Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (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 listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Total | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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 VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (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...... | 12,565,715 | 14,054,291 | 14,854,991 | 15,207,877 | 15,032,184 | 71,715,058 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | 66,646 | 66,646 | ||||
| 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. | 12,565,715 | 14,054,291 | 14,854,991 | 15,207,877 | 15,098,830 | 71,781,704 |
| 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. | 386,642 | 386,642 | ||||
| c | Add lines 7a and 7b.. | 386,642 | 386,642 | ||||
| 8 | Public support (Subtract line 7c from line 6.) | 71,395,062 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 12,565,715 | 14,054,291 | 14,854,991 | 15,207,877 | 15,098,830 | 71,781,704 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 1,367 | 145 | 109 | 13 | 1,634 | |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | 1,367 | 145 | 109 | 13 | 1,634 | |
| 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 VI.) .. | 4,654 | 4,654 | ||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 12,571,736 | 14,054,436 | 14,855,100 | 15,207,890 | 15,098,830 | 71,787,992 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
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|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| PART III, LINE 12 | 4,654 |
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PAGE 2, PART III, LINE 4A | INPATIENT AND OUTPATIENT PHYSICAL THERAPY, SPEECH THERAPY AND OCCUPATIONAL THERAPY, RESIDENTIAL CUSTODIAL CARE, RESPITE AND HOSPICE CARE. THE ALIGNING OF THE TWO ORGANIZATIONS ENHANCES THE CONTINUUM OF CARE THE REGION'S PATIENTS RECEIVE. IT RESULTS IN A SEAMLESS TRANSITION FROM ONE HEALTHCARE SETTING TO ANOTHER, WHILE RETAINING THE SAME QUALITY THROUGHOUT THE CARE PROCESS. SPECIAL ATTENTION IS GIVEN TO THE PERSONAL NEEDS OF EACH RESIDENT. SOCIAL, RELIGIOUS, RECREATIONAL AND EDUCATIONAL PROGRAMS, ALONG WITH OTHER AMENITIES, ARE PROVIDED SO EACH RESIDENT CAN LEAD A FULFILLING LIFE AND EXPERIENCE AS MUCH PERSONAL FREEDOM AS POSSIBLE. SERVICES AT WELLMONT WEXFORD HOUSE INCLUDE NURSING AND HEALTH CARE PROGRAMS THAT OFFER A WIDE RANGE OF INDIVIDUALIZED CARE. IN ADDITION TO THE SERVICES NOTED ABOVE, OTHER EXAMPLES INCLUDE RESPIRATORY CARE, THERAPEUTIC MANAGEMENT, RESTORATIVE THERAPIES, NUTRITIONAL COUNSELING AND RECREATIONAL ACTIVITIES, AS WELL AS CONVALESCENT NURSING CARE TO THE ACUTELY ILL. RESIDENTS ALSO HAVE ONSITE ACCESS TO DIAGNOSTIC SERVICES SUCH AS ULTRASOUND, X-RAY AND EKG. MOTIVATIONAL PROGRAMS EMPHASIZE THE REHABILITATION OF EACH RESIDENT TO THEIR MAXIMUM LEVEL OF FUNCTIONING. OTHER MEDICAL SERVICES OFFERED INCLUDE ENTERAL NUTRITIONAL AND TUBE FEEDING, FOLEY CATHETER CARE, COLOSTOMY, UROSTOMY, NEPHROSTOMY CARE, TRACHEOSTOMY CARE AND NASO/PHARYNGEAL SUCTIONING, IV ACCESS CARE AND THERAPY/ANTIBIOTICS, PAIN MANAGEMENT, DIABETES CARE, WOUND CARE, LAB SERVICES, ORTHOPEDIC REHABILITATION, INCONTINENCE CARE, AND DENTAL AND VISION CARE. WELLMONT WEXFORD HOUSE EARNED THE JOINT COMMISSION'S GOLD SEAL OF APPROVAL FOR ACCREDITATION AND CERTIFICATION. IT ACHIEVED THAT DESIGNATION BY COMPLYING WITH NATIONAL STANDARDS FOR ADVANCED REHABILITATION SERVICES, HEALTHCARE QUALITY AND PATIENT AND RESIDENT SAFETY IN NURSING HOME CARE. FOR THE ELEVENTH YEAR IN A ROW, WEXFORD HOUSE WAS SELECTED BY KINGSPORT TIMES-NEWS READERS AS THE BEST NURSING HOME. DURING FISCAL YEAR 2015, WEXFORD HOUSE SERVED 419 RESIDENTS AND PROVIDED 60,674 DAYS OF CARE. |
