Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
St Catherines Laboure Manor Inc
Employer identification number
59-1878316
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
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
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
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
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)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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
Gross receipts from related activities, etc. (see instructions)
..................
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.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
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
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
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)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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
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.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
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) 2013
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
St Catherines Laboure Manor Inc
Employer identification number
59-1878316
Return Reference
Explanation
Form 990, Part III:
St. Catherines Laboure Manor, Inc. Community Benefit Report June 30, 2014 This report illustrates the significant degree to which St. Catherines Laboure Manor contributes to the positive health status of the residents of Jacksonville, Florida and surrounding communities. St. Catherines Laboure Manor is a subsidiary of St. Vincent's HealthCare, a multi entity healthcare network that provides essential health services to its community. As a member of Ascension Health, the nation's largest Catholic healthcare system, St. Vincent's HealthCare continues to build and strengthen sustainable collaborative efforts that benefit the health of individuals, families, and society as a whole. The goal of St. Vincent's HealthCare is to perpetuate the healing mission of the church. St. Vincent's HealthCare furthers this goal through delivery of patient services, care to the elderly and indigent, patient education and health awareness programs for the community, and medical research. Our concern for all human life and dignity of each person leads the organization to provide medical services to all people in the community without regard to the patient's race, creed, national origin, economic status, or ability to pay. In order to portray the full breadth of our contribution, our community benefit information is described below: Organizational Commitment to Providing Community Benefit: St. Catherines Laboure Manor is a 240 bed nursing home. St. Catherines' serves the residents of northeast Florida and southeast Georgia. As one of the largest long-term nursing facilities in Jacksonville, St. Catherines' offers many of the services residents need in a home-like atmosphere. Services include a 60-bed Special Care Unit for Alzheimer's and Dementia residents, dental and pharmacy services, a library, a beauty/barber shop, and chapel services. With a mission of healing through dignity, compassion and respect, St. Catherines Laboure Manor is uniquely suited to caring for those in need of short-term respite care, long-term care, 24-hour care or Hospice care. Through its wide range of services, staff is prepared to meet the physical, emotional, and spiritual needs of residents. St. Catherines' has a specialized Alzheimer/Dementia unit designed to meet the needs of these residents. Combining thoughtful design of the interior with specialized training of the staff, St. Catherines' provides a responsive and secure living area for up to 60 residents with memory impairments. This separate unit offers its own enclosed garden to provide patients access to safe outdoor activities, as well as specialized activity programs and a family support group. St. Catherines' contracts with RehabCare, Inc. for its physical, occupational, and speech therapy services. Upon admission for short-term or long-term care, a licensed and qualified therapist will assess the new resident, and work with the physician to help the resident meet their goals. St. Catherines' offers an activities program designed to meet residents' needs and abilities. Staff members schedule many special events throughout the year including several family nights and programs featuring special guests to entertain our patients and residents. The patients and residents especially enjoy visits from Body & Soul: The Art of Healing, a unique group of performers and artists from Jacksonville that recognizes the value of the arts to one's health and well being. Body & Soul: The Art of Healing is a program that links the arts and healing to diminish the stresses that many in the healthcare and extended care environment experience. It brings professional artists into hospitals, assisted living and psychiatric facilities to enhance the quality of healthcare through the arts as well as to enlarge the arts through service. Monthly performances are held at St. Catherines' in group and room-to-room settings, featuring instrumental, vocal and theatrical performances by celebrated Jacksonville performers. The program, developed and implemented by James Jenkins of the Jacksonville Symphony Orchestra and board member of Riverside Fine Arts Association, is partnered by the Cummer Museum of Art in Jacksonville and St. Vincent's Foundation. Additional information about St. Catherines' can be found on the St. Vincent's HealthCare webpage, located at www.jaxhealth.com. Unreimbursed Services Provided to the Elderly and the Poor: In the spirit of principles adopted by Ascension Health, St. Catherines Laboure Manor has taken proactive steps to address those issues that will affect accessibility, the financing, and the delivery of nursing home services to all persons, especially the uninsured and the underserved. During the fiscal year ending June 30, 2014, approximately 22% of the values of services rendered were to elderly patients under the Medicare program, and approximately 53% of the services were provided to patients under the Medicaid program. Operations and Governance: St. Catherines Laboure Manor - has a governing body composed of community representatives and officials of St. Vincent's HealthCare. - is subject to all federal and state regulations including CMS, OBRA and OSHA. - participates in Medicaid, Medicare, CHAMPUS, Tricare, and/or other government-sponsored health care programs. Patient Services: St. Catherines Laboure Manor provides quality inpatient resident care services to the elderly and/or infirm residents of Jacksonville, Florida and the surrounding communities. The facility operates an Alzheimer's unit that has been recognized for the skilled and caring ministry of its residents. St. Catherines' has been awarded recognition as a top nursing home care facility in the state of Florida. During the fiscal year ended June 30, 2014, St. Catherines' provided 83,395 days of residential care. Summary: St. Catherines Laboure Manor furthers its charitable purposes by providing a broad array of services to meet the healthcare and residential needs of those unable to care for themselves. We provide essential services to the community and provide appropriate charity services to those residents who are not able to pay for their own needs, and present education information classes and activities to the community in order to improve the overall status of the elderly. The care of these people who are so in need of support is the founding mission of the Daughters of Charity.
