIAN OVER PATIENT ACCOUNTS, AND THESE AMOUNTS HAVE BEEN INCLUDED ON THE AUDITED FINANCIAL STATEMENTS AS A LIABILITY.
DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE COMPANY IS GENERALLY EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, AS AMENDED. THE COMPANY DOES NOT BELIEVE ITS FINANCIAL STATEMENTS INCLUDE (OR REFLECT) ANY UNCERTAIN TAX POSITIONS.
Schedule D (Form 990) 2012

Additional Data


Software ID:  
Software Version:  




Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990
OMB No. 1545-0047
2012
Open to Public
Inspection
Name of the organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Employer identification number
54-6074529
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC Code section
if applicable		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
non-cash assistance		 (h) Purpose of grant
or assistance
(1) HALIFAX REGIONAL PROPERTIES INC
2204 WILBORN AVENUE
SOUTH BOSTON,VA24592 		54-1801463 501(C)(3) 300,000       TO FUND CONSTRUCTION OF DENTAL FACILITY
(2) HALIFAX REGIONAL DEVELOPMENT FOUNDATION INC
2204 WILBORN AVENUE
SOUTH BOSTON,VA24592 		54-1801459 501(C)(3) 15,000       TO FUND COMMUNITY PARTNERSHIP




















2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................ Bullet Image
2
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2012

Schedule I (Form 990) 2012
Page 2
Part III
Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a)Type of grant or assistance (b)Number of
recipients		 (c)Amount of
cash grant		 (d)Amount of
non-cash assistance		 (e)Method of valuation (book,
FMV, appraisal, other)		 (f)Description of non-cash assistance












Part IV
Supplemental Information.
Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information.
Identifier Return Reference Explanation
PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: GRANTS FROM HALIFAX REGIONAL LONG TERM CARE, INC. ARE ONLY MADE TO AFFILIATES WHOSE FINANCIAL RECORDS ARE MAINTAINED BY HALIFAX REGIONAL HOSPITAL.
Schedule I (Form 990) 2012


Additional Data


Software ID:  
Software Version:  


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
2012
Open to Public Inspection
Name of the organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Employer identification number

54-6074529
Part I
Questions Regarding Compensation
Yes
No
1a
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.
b
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 of the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
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? .......
2
 
 
3
Indicate which, if any, of the following the filing organization used 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.
4
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:
a
Receive a severance payment or change-of-control payment? ................
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
 
No
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
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.
5
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:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
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:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
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 ............
7
 
No
8
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 .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
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 (E) amounts for that individual.
(A) Name and Title (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
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1)CHRIS A LUMSDENCEO(THRU 6/30)/PRES/SEC(EFF 7/1/13) (i)
(ii)		 12,870
307,930 		0
30,000 		0
42,855 		554
1,947 		4,125
14,484 		17,549
397,216 		0
0
(2)STEWART R NELSONCHIEF FINANCIAL OFFICER (i)
(ii)		 8,668
207,394 		0
20,000 		0
23,341 		622
2,182 		410
1,441 		9,700
254,358 		0
0
(3)THOMAS S KLUGECHIEF OPERATING OFFICER (i)
(ii)		 7,639
182,790 		0
10,000 		0
23,341 		-894
-3,143 		4,073
14,302 		10,818
227,290 		0
0
Schedule J (Form 990) 2012

Schedule J (Form 990) 2012
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.
Identifier Return Reference Explanation
  PART I, LINE 3 THE ORGANIZATION RELIED ON A RELATED ORGANIZATION THAT USED ONE OR MORE METHODS LISTED ON LINE 3 TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION.
Schedule J (Form 990) 2012

Additional Data


Software ID:  
Software Version:  
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
2012
Open to Public
Inspection
Name of the organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Employer identification number