| FORM 990, PAGE 6, PART VI, LINE 6 | THE BUSINESS AND AFFAIRS OF WELLMONT WEXFORD HOUSE (THE CORPORATION) SHALL BE GOVERNED EXCLUSIVELY BY THE BOARD OF DIRECTORS. THE CORPORATION'S BOARD OF DIRECTORS IS DESIGNATED BY WELLMONT HEALTH SYSTEM, THE SOLE MEMBER OF THE CORPORATION. IN ADDITION TO SUCH RIGHTS OF APPROVAL AND CONSENT AS MAY BE RESERVED TO THE SOLE MEMBER OF THE CORPORATION PURSUANT TO APPLICABLE LAW, TRANSACTIONS OF THE FOLLOWING MATTERS BY THE CORPORATION SHALL REQUIRE THE PRIOR APPROVAL OF WELLMONT HEALTH SYSTEM, THE SOLE MEMBER OF THE CORPORATION: A) IMPLEMENTATION OF THE CORPORATION'S ANNUAL BUDGET, B) INCURRING ANY LOAN OR OTHER INDEBTEDNESS FOR BORROWED MONEY, C) ACQUISITION OF ANY EQUIPMENT OR PERSONAL PROPERTY FOR A PURCHASE PRICE IN EXCESS OF 50,000 OR THE ACQUISITION OF ANY REAL ESTATE, REGARDLESS OF PURCHASE PRICE, D) THE UNDERTAKING OF CERTAIN CONTRACTUAL COMMITMENTS, E) ENTERING INTO ANY PLAN OF MERGER OR CONSOLIDATION, F) ACQUISITION OF SUBSTANTIALLY ALL OF THE ASSETS OF ANY OTHER LEGAL ENTITY, AND G) INSTITUTION OF ANY LITIGATION BY OR ON BEHALF OF THE CORPORATION. |
| FORM 990, PAGE 6, PART VI, LINE 7A | SEE FORM 990, PART VI, SECTION A, LINE 6 EXPLANATION. |
| FORM 990, PAGE 6, PART VI, LINE 7B | SEE FORM 990, PART VI, SECTION A, LINE 6 EXPLANATION. |
| FORM 990, PAGE 6, PART VI, LINE 9 | LOUIS COLLIER (TERMED 9/26/14) 1905 AMERICAN WAY KINGSPORT, TN 37660 TRACEY P. MOFFATT (TERMED 10/3/14) 1905 AMERICAN WAY KINGSPORT, TN 37660 KATHY GREEN (TERMED 11/4/14) 1905 AMERICAN WAY KINGSPORT, TN 37660 |
| FORM 990, PAGE 6, PART VI, LINE 11B | WELLMONT WEXFORD HOUSE FORM 990 IS REVIEWED BY THE EXECUTIVE DIRECTOR OF WELLMONT WEXFORD HOUSE, THE SENIOR VICE PRESIDENT OF FINANCE, THE CORPORATE CONTROLLER, AND THE MANAGER OF ACCOUNTING FOR WELLMONT HEALTH SYSTEM, AND THE BOARD OF DIRECTORS OF WELLMONT WEXFORD HOUSE PRIOR TO FILING. ANY QUESTIONS OR COMMENTS ARISING FROM THE INITIAL REVIEW ARE ADDRESSED TO ENSURE THE RETURN IS COMPLETE AND ACCURATE. ANY CHANGES OR CORRECTIONS ARE MADE, AND THE RETURN IS THEN PROVIDED TO THE ABOVE INDIVIDUALS PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. |
| FORM 990, PAGE 6, PART VI, LINE 12C | OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE REQUIRED TO SIGN A CONFLICT OF INTEREST POLICY ACKNOWLEDGEMENT. ANY POTENTIAL CONFLICTS ARE DISCUSSED WITH THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT, AS THEY ARISE. WELLMONT WEXFORD HOUSE OFFICERS, DIRECTORS AND KEY EMPLOYEES ARE GOVERNED BY WELLMONT HEALTH SYSTEM'S CONFLICT OF INTEREST POLICY. WELLMONT HEALTH SYSTEM ALSO HAS A POLICY ON BUSINESS PRACTICES THAT DISCUSSES CONFLICT OF INTEREST AND INFORMS THE WORKFORCE TO DISCLOSE ANY ISSUES TO THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT, FOR RESOLUTION. WELLMONT HEALTH SYSTEM ALSO USES A HOTLINE THAT ALLOWS ANONYMOUS REPORTING OF POSSIBLE CONFLICT OF INTEREST SITUATIONS FOR INVESTIGATION BY THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT. |
