TY 2018 Form 990

(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)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) TIMOTHY KELLNER 2018 VICE CHAIR & 2019 Chair	1.0 ................. 0	X	X	0	0	0
(2) JAMIE LOIACONO 2019 Secretary	1.0 ................. 0	X	X	0	0	0
(3) THERESE B PANDL INTERIM PRES/ CEO EASTERN WISCONSIN DIVISION	12.0 ................. 48.0	X	X	0	924,387	174,302
(4) Justin Selle President & CEO as of 8/20/18	20.0 ................. 0	X	X	0	158,718	19,143
(5) DAVID VAN DE WATER JD 2018 CHAIR	1.0 ................. 0	X	X	0	0	0
(6) JOHN WENIG 2018 SECRETARY & 2019 Vice Chair	1.0 ................. 0	X	X	0	0	0
(7) John Brotz BOARD MEMBER	1.0 ................. 0	X		0	0	0
(8) CARL CLAERBOUT BOARD MEMBER	1.0 ................. 0	X		0	0	0
(9) MICHAEL W COTTRELL BOARD MEMBER/HSHS CFO	1.0 ................. 59.0	X		0	828,161	189,746
(10) SR MAUREEN FAGAN OSF BOARD MEMBER	1.0 ................. 2.0	X		0	0	0
(11) Lindsey Harrison-Eirich BOARD MEMBER	1.0 ................. 0	X		0	0	0
(12) Sara Smith MD BOARD MEMBER	1.0 ................. 0	X		0	0	0
(13) WILLIAM TRAGER MD BOARD MEMBER	1.0 ................. 0	X		0	0	0
(14) STEPHEN WERNER MD BOARD MEMBER	1.0 ................. 0	X		0	0	0
(15) ANN M CARR TREASURER	0.3 ................. 59.7		X	0	329,829	110,463
(16) MARY MARTIN CHIEF NURSING OFFICER	40.0 ................. 0		X	190,688	0	56,480
(17) GREG SIMIA DIVISION CFO	10.0 ................. 30.0		X	0	456,456	89,224

(A) Name and business address	(B) Description of services	(C) Compensation
TOTAL MSP LLC 221 W COLLEGE AVE FLOOR 2 APPLETON,WI54911	CONTRACT LABOR	1,305,561
PREVEA PO BOX 19070 GREEN BAY,WI543079070	SHARED LABOR & SERVICES	996,105
COMPASS ONE PO BOX 102289 ATLANTA,GA30368	FOOD & HOUSEKEEPING SERVICES	731,578
EAGLE TELEMEDICINE 280 INTERSTATE NORTH CIRCLE SE ATLANTA,GA30339	TELEMEDICINE SERVICES	487,737
ANESTHESIOLOGY ASSOCIATES PO BOX 68-6160 MILWAUKEE,WI53268	ANESTHESIA	385,302
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 18

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

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

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc
is

Employer identification number

39-0808480

Part I

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

The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.)

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

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).)

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

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

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.)

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

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

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

An agricultural research organization described in 170(b)(1)(A)(ix) operated in conjunction with a land-grant college or university or a non-land grant college of agriculture. See instructions. Enter the name, city, and state of the college or university:

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

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

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 12a through 12d that describes the type of supporting organization and complete lines 12e, 12f, and 12g.

Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B.

Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C.

Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E.

Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V.

Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization.

Enter the number of supported organizations ...............................

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

(i) Name of supported organization	(ii) EIN	(iv) Is the organization listed in your governing document?		(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)
(i) Name of supported organization	(ii) EIN	Yes	No	(v) Amount of monetary support (see instructions)	(vi) Amount of other support (see instructions)


Total

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

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2018

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv), 170(b)(1)(A)(vi), and 170(b)(1)(A)(ix)
(Complete only if you checked the box on line 5, 7, 8, or 9 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) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..
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) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(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

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

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

Section C. Computation of Public Support Percentage

Public support percentage for 2018 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2017 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2018. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2017. 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 ..................... right arrow

17a

10%-facts-and-circumstances test—2018. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2017. 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 VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

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

Schedule A (Form 990 or 990-EZ) 2018

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(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) 2014	(b) 2015	(c) 2016	(d) 2017	(e) 2018	(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 VI.) ..
13	Total support. (Add lines 9, 10c, 11, and 12.)..