Form 990, Part VI, Section A, line 2
Many of the persons listed on Part VII have a "business relationship" with each other by virtue of employment by St. Vincent's Health related entities.
Form 990, Part VI, Section A, line 6
St. Catherines Laboure Manor, Inc. has a single corporate member, St. Vincent's Health System, Inc.
Form 990, Part VI, Section A, line 7a
St. Catherines Laboure Manor, Inc. has a single corporate member, St. Vincent's Health System, Inc., who has the ability to elect members to the governing body of St. Catherines Laboure Manor, Inc.
Form 990, Part VI, Section A, line 7b
All decisions that have a material impact to St. Catherines Laboure Manor, Inc. financial information or corporation as a whole are subject to approval by its sole corporate member, St. Vincent's Health System, Inc.
Form 990, Part VI, Section A, line 8b
There are no separate committees that have the authority to act on behalf of the governing body for St. Catherines Laboure Manor, Inc.
Form 990, Part VI, Section B, line 11
Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Management presents the Form to the Board, or a designated committee, to review and answer any questions. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members' questions.
Form 990, Part VI, Section B, line 12c
Officers, directors or trustees, and key employees are required to complete a Conflict of Interest Attestation Statement at the time of hiring or when their service begins. Annually, the Corporate Responsibility Officer sends the Conflict of Interest Policy and Attestation Statement to all officers, directors or trustees, and key employees for completion and return within two weeks. Three separate mailings are sent out with two week deadlines to receive a maximum response. The responses from the returned Attestation Statement are organized in a spreadsheet and are carefully reviewed by the Corporate Responsibility Officer, the Chief Legal Officer, and the Chief Executive Officer. A full report is presented to the Audit Committee and any potential conflicts of interest are handled by the Committee in an appropriate manner.
Form 990, Part VI, Section B, line 15
In determining the compensation of the organization's CEO, the process, performed by Ascension Health, a related organization of St. Catherines Laboure Manor, Inc., included a review and approval by independent persons, comparability data and contemporaneous substantiation of the deliberation and decision. The Compensation Committee reviewed and approved the compensation. In the review of the compensation, the CEO was compared to individuals at other organizations in the area who hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the Committee minutes. The individual was not present when his compensation was decided. In determining the compensation of other officers and key employees of the organization, the process, performed by St. Vincent's Health System, Inc., a related organization who paid the other officers and key employees, included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Audit Committee reviewed and approved the compensation. In the review of the compensation, the other officers and key employees were compared to individuals at other organizations in the area who hold the same title. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes.
Form 990, Part VI, Section C, line 19
The organization will provide any documents open to public inspection upon request.
Form 990, Part VII, Section B:
Independent Contractor Reporting: Compensation of independent contractors is paid by and reported on the Form 1096, Annual Summary and Transmittal of U.S. Information Returns, of Ascension Health EIN 31-1662309. Expenses are allocated to and reimbursed by the filing organization to Ascension Health. As such, the organization has not reported independent contractors paid on Form 990, Part VII, Section B.
Form 990, Part IX, Line 24e:
All Other Expenses Breakout: Dietary Purchased Svcs - $913,912 Envtl Purchased Svcs - $632,106 Repairs Purchased Svcs - $551,217 Laundry Purchased Svcs - $483,129 All Other - $350,522 Total - $2,580,364
Form 990, Part XI, line 9:
Transfer to Affiliates -1,072,971. Unrestricted Defined Pension Cost -307,604. Other Temporary Restricted -6,384.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.