| FORM 990, PAGE 6, PART VI, LINE 15A | THE COMPENSATION OF BARTON A. HOVE, THE PRESIDENT AND CEO OF WELLMONT HEALTH SYSTEM, IS REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE AND BOARD OF DIRECTORS. BARTON A. HOVE IS ALSO A BOARD MEMBER OF WELLMONT WEXFORD HOUSE. IN ADDITION, THESE BODIES USE COMPARABILITY DATA TO DETERMINE THE APPROPRIATE COMPENSATION. ALL COMPENSATION DELIBERATIONS AND REVIEWS ARE CONTEMPORANEOUSLY DOCUMENTED. THE LAST COMPENSATION DELIBERATION AND REVIEW PROCESS FOR BARTON A. HOVE WAS COMPLETED AND APPROVED BY THE BOARD OF DIRECTORS OF WELLMONT HEALTH SYSTEM ON MARCH 20, 2015. |
| FORM 990, PAGE 6, PART VI, LINE 15B | THE COMPENSATION OF THE OTHER OFFICERS AND KEY EMPLOYEES OF WELLMONT WEXFORD HOUSE ARE REVIEWED, APPROVED AND DOCUMENTED BY THE WELLMONT HEALTH SYSTEM HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS. OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION HAVE WRITTEN EMPLOYMENT CONTRACTS, AND COMPENSATION IS BASED ON SURVEYS/STUDIES AND THEN APPROVED BY THE WELLMONT HEALTH SYSTEM CEO. IN ADDITION, THESE BODIES USE COMPARABILITY DATA TO DETERMINE THE APPROPRIATE COMPENSATION. ALL COMPENSATION DELIBERATIONS AND REVIEWS ARE CONTEMPORANEOUSLY DOCUMENTED. THIS PROCESS IS COMPLETED ON AN ANNUAL BASIS. THE HUMAN RESOURCES COMMITTEE OF THE BOARD OF DIRECTORS REVIEW THE SALARY AND MARKET COMPENSATION DATA FOR THE FOLLOWING OTHER OFFICERS AND KEY EMPLOYEES ON DECEMBER 10, 2013. - WELLMONT HEALTH SYSTEM CHIEF OPERATIONS OFFICER - TRACEY P. MOFFATT - WELLMONT HEALTH SYSTEM EXECUTIVE VP AND CHIEF FINANCIAL OFFICER - ALICE POPE WELLMONT HEALTH SYSTEM USES ONE OR MORE OF THE METHODS DESCRIBED TO ESTABLISH THE COMPENSATION OF THE FOLLOWING OTHER OFFICERS AND KEY EMPLOYEES. - WELLMONT HEALTH SYSTEM SR. VP AND GENERAL COUNSEL - GARY D. MILLER - HOLSTON VALLEY MEDICAL CENTER PRESIDENT - TIM ATTEBERY - WELLMONT HEALTH SYSTEM VP POST ACUTE SERVICES AND HOSPITALIST CARE - LOUIS COLLIER - WELLMONT WEXFORD HOUSE EXECUTIVE DIRECTOR - LEE ELLIOTT - WELLMONT WEXFORD HOUSE EXECUTIVE DIRECTOR - KATHY GREEN |
| FORM 990, PAGE 6, PART VI, LINE 19 | WELLMONT WEXFORD HOUSE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. WELLMONT HEALTH SYSTEM'S AUDITED FINANCIAL STATEMENTS AND QUARTERLY UNAUDITED FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE ELECTRONIC MUNICIPAL MARKET ACCESS WEBSITE. |
| FORM 990, PART IX, LINE 11G | PURCHASE SERVICES 1,500,095 188,332 0 |
| FORM 990, PART XI, LINE 9 | INTERCOMPANY DISTRIBUTION 797,234 |
| FORM 990, PAGE 12, PART XII, LINE 2C | WELLMONT WEXFORD HOUSE FINANCIAL STATEMENTS ARE INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF WELLMONT HEALTH SYSTEM. WELLMONT WEXFORD HOUSE FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2015 WERE AUDITED AS PART OF WELLMONT HEALTH SYSTEM'S CONSOLIDATED FINANCIAL STATEMENTS. WELLMONT HEALTH SYSTEM HAS AN AUDIT COMMITTEE WHICH ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT AUDITOR. THIS REVIEW PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
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| Software Version: |