54-6074529
Identifier Return Reference Explanation
ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 HALIFAX REGIONAL LONG TERM CARE, INC. IS ORGANIZED AND OPERATED EXCLUSIVELY FOR THE BENEFIT OF, TO PERFORM THE FUNCTIONS OF, OR CARRY OUT THE PURPOSES OF HALIFAX REGIONAL HOSPITAL, INC. THE FUNCTIONS TO BE PERFORMED ARE TO PROVIDE EXTENDED CARE, OUTPATIENT CARE, HOME CARE, ASSISTED LIVING CARE, SENIOR LIVING COMMUNITY OR HOME FOR THE AGED, AND RELATED MEDICAL SERVICES FOR HALIFAX REGIONAL HOSPITAL, INC. OR ANY OTHER SERVICES REQUESTED BY HALIFAX REGIONAL HOSPITAL, INC. AND TO CARRY OUT OTHER EXCLUSIVELY CHARITABLE, EDUCATIONAL, OR SCIENTIFIC PURPOSES OF HALIFAX REGIONAL HOSPITAL, INC.
PROGRAM SERVICE ACCOMPLISHMENTS FORM 990, PART III, LINE 4A THIS ORGANIZATION, DOING BUSINESS AS THE WOODVIEW AND SEASONS AT THE WOODVIEW IS COMPOSED OF A 180-BED DUALLY CERTIFIED (MEDICAID AND MEDICARE) NURSING FACILITY, (THE WOODVIEW), PROVIDING PERSONAL SERVICES, HEALTH CARE SERVICES AND REHABILITATION SERVICES; AND AN 18-BED LICENSED ASSISTED LIVING NEIGHBORHOOD (SEASONS AT THE WOODVIEW), FOR INDIVIDUALS WITH ALZHEIMER'S DISEASE OR A RELATED DEMENTIA. 59.1 PERCENT OF THE FACILITY'S REVENUES WERE REIMBURSABLE UNDER THE MEDICAID PROGRAM IN FY13 AND 18.4 PERCENT WERE REIMBURSABLE UNDER MEDICARE. THE WOODVIEW UTILIZES EXCESS REVENUE OVER EXPENSES TO UPGRADE FACILITIES, TO PURCHASE NEW EQUIPMENT AND TO UPGRADE CLINICAL AND INFORMATION TECHNOLOGY IN ORDER TO IMPROVE QUALITY AND RESIDENT SAFETY. THE WOODVIEW WORKS IN CONJUNCTION WITH HALIFAX REGIONAL HOSPITAL, INC. ("THE HOSPITAL") TO PROVIDE HEALTH INFORMATION TO THE COMMUNITY. WITH THE HIGH PREVALENCE OF ALZHEIMER'S DISEASE (5.4 MILLION AMERICANS) AND WITH A HIGH PERCENT OF NURSING HOME RESIDENTS DIAGNOSED WITH ALZHEIMER'S DISEASE OR RELATED DEMENTIAS, THE WOODVIEW DEVOTES RESOURCES TO ACTIVITIES THAT WILL HELP RAISE AWARENESS OF ALZHEIMER'S DISEASE AND THAT WILL HELP THOSE AFFECTED BY THE DISEASE TO LEARN AND UNDERSTAND MORE ABOUT IT. IN ADDITION, THE WOODVIEW HELPS SUPPORT COMMUNITY ACTIVITIES BY PROVIDING STAFF EXPERTISE AND RESOURCES FOR A NUMBER OF ORGANIZATIONS. COMMUNITY HEALTH IMPROVEMENT SERVICES & EDUCATION EDUCATIONAL FAMILY NIGHT THE WOODVIEW WELCOMES THE RESIDENTS' FAMILIES AND THE COMMUNITY INTO THE FACILITY FOR PROGRAMS OF INTEREST TO THE GENERAL PUBLIC. PROGRAMS DURING FY13 INCLUDED HELPING FAMILIES UNDERSTAND RESPONSIBILITIES IN LONG TERM CARE WITH JUDITH ANDERSON FNP; DINNER WITH SANTA; AND A PERFORMANCE BY HAROLD YOUNG & FRIENDS. SEASONS HOSTED FOUR FAMILY NIGHTS: DIABETIC AWARENESS, HEART HEALTHY EATING, A SANTA PARTY AND A FAMILY COOKOUT. WOODVIEW AND SEASONS AT THE WOODVIEW NEWSLETTERS IN-HOUSE PREPARED NEWSLETTERS FROM THE WOODVIEW AND SEASONS AT THE WOODVIEW ARE DISTRIBUTED TO OVER 520 FAMILIES, BUSINESSES AND INDIVIDUALS EACH MONTH. THE WOODVIEW WHISTLE INCLUDES A SPECIAL FEATURE FOCUSING ON AN EMPLOYEE AND ONE OR MORE RESIDENTS AND FEATURES OTHER ITEMS OF INTEREST RELATED TO ACTIVITIES AT THE WOODVIEW. MAKING THE WOODVIEW WHISTLE ESPECIALLY INTERESTING, ARE DRAWINGS BY RESIDENTS THAT DEPICT LIFE AND TIMES AND/OR ACTIVITIES THEY FONDLY REMEMBER. OFTEN THE ARTIST WILL INCLUDE A HANDWRITTEN EXPLANATION WITH THE ARTWORK. ALSO INCLUDED ARE PHOTOS THAT DEPICT RESIDENTS INVOLVED IN THE LIFE OF THE FACILITY. THE SEASONS AT THE WOODVIEW NEWSLETTER FEATURES EDUCATIONAL INFORMATION RELATED TO ALZHEIMER'S DISEASE AND GENERAL INFORMATION ABOUT THE RESIDENTS AND FACILITY EVENTS. SEASONS' RESIDENTS HELP IN FOLDING AND INSERTING THE NEWSLETTER, AS WELL AS LABELING IT. HEALTHY LIVING EXPO AGAIN THIS YEAR, THE WOODVIEW AND SEASONS AT THE WOODVIEW PARTICIPATED IN THE HEALTHY LIVING EXPO, AN ANNUAL COMMUNITY HEALTH FAIR THAT PROVIDES A MYRIAD OF FREE HEALTH SCREENINGS AND HEALTH AND WELLNESS EDUCATIONAL ACTIVITIES AND INFORMATION TO THE PUBLIC. IN ADDITION TO ASSISTING WITH PLANNING FOR THIS EVENT, THE WOODVIEW AND SEASONS AT THE WOODVIEW PROVIDED LONG TERM CARE AND ALZHEIMER'S DISEASE INFORMATION. APPROXIMATELY 325 PEOPLE WERE REACHED THROUGH THIS EVENT. ALZHEIMER'S SUPPORT GROUP THE WOODVIEW PROVIDES FREE SPACE FOR ALZHEIMER'S SUPPORT GROUP MEETINGS ON THE FOURTH WEDNESDAY OF EACH MONTH. THE MEETINGS ARE CO-FACILITATED BY THE SEASONS AT THE WOODVIEW MANAGER AND A MEMBER OF THE HOSPITAL STAFF. MEETINGS ARE DESIGNED TO PROVIDE EDUCATION AND SUPPORT FOR FAMILY MEMBERS AND CAREGIVERS OF THOSE EXPERIENCING ALZHEIMER'S DISEASE OR OTHER FORMS OF DEMENTIA. OTHER IN FY13 WOODVIEW STAFF PROVIDED INFORMATION AND PRESENTATIONS ON CAREERS IN HEALTHCARE DURING CAREER DAYS AT LOCAL ELEMENTARY SCHOOLS. WOODVIEW STAFF ALSO WORKED WITH HABITAT FOR HUMANITY'S "PUMPKIN PATCH" FUNDRAISER TO RAISE MONEY FOR HABITAT HOMES. FINANCIAL AND IN-KIND CONTRIBUTIONS ALZHEIMER'S MEMORY WALK IN FY2013 THE WOODVIEW AND SEASONS AT THE WOODVIEW STAFF AND VOLUNTEERS PLANNED, COORDINATED AND HOSTED THE ANNUAL ALZHEIMER'S SUPPORT WALK. A NUMBER OF FUNDRAISING EVENTS HELD THROUGHOUT THE YEAR BY THE WOODVIEW AND SEASONS LEAD UP TO WALK DAY WITH 80 WALKERS PARTICIPATING. FUNDS RAISED IN THESE EVENTS WERE DONATED TO THE SOUTHEASTERN VIRGINIA CHAPTER OF THE ALZHEIMER'S ASSOCIATION. THE MONEY IS USED LOCALLY TO SUPPORT ALZHEIMER'S RELATED PROGRAMS INCLUDING FAMILY ORIENTATIONS, THE 24-HOUR HELPLINE, EDUCATIONAL SEMINARS AND TRAINING SESSIONS FOR BOTH FAMILY AND PROFESSIONAL CAREGIVERS, THE SAFE RETURN PROGRAM, LOCAL SUPPORT GROUPS AND THE SPEAKER'S BUREAU, ALL OF WHICH ASSIST INDIVIDUALS AND FAMILIES AFFECTED BY THE DISEASE. NEARLY $4,000 WAS COLLECTED FROM FUND-RAISING EFFORTS THROUGHOUT THE YEAR INCLUDING BAKE SALES, ICE CREAM SUNDAE SALES, YARD SALES, DONATIONS AND THE ALZHEIMER'S WALK ITSELF. IN ADDITION, THE WOODVIEW PROVIDED SPACE AND LUNCH FOR THE AREA ALZHEIMER'S WALK TEAM COMMITTEE CAPTAIN KICK-OFF MEETING. OTHER IN-KIND CONTRIBUTIONS LONG-TERM CARE RESIDENTS ARE ENCOURAGED TO BECOME INVOLVED IN THE LIFE OF THE FACILITY AS WELL AS THE LIFE OF THE COMMUNITY, ADDING TO THEIR QUALITY OF LIFE ALONG WITH ASSISTING THOSE TO WHOM THEIR EFFORTS ARE CONCENTRATED. WITH LEADERSHIP AND COORDINATION FROM THE STAFF, IN FY13, THE WOODVIEW FAMILY RESIDENTS, VOLUNTEERS AND STAFF ALIKE CO-HOSTED A FALL BAZAAR WHICH THIS YEAR INCLUDED VENDORS FROM THE COMMUNITY. FUNDS RAISED WERE DONATED TO THE HALIFAX COUNTY CANCER ASSOCIATION. AGAIN IN FY13 WOODVIEW RESIDENTS PREPARED HAND-MADE DOLLS AND STUFFED ANIMALS FOR THE "TOYS FOR TOTS" PROGRAM AND MADE AND DONATED COOKIES TO THE UNITED MISSIONARY SOUP KITCHEN FOR THANKSGIVING. FACILITY USE THE WOODVIEW AND SEASONS AT THE WOODVIEW PROVIDE FREE CLASSROOM SPACE AND AVAILABLE EQUIPMENT FOR CLINICAL TRAINING PROGRAMS. THE WOODVIEW SERVES AS A CLINICAL SITE FOR: -HALIFAX COUNTY HIGH SCHOOL NURSE AIDE CLASSES; 20 STUDENTS PER SEMESTER -SOUTHSIDE VIRGINIA COMMUNITY COLLEGE, SVCC; 50 NURSING ASSISTANT STUDENTS PER YEAR -SVCC; 20 LPN AND RN STUDENTS PER YEAR -DANVILLE COMMUNITY COLLEGE NURSE AIDE CLASSES 50 NURSING ASSISTANT STUDENTS PER YEAR. THE WOODVIEW ALSO SERVES AS A TESTING SITE FOR BELTONE HEARING AIDS. COMMUNITY BUILDING THE WOODVIEW AND SEASONS AT THE WOODVIEW TAKE PRIDE IN BEING A CONTRIBUTING MEMBER OF THE SOUTH BOSTON AND HALIFAX COUNTY COMMUNITY AND AS SUCH, REACH OUT INTO THE COMMUNITY IN A VARIETY OF WAYS: INTERGENERATIONAL PROGRAMS THE WOODVIEW VISITS THE DAN RIVER WEE SCHOOL ON A REGULAR BASIS TO PROVIDE LEARNING EXPERIENCES FOR BOTH THE YOUNG CHILDREN AND THE RESIDENTS. THE CHILDREN AND RESIDENTS VISIT TOGETHER, WORK ON CRAFTS AND ENJOY VARIOUS HOLIDAY PRESENTATIONS AND PROJECTS. PEOPLE OF ALL AGES FROM APPROXIMATELY 50 COMMUNITY GROUPS (CHURCHES, DANCE GROUPS, BANDS AND VARIOUS CLUBS) SHARE THEIR TALENTS WITH RESIDENTS, STAFF MEMBERS, AND FAMILIES AT BOTH THE WOODVIEW AND SEASONS AT THE WOODVIEW. WOODVIEW RESIDENTS OFTEN JOIN OTHER COMMUNITY GROUPS TO HELP WITH LOCAL EVENTS, TOO. EACH YEAR, THE WOODVIEW PLANS, COORDINATES AND HOSTS COMMUNITY EVENTS ESPECIALLY FOR CHILDREN. APPROXIMATELY SIXTY CHILDREN FROM THE COMMUNITY ENJOYED THE WOODVIEW'S ANNUAL EASTER EGG HUNT THIS YEAR WITH CHILDREN ENJOYING FUN ACTIVITIES AND DELICIOUS REFRESHMENTS PROVIDED BY THE FACILITY. DINNER WITH SANTA WAS A TREAT FOR APPROXIMATELY 45 LOCAL YOUNGSTERS AND 25 FAMILY MEMBERS, AND APPROXIMATELY 150 CHILDREN PARTICIPATED IN THE FY13 SAFE TRICK OR TREAT. THE WOODVIEW PARTNERED WITH CLAYS MILL ELEMENTARY SCHOOL FOR THE GREAT GRANDS PROGRAM, WHERE STUDENTS ADOPT A GREAT GRANDPARENT. IN FY13 AMERICAN LEGION POST #8 PROVIDED THE RESIDENTS WITH A VETERANS DAY PROGRAM AND CELEBRATION AND THE WOMAN'S AUXILIARY OF POST #8 AND AMERICAN LEGION POST #99 PROVIDED GIFTS FOR RESIDENTS AT CHRISTMAS, EASTER, VALENTINE'S DAY AND VETERANS DAY. AT CHRISTMAS, THE SALVATION ARMY DONATED GIFTS TO ALL 180 RESIDENTS AT THE WOODVIEW. IN FY13 SEASONS AT THE WOODVIEW WAS VISITED BY BOTH CENTERVILLE CHRISTIAN SCHOOL STUDENTS AND WE'VE GOT RHYTHM, STUDENTS FROM A LOCAL DANCE COMPANY. IN FY13 THE WOODVIEW PARTNERED WITH HELPING HANDS, A SERVICE ORGANIZATION OF HALIFAX COUNTY HIGH SCHOOL. HELPING HANDS ASSISTED RESIDENTS IN A BINGO GAME AND HOSTED A VALENTINES PROGRAM FOR THEM. HALIFAX COUNTY HIGH SCHOOL JROTC ALSO HOSTED A VETERANS PROGRAM AND VALENTINES PROGRAM FOR RESIDENTS. SOUTH BOSTON EARLY LEARNING CENTER HOSTED A SPRING PROGRAM FOR RESIDENTS.
    POETRY PROJECT DURING FY13 VIRGINIA'S POET LAUREATE KELLY CHERRY MET REGULARLY WITH RESIDENTS IN POETRY WORKSHOPS AFTER WHICH ACTIVITY STAFF HELPED RESIDENTS WRITE THEIR OWN POEMS. THIS PROJECT CONTINUED AND THE POEMS WERE COMPILED A SMALL BOOK OF POEMS. ADOPT A US SOLDIER PROGRAM IN FY13 SEASONS AT THE WOODVIEW CONTINUED SUPPORT OF THE ADOPT A US SOLDIER PROGRAM, DESPITE LOSING THEIR SOLDIER. THE RESIDENTS, THEIR FAMILIES AND THE SEASONS STAFF REMAIN INVOLVED IN THE PROJECT AND CONTINUE TO SEND CARDS TO HIS PLATOON. COMMUNITY INVOLVEMENT EMPLOYEES PARTICIPATE IN AND SHARE THEIR TALENTS AND EXPERTISE AS MEMBERS OF VARIOUS CIVIC AND RELIGIOUS ORGANIZATIONS IN THEIR RESPECTIVE COMMUNITIES. THEY PARTICIPATE IN THE CHAMBER OF COMMERCE IN HALIFAX COUNTY; SERVE ON VIRGINIA HEALTH CARE ASSOCIATION COMMITTEES; AND SERVE ON VARIOUS BOARDS AND ADVISORY COMMITTEES SUCH AS THE, LAKE COUNTRY COMMISSION ON AGING, THE SOUTHSIDE VIRGINIA COMMUNITY COLLEGE LPN SCHOOL ADVISORY COUNCIL, HALIFAX VOCATIONAL FOUNDATION ADVISORY COUNCIL, LAKE COUNTRY AREA AGENCY ON AGING AND THE HALIFAX COUNTY COMMUNITY FEDERAL CREDIT UNION. COMMUNITY INVOLVEMENT RECOGNITION THE WOODVIEW AND SEASONS AT THE WOODVIEW HAVE BEEN RECOGNIZED FOR COMMUNITY INVOLVEMENT BY THE VIRGINIA HEALTH CARE ASSOCIATION (VHCA) FREQUENTLY OVER THE YEARS. THE ANNUAL VHCA AWARDS ARE PRESENTED TO FACILITIES THAT DEMONSTRATE A HIGH DEGREE OF PROFESSIONALISM AND CREATIVITY IN IMPLEMENTING PROGRAMS THAT ENCOURAGE AND SUPPORT STRONG COMMUNITY RELATIONS. IN FY13, THE WOODVIEW WAS AGAIN RECOGNIZED, RECEIVING FIRST PLACE FOR YEAR ROUND PUBLIC RELATIONS. SEASON'S WAS RECOGNIZED WITH THIRD PLACE IN SPECIAL EVENT AND YEAR ROUND COMMUNITY INVOLVEMENT. OTHER OTHER PROGRAMS INCLUDED A SPA/RELAXATION DAY OFFERED TO RESIDENTS, AND A BLACK HISTORY PROGRAM GIVEN BY VOLUNTEERS RETHA & FRIENDS. THE WOODVIEW CONTINUED PROVIDING "STRESS FREE" DAYS AND THE WOODVIEW RESIDENT GLEE CLUB PERFORMED AT CHRISTMAS AND EASTER. HEALTHY DIRECTIONS EMPLOYEE PROGRAMS A VARIETY OF WELLNESS PROGRAMS COORDINATED BY THE HOSPITAL ARE HELD ON A MONTHLY BASIS TO HELP EMPLOYEES AND THEIR FAMILY MEMBERS WITH WEIGHT LOSS, EXERCISE, AND NUTRITION TO LOWER BMI, CHOLESTEROL, GLUCOSE, BLOOD PRESSURE AND RISKS FOR HEART ATTACK, STROKE AND OTHER COMPLICATIONS OF CARDIOVASCULAR DISEASE. BY LOOKING BETTER AND FEELING BETTER, EMPLOYEES "SHOW" THE COMMUNITY THAT GOOD HEALTH IS ACHIEVABLE AND SET A GOOD EXAMPLE FOR THE HEALTHCARE ROLE THE ORGANIZATION PLAYS IN THE COMMUNITY. VOLUNTEER SERVICES PROGRAM VOLUNTEERS FROM THE COMMUNITY, INDIVIDUALS AND GROUPS, HAVE DONATED MANY HOURS AT THE WOODVIEW AND SEASONS AT THE WOODVIEW DURING FY13, PROVIDING COMPANIONSHIP, RECREATION AND SPIRITUAL ACTIVITIES FOR RESIDENTS. VOLUNTEERS ALSO INCLUDE CERTIFIED PET THERAPY DOGS. VOLUNTEERS AT THE WOODVIEW AND SEASONS AT THE WOODVIEW, COORDINATE BINGO GAMES, CRAFT ACTIVITIES, BIRTHDAY OBSERVANCES AND HOLIDAY CELEBRATIONS. THEY ALSO ACCOMPANY RESIDENTS ON PICNICS AND FISHING EXCURSIONS AND OUT-OF-RESIDENCE ACTIVITIES, INCLUDING BUS TRIPS TO COUNTY FAIRS AND OTHER COMMUNITY EVENTS/FESTIVALS. THE VOLUNTEERS ASSIST WITH THE ANNUAL EASTER EGG HUNT, DINNER WITH SANTA, THE SAFE TRICK-OR-TREAT AND COOKOUTS FOR RESIDENTS AND FAMILIES. AN ANNUAL VOLUNTEER RECOGNITION LUNCHEON IS HOSTED TO RECOGNIZE AND HONOR VOLUNTEERS FOR THEIR SERVICE.
  FORM 990, PART VI, SECTION A, LINE 2 DAVID H. WHITE, JR. AND CHRIS A. LUMSDEN HAVE A BUSINESS RELATIONSHIP. THE ORGANIZATION'S OFFICERS AND DIRECTORS SERVED TOGETHER ON THE BOARDS OF OTHER TAXABLE ORGANIZATIONS WITHIN THE SENTARA HEALTHCARE SYSTEM ("THE SYSTEM"), AS WELL AS JOINT VENTURES IN WHICH THE SYSTEM HAD AN OWNERSHIP INTEREST. SEE SCHEDULE R FOR A LISTING OF SUCH ENTITIES.
  FORM 990, PART VI, SECTION A, LINE 4 EFFECTIVE JULY 1, 2013, HALIFAX REGIONAL HOSPITAL, INC. ("HRH"), A 501(C)(3) AFFILIATE, REPLACED HALIFAX REGIONAL HEALTH SYSTEM, INC.("HRHS") AS SOLE MEMBER OF THE ORGANIZATION. THE MEMBER CHANGE OCCURRED IN ACCORDANCE WITH THE APRIL 23, 2013 AFFILIATION AGREEMENT AMONG HRHS, HRH, AND SENTARA HEALTHCARE ("SENTARA"), A 501(C)(3) ORGANIZATION, WHEREBY SENTARA REPLACED HRHS AS THE SOLE MEMBER OF HRH. AS A RESULT OF THE AFFILIATION, THE ORGANIZING AND GOVERNING DOCUMENTS OF THE ORGANIZATION WERE CHANGED IN THE FOLLOWING MANNER: -HRH REPLACED HRHS AS SOLE MEMBER OF THE ORGANIZATION. -THE NUMBER OF DIRECTORS ON THE BOARD WAS CHANGED FROM FIVE TO NO LESS THAN THREE. DIRECTORS ARE STILL APPOINTED BY THE SOLE MEMBER BUT NOW MUST BE RATIFIED BY SENTARA. -AS SOLE MEMBER OF HRH, SENTARA HAS BEEN GRANTED CERTAIN RESERVED POWERS, AS OUTLINED IN THE APRIL 23, 2013 AFFILIATION AGREEMENT, WHEREBY HRH WILL NOT PERMIT THE ORGANIZATION TO TAKE OR ALLOW CERTAIN ACTIONS WITHOUT THE PRIOR WRITTEN CONSENT OF SENTARA . SEE PART VI SECTION A LINE 7B FOR FURTHER INFORMATION. -DURING THE COVENANT PERIOD, AS DEFINED IN THE AFFILIATION AGREEMENT, ANY ALTERATION, AMENDMENT, RESTATEMENT OR REPEAL OF ANY GOVERNING DOCUMENTS; THE ADOPTION OF ANY NEW GOVERNING DOCUMENTS; OR ANY ACTION TO BE TAKEN AS THE MEMBER UNDER THE GOVERNING DOCUMENTS REQUIRE THE APPROVAL OF A MAJORITY OF CLASS A DIRECTORS OF HRH, VOTING AS A SEPARATE CLASS, AND OF SENTARA.
  FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAD ONE CLASS OF MEMBER. EFFECTIVE JULY 1, 2013, THE SOLE MEMBER WAS HALIFAX REGIONAL HOSPITAL, INC., A VIRGINIA NONSTOCK CORPORATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION'S SOLE MEMBER PRIOR TO JULY 1, 2013 WAS HALIFAX REGIONAL HEALTH SYSTEM, INC., A VIRGINIA NONSTOCK CORPORATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE.
  FORM 990, PART VI, SECTION A, LINE 7A PRIOR TO JULY 1, 2013, THE DATE OF AFFILIATION WITH THE SENTARA HEALTHCARE SYSTEM, MEMBERS OF THE GOVERNING BODY WERE ELECTED BY THE ORGANIZATION'S FORMER SOLE MEMBER, HALIFAX REGIONAL HEALTH SYSTEM, INC. EFFECTIVE JULY 1, 2013, HALIFAX REGIONAL HOSPITAL, INC. REPLACED HALIFAX REGIONAL HEALTH SYSTEM, INC. AS SOLE MEMBER OF THE ORGANIZATION AND APPOINTED MEMBERS OF THE GOVERNING BODY IN ACCORDANCE WITH THE APRIL 23, 2013 AFFILIATION AGREEMENT WITH SENTARA HEALTHCARE.
  FORM 990, PART VI, SECTION A, LINE 7B SENTARA HEALTHCARE ("SENTARA"), IN ITS CAPACITY AS THE 501(C)(3) SOLE MEMBER OF HALIFAX REGIONAL HOSPITAL, INC. ("HRH"), THE SOLE MEMBER OF THE ORGANIZATION, HAS RESERVED THE EXCLUSIVE RIGHT, POWER AND AUTHORITY TO MAKE DECISIONS FOR AND ON BEHALF OF THE ORGANIZATION WITH RESPECT TO THE APPROVAL OR ADOPTION OF ANY PLAN OF MERGER OR CONSOLIDATION; ANY SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL, THE PROPERTY AND ASSETS OF THE ORGANIZATION; AND THE VOLUNTARY DISSOLUTION OR LIQUIDATION OF THE ORGANIZATION, REVOCATION OF ANY SUCH VOLUNTARY DISSOLUTION PROCEEDINGS, OR ANY DECISION TO FILE A PETITION REQUESTING OR CONSENTING TO AN ORDER FOR RELIEF UNDER THE FEDERAL BANKRUPTCY LAWS OR SIMILAR STATE LAWS FOR THE ORGANIZATION. ELECTION OF THE ORGANIZATION'S GOVERNING BODY IS ALSO SUBJECT TO RATIFICATION BY SENTARA. FINALLY, SPECIAL APPROVAL BY HRH'S GOVERNING BODY IS REQUIRED FOR CERTAIN OTHER ACTIONS OF THE ORGANIZATION. THESE INCLUDE A CHANGE IN THE ORGANIZATION'S MISSION; THE ESTABLISHMENT OF, AND APPOINTMENT OF MEMBERS TO, ANY COMMITTEES WHICH WILL HAVE ANY OF THE AUTHORITY OF THE HRH GOVERNING BODY; AND ANY ALTERATION, AMENDMENT, RESTATEMENT OR REPEAL OF ANY GOVERNING DOCUMENTS, THE ADOPTION OF ANY NEW GOVERNING DOCUMENTS; OR ANY ACTION TO BE TAKEN AS THE MEMBER UNDER THE GOVERNING DOCUMENTS. FINAL AUTHORITY FOR THE ESTABLISHMENT OF ALL POLICY PERTAINING TO THE ORGANIZATION FOR ITS OPERATION, MAINTENANCE AND DEVELOPMENT, AND FOR THE ATTAINMENT OF ITS OBJECTIVES, IS VESTED IN THE GOVERNING BODY OF HRH, AND SUBJECT TO RATIFICATION AND APPROVAL BY SENTARA.
  FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS PREPARED BY ORGANIZATION'S CORPORATE TAX DEPARTMENT, BASED ON INFORMATION PROVIDED BY ORGANIZATION AND IN CONSULTATION WITH ORGANIZATION STAFF. THE DRAFT PREPARED BY CORPORATE IS THEN CAREFULLY REVIEWED BY ORGANIZATION MANAGEMENT AND STAFF. CHANGES ARE MADE AS APPROPRIATE. THE FINAL VERSION IS MADE AVAILABLE TO ALL MEMBERS OF THE BOARD OF TRUSTEES PRIOR TO FILING WITH THE IRS.
  FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO EACH BOARD MEMBER IN JANUARY EVERY YEAR. THE QUESTIONNAIRE MUST BE COMPLETED BY ALL MEMBERS. A REPORT OF THE DISCLOSED POTENTIAL CONFLICTS IS PRESENTED BY THE SOLE MEMBER'S BOARD CHAIRMAN TO ITS BOARD IN EXECUTIVE SESSION ANNUALLY. IF IT IS DETERMINED BY THE SOLE MEMBER'S BOARD SECRETARY, BOARD PRESIDENT, AND MEDICAL STAFF PRESIDENT THAT AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST EXISTS, THE CIRCUMSTANCES OF THE CONFLICT OF INTEREST SHALL BE SET FORTH IN DETAIL BY THE AFFECTED PARTY. SUBSEQUENTLY, WHEN A RESOLUTION CANNOT BE FOUND TO THE SATISFACTION OF THE SOLE MEMBER'S BOARD SECRETARY, BOARD PRESIDENT, AND MEDICAL STAFF PRESIDENT, THE MATTER WILL BE REVIEWED AND ADDRESSED BY THE SOLE MEMBER'S EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. A RECOMMENDATION WILL BE MADE TO THE AFFECTED PARTY ON HOW TO REMOVE THE CONFLICT. IF THE CONFLICT CANNOT BE RESOLVED TO THE SATISFACTION OF THE SOLE MEMBER'S EXECUTIVE COMMITTEE, A RECOMMENDATION WILL BE MADE TO REMOVE THE AFFECTED BOARD MEMBER FROM THE BOARD. IN SUCH CASE WHERE REMOVAL IS RECOMMENDED, SUCH REMOVAL PROCEDURES OUTLINED IN THE CORPORATE BYLAWS WILL BE FOLLOWED. THE RESPONSES TO THE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRE ARE RETAINED BY THE SOLE MEMBER'S BOARD SECRETARY.
    THE ORGANIZATION SEEKS TO PAY REASONABLE COMPENSATION UNDER IRC SECTION 4958 TO ATTRACT AND RETAIN THE APPROPRIATE CALIBER OF EMPLOYEES DEDICATED TO CARRYING OUT ITS TAX-EXEMPT MISSION. THE SOLE MEMBER OF THE ORGANIZATION PERIODICALLY CONDUCTS A REVIEW TO DETERMINE THE GOING FAIR MARKET COMPENSATION RANGES FOR COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. THE SOLE MEMBER SETS COMPENSATION WITHIN THE RANGE OF THE GOING MARKET RATE. NO INDIVIDUAL HAVING A CONFLICT OF INTEREST IS PERMITTED TO PARTICIPATE IN THE REVIEW OR DECISION. THE SOLE MEMBER MAINTAINS RECORDS REGARDING COMPENSATION. THE SOLE MEMBER'S BOARD CHAIRMAN ALSO SERVES AS THE CHAIRMAN OF ITS EXECUTIVE (COMPENSATION) COMMITTEE, COORDINATING WITH THE CHIEF EXECUTIVE OFFICER/PRESIDENT TO REVIEW ANNUAL PERFORMANCE AND COMPARATIVE MARKET INFORMATION FOR THE POSITION OF CHIEF EXECUTIVE OFFICER (CEO)/PRESIDENT, CHIEF OPERATING OFFICER (COO), AND CHIEF FINANCIAL OFFICER (CFO). A RECOMMENDATION IS PRESENTED TO THE EXECUTIVE COMMITTEE BY ITS CHAIRMAN. THE EXECUTIVE COMMITTEE TAKES ACTION ON THE RECOMMENDATION. THE SOLE MEMBER'S FULL BOARD OF DIRECTORS IS MADE AWARE THAT ITS EXECUTIVE COMMITTEE HAS TAKEN ACTION ON COMPENSATION FOR THE CEO/PRESIDENT, COO, AND CFO WITH DETAILS AVAILABLE FOR THEIR REVIEW UPON REQUEST. THIS PROCESS WAS LAST UNDERTAKEN DURING THE TAX YEAR.
  FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION CURRENTLY MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND CONSOLIDATED FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
  FORM 990, PART VII, SECTION A THE EFFECTIVE DATE OF THE ORGANIZATION'S AFFILIATION WITH SENTARA HEALTHCARE, ITS NEW 501(C)(3) SOLE MEMBER, WAS JULY 1, 2013. SINCE THE COMPENSATION REQUIRED TO BE REPORTED IN PART VII SECTION A IS FROM THE 2012 CALENDAR YEAR, AND SENTARA HEALTHCARE WAS NOT RELATED TO THE ORGANIZATION AT ANY TIME DURING 2012, NO RELATED COMPENSATION HAS BEEN REPORTED IN PART VII SECTION FOR BOARD MEMBER AND TREASURER ROBERT BROERMANN, WHO IS AN EMPLOYED OFFICER OF SENTARA HEALTHCARE.
CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: ASU 2010-07 FMV ADJUSTMENTS 2,965,000. CHANGE IN PENSION LIABILITY 197,898.
CHANGE IN AFS OVERSIGHT PROCESS FORM 990, PART XII, LINE 2C DURING THE YEAR, THE ORGANIZATION AFFILIATED WITH THE SENTARA HEALTHCARE SYSTEM, WHO ASSUMED RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTED THE INDEPENDENT ACCOUNTANT.
STATEMENT FILED PURSUANT TO TREASURY REGULATION SEC. 1.6038-2(J)(3):   HALIFAX REGIONAL HOSPITAL, INC. ("HRH"), THE TAXPAYER'S 501(C)(3) SOLE MEMBER, OWNS A NON-CONTROLLING INTEREST IN VIRGINIA SOLUTIONS SPC, LTD., A CONTROLLED FOREIGN CORPORATION. ALL INFORMATION REQUIRED OF THE TAXPAYER BY IRC SECTION 6038 AND THE REGULATIONS THEREUNDER WITH RESPECT TO VIRGINIA SOLUTIONS SPC, LTD. IS FURNISHED BY HRH, EIN 54-0648699. THEREFORE, PURSUANT TO TREASURY REGULATION SEC. 1.6038-2(J)(2), THE TAXPAYER IS EXCEPTED FROM PROVIDING SUCH INFORMATION. THE REQUIRED INFORMATION IS E-FILED WITH HRH'S FORM 990 RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2012

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
HALIFAX REGIONAL LONG TERM CARE INC
 
Employer identification number

54-6074529
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" to Form 990, Part IV, line 33.)
(a)
Name, address, and EIN (if applicable) 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










Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" to 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 entity?
Yes No
(1) HALIFAX REGIONAL HOSPITAL INCORPORATED

2204 WILBORN AVENUE

SOUTH BOSTON,VA24592
54-0648699 		HEALTHCARE VA 501(C)(3) 3 SENTARA HEALTHCARE
 
Yes
 
(2) HALIFAX REGIONAL DEVELOPMENT FOUNDATION

2204 WILBORN AVENUE

SOUTH BOSTON,VA24592
54-1801459 		HLTH/WELFARE VA 501(C)(3) 11A TYPE I HALIFAX REGIONAL HOSPITAL
 
Yes
 
(3) HALIFAX REGIONAL PROPERTIES INC

2204 WILBORN AVENUE

SOUTH BOSTON,VA24592
54-1801463 		HLTH/WELFARE VA 501(C)(3) 11A TYPE I HALIFAX REGIONAL HOSPITAL
 
Yes
 
(4) HALIFAX REGIONAL HEALTH SYSTEM INC

2204 WILBORN AVENUE

SOUTH BOSTON,VA24592
54-1801466 		HEALTHCARE VA 501(C)(3) 11B TYPE II N/A
 
No
(5) CLARKSVILLE SENIOR CARE LLC

2204 WILBORN AVENUE

SOUTH BOSTON,VA24592
54-1957066 		SENIOR CARE VA 501(C)(3) 11A TYPE I HALIFAX REGIONAL HOSPITAL
 
Yes
 
(6) SENTARA HEALTHCARE

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
52-1271901 		HEALTH CARE VA 501(C)(3) LN7_NORMALGOVTSUPPOR N/A
 
No
(7) SENTARA PRINCESS ANNE HOSPITAL

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
52-1277419 		HEALTH CARE VA 501(C)(3) LN3_HOSPITALCOOPINSE SENTARA HOSPITALS
 
Yes
 
(8) SENTARA HOSPITALS

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1547408 		HEALTH CARE VA 501(C)(3) LN3_HOSPITALCOOPINSE SENTARA HEALTHCARE
 
Yes
 
(9) SENTARA MEDICAL GROUP

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1217184 		HEALTH CARE VA 501(C)(3) LN9_MORETHAN30PCTCON SENTARA HEALTHCARE
 
Yes
 
(10) SENTARA ENTERPRISES

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1917649 		HEALTH CARE VA 501(C)(3) LN9_MORETHAN30PCTCON SENTARA HEALTHCARE
 
Yes
 
(11) SENTARA LIFE CARE CORP

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1217183 		HEALTH CARE VA 501(C)(3) LN9_MORETHAN30PCTCON SENTARA HEALTHCARE
 
Yes
 
(12) MPB INC

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1346393 		TITLE HOLDING COMPANY VA 501(C)(2)   SENTARA ENTERPRISES
 
Yes
 
(13) OPTIMA HEALTH PLAN

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-1283337 		HMO VA 501(C)(3) 11A - I SENTARA HEALTHCARE
 
Yes
 
(14) POTOMAC HOSPITAL CORP OF PRINCE WILLIAM

6015 POPLAR HALL DRIVE

NORFOLK,VA23502
54-0853898 		HEALTH CARE VA 501(C)(3) LN3_HOSPITALCOOPINSE SENTARA HEALTHCARE
 
Yes
 
(15) ROCKINGHAM MEMORIAL HOSPITAL

2010 HEALTH CAMPUS DRIVE

HARRISONBURG,VA22801
54-0506331 		HEALTH CARE VA 501(C)(3) LN3_HOSPITALCOOPINSE SENTARA HEALTHCARE
 
Yes
 
(16) VALLEY WELLNESS CENTER

501 STONE SPRING ROAD

HARRISONBURG,VA22801
52-1309257 		PREVENTATIVE HEALTH/REHAB VA 501(C)(3) LN9_MORETHAN30PCTCON ROCKINGHAM MEMORIAL HOSPITAL
 
Yes
 
(17) MJH FOUNDATION

500 MARTHA JEFFERSON DRIVE

CHARLOTTESVILLE,VA22911
54-1401357 		INVEST/MGT SVCS FOR MARTHA JEFFERSON HOSPITAL VA 501(C)(3) 11A - I MARTHA JEFFERSON HOSPITAL
 
Yes
 
(18) MARTHA JEFFERSON HOSPITAL FOUNDATION

500 MARTHA JEFFERSON DRIVE

CHARLOTTESVILLE,VA22911
30-0041113 		FUNDRAISING VA 501(C)(3) 11A - I MARTHA JEFFERSON HOSPITAL
 
Yes
 
(19) MARTHA JEFFERSON HOSPITAL

500 MARTHA JEFFERSON DRIVE

CHARLOTTESVILLE,VA22911
54-0261840 		HEALTH CARE VA 501(C)(3) LN3_HOSPITALCOOPINSE SENTARA HEALTHCARE
 
Yes
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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 V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) MANAGEMENT SERVICES LLC

814 GREENBRIER CIRCLE
CHESAPEAKE,VA23320
54-1365012 		HLTH MGT SV VA N/A
                  
(2) OBICI REAL ESTATE HOLDINGS LLC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
26-1749881 		RE RENTAL VA N/A
                  
(3) PRINCESS ANNE AMB SURG MGT LLC

1975 GLENN MITCHELL STE 300
VA BEACH,VA23456
20-4920880 		HEALTH CARE VA N/A
                  
(4) VA BEACH AMBULATORY SURGERY CENTER

1700 WILL O WISP DRIVE
VA BEACH,VA23454
54-1448218 		HEALTH CARE VA N/A
                  
(5) AMER HEALTH EVAL CTR-WMSBG LLC

739 THIMBLE SHOALS STE 105
NEWPORT NEWS,VA23606
26-3761741 		HEALTH CARE VA N/A
                  
(6) CANCER CENTERS OF VA LLC

5900 LAKE WRIGHT DRIVE
NORFOLK,VA23502
20-1338518 		HEALTH CARE VA N/A
                  
(7) HAMPTON ROADS LITHOTRIPSY LLC

225 CLEARFIELD AVE
VIRGINIA BEACH,VA23462
20-0942600 		HEALTH CARE VA N/A
                  
(8) HEALTHCARE PERFORMANCE IMPROVEMENT LLC

5041 CORPORATE WOODS DR STE 180
VIRGINIA BEACH,VA23462
20-4024074 		CONSULTING VA N/A
                  
(9) RADIOLOGY SERVICES OF HAMPTON ROADS LC

814 GREENBRIER CIRCLE STE L
CHESAPEAKE,VA23320
54-1774472 		HEALTH CARE VA N/A
                  
(10) SENTARA OBICI AMBULATORY SURGERY LLC

2750 GODWIN BLVD
SUFFOLK,VA23434
26-0144898 		HEALTH CARE VA N/A
                  
(11) ST LUKES PROPERTIES LLC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
27-2774684 		MOB RENTAL VA N/A
                  
(12) POTOMAC INOVA HEALTHCARE ALLIANCE LLC

8110 GATEHOUSE RD STE 400W
FALLS CHURCH,VA22042
54-1802733 		HEALTHCARE VA N/A
                  
(13) CAREPLEX WEST LLC

18000 W SARAH LANE STE 250
BROOKFIELD,WI53045
20-2738977 		RENTAL RE WI N/A
                  
(14) PORT WARWICK II LLC

18000 WEST SARAH LANE STE 250
BROOKFIELD,WI53045
20-2739075 		RENTAL RE WI N/A
                  
(15) ORTHOPAEDIC HOSPITAL MANAGEMENT LLC

3000 COLISEUM DRIVE
HAMPTON,VA23666
27-4185117 		MGT SVCS VA N/A
                  
(16) CAREPLEX ORTHOPAEDIC ASC LLC

3000 COLISEUM DRIVE
HAMPTON,VA23666
27-1867311 		HEALTH CARE VA N/A
                  
(17) PORT WARWICK III LLC

18000 WEST SARAH LANE STE 250
BROOKFIELD,WI53045
61-1499371 		RENTAL RE WI N/A
                  
(18) MARTHA JEFFERSON OSC LLC

595 MARTHA JEFFERSON DR
CHARLOTTESVILLE,VA22911
11-3656095 		HEALTH CARE VA N/A
                  
(19) VALIANCE HEALTH LLC

3190 PEOPLES DRIVE
HARRISONBURG,VA22801
54-1866081 		HEALTH CARE VA N/A
                  
(20) PHYSICAL THERAPY ACACLLC

501 ALBEMARLE SQUARE
CHARLOTTESVILLE,VA22901
26-0080717 		HEALTH CARE VA N/A
                  
(21) NORTHERN VIRGINIA HOME CARE LLC

601 SOUTH CARLIN SPRINGS RD
ARLINGTON,VA22204
45-3940053 		HOME CARE VA N/A
                  
(22) MNS SUPPLY CHAIN NETWORK LLC

2085 FRONTIS PLAZA BLVD
WINSTON SALEM,NC27103
45-4235238 		GPO DE N/A
                  
(23) LAKE RIDGE AMBULATORY SURGERY CENTER LLC

12825 MINNIEVILLE RD STE 204
WOODBRIDGE,VA22192
45-5347932 		HEALTH CARE VA N/A
                  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" to 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) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) SOUTHSIDE HEALTH SERVICES INC

2204 WILBORN AVENUE
SOUTH BOSTON,VA24592
54-1417772 		HEALTH SERVICES VA N/A
 C       Yes  
(2) DOMINION HEALTH MEDICAL ASSOCIATES LTD

2204 WILBORN AVENUE
SOUTH BOSTON,VA24592
54-1060357 		PHYS PRACTICE VA N/A
 C       Yes  
(3) SENTARA HOLDINGS INC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1555638 		HOLDING COMPANY VA N/A
 C       Yes  
(4) SENTARA HEALTH PLANS INC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
52-2368125 		TPA VA N/A
 C       Yes  
(5) OPTIMA HEALTH GROUP

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1473382 		HMO VA N/A
 C       Yes  
(6) OPTIMA HEALTH INSURANCE COMPANY

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1642752 		HEALTH INSURANCE VA N/A
 C       Yes  
(7) OPTIMA BEHAVIORAL HEALTH SERVICES

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
62-1382666 		MENTAL HEALTH SVCS VA N/A
 C       Yes  
(8) SENTARA VENTURES INC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1688615 		HOLDING COMPANY VA N/A
 C       Yes  
(9) SMG INNOVATIONS INC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
20-3730331 		HEALTH CARE VA N/A
 C       Yes  
(10) SENTARA OBICI PROFESSIONAL CENTER

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1445865 		RE RENTAL VA N/A
 C       Yes  
(11) SENTARA STRATEGIC SOLUTIONS INC

6015 POPLAR HALL DRIVE
NORFOLK,VA23502
54-1020941 		HEALTH CARE VA N/A
 C       Yes  
(12) POTOMAC VENTURES CORP

2300 OPITZ BLVD
WOODBRIDGE,VA22191
54-1441420 		PHARMACY VA N/A
 C       Yes  
(13) ROCKINGHAM HEALTH SERVICES INC

2010 HEALTH CAMPUS DRIVE
HARRISONBURG,VA22801
54-1721387 		CONTRACTING SVCS VA N/A
 C       Yes  
(14) MARTHA JEFFERSON MEDICAL ENTERPRISES INC

500 MARTHA JEFFERSON DRIVE
CHARLOTTESVILLE,VA22911
54-1841528 		MEDICAL BILLING SVCS VA N/A
 C       Yes  
(15) BAY PRIMEX INSURANCE COMPANY LTD

PO BOX 1051
GRAND CAYMAN   KY1-1102
CJ
98-0704114 		INSURANCE CJ N/A
 C       Yes  
Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" to Form 990, Part IV, line 34, 35b, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
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 or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
Yes
 
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
Yes
 
r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1s
 
No
2
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-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) CLARKSVILLE SENIOR CARE LLC

 C 650,000 CORP BOOKS/REC
(2) HALIFAX REGIONAL PROPERTIES

 B 300,000 CORP BOOKS/REC
(3) HALIFAX REGIONAL HOSPITAL INC

 O 610,668 CORP BOOKS/REC
(4) HALIFAX REGIONAL HOSPITAL INC

 P 2,207,552 CORP BOOKS/REC


Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" to 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) 		(d)
Predominant income (related, unrelated, excluded from tax under section 512-514)

(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 V—UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2012
Schedule R (Form 990) 2012
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

Additional Data


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