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

Section C. Computation of Public Support Percentage

Public support percentage for 2018 (line 8, column (f) divided by line 13, column (f)) .........

Public support percentage from 2017 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2018 (line 10c, column (f) divided by line 13, column (f)) ......

Investment income percentage from 2017 Schedule A, Part III, line 17 .............

19a

331/3% support tests—2018. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ....... right arrow

33 1/3% support tests—2017. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

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

Schedule A (Form 990 or 990-EZ) 2018

Page 4

Part IV

Supporting Organizations

(Complete only if you checked a box on line 12 of Part I. If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C. If you checked 12c of Part I, complete Sections A, D, and E. If you checked 12d of Part I, complete Sections A and D, and complete Part V.)

Section A. All Supporting Organizations

Yes

Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.

Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).

Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below.

Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.

Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.

Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked 12a or 12b in Part I, answer (b) and (c) below.

Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.

Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.

Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).

Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?

Substitutions only. Was the substitution the result of an event beyond the organization's control?

Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.

Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ) .

Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If “Yes,” complete Part I of Schedule L (Form 990 or 990-EZ).

Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.

Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.

Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.

10a

Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.

10a

Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).

10b

Schedule A (Form 990 or 990-EZ) 2018

Page 5

Part IV

Supporting Organizations (continued)

Yes

Has the organization accepted a gift or contribution from any of the following persons?

A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization?

11a

A family member of a person described in (a) above?

11b

A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI.

11c

Section B. Type I Supporting Organizations

Yes

Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.

Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.

Section C. Type II Supporting Organizations

Yes

Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).

Section D. All Type III Supporting Organizations

Yes

Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?

Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).

By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.

Section E. Type III Functionally-Integrated Supporting Organizations

Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):

The organization satisfied the Activities Test. Complete line 2 below.

The organization is the parent of each of its supported organizations. Complete line 3 below.

The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions)

Activities Test. Answer (a) and (b) below.

Yes

Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.

Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.

Parent of Supported Organizations. Answer (a) and (b) below.

Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI.

Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.

Schedule A (Form 990 or 990-EZ) 2018

Page 6

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations

Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970 (explain in Part VI). See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E.

	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

Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions)

Schedule A (Form 990 or 990-EZ) 2018

Page 7

Part V

Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued)

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 2018 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-2018	(iii) Distributable Amount for 2018
1 Distributable amount for 2018 from Section C, line 6
2 Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions.
3 Excess distributions carryover, if any, to 2018:
a From 2013.......
b From 2014.......
c From 2015.......
d From 2016.......
e From 2017.......
fTotal of lines 3a through e
g Applied to underdistributions of prior years
h Applied to 2018 distributable amount
i Carryover from 2013 not applied (see instructions)
j Remainder. Subtract lines 3g, 3h, and 3i from 3f.
4Distributions for 2018 from Section D, line 7:
$
a Applied to underdistributions of prior years
b Applied to 2018 distributable amount
c Remainder. Subtract lines 4a and 4b from 4.
5 Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions.
6 Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions.
7 Excess distributions carryover to 2019. Add lines 3j and 4c.
8 Breakdown of line 7:
a Excess from 2014......
b Excess from 2015.....
c Excess from 2016.....
d Excess from 2017.....
e Excess from 2018.....

Schedule A (Form 990 or 990-EZ) (2018)

Schedule A (Form 990 or 990-EZ) 2018

Page 8

Part VI

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Return Reference	Explanation

Schedule A (Form 990 or 990-EZ) 2018

Additional Data

Software ID:	18007697
Software Version:	2018v3.1

- TIN:

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

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Name of the organization

St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc
is

Employer identification number

39-0808480

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

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

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

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

501(c)(3) taxable private foundation

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

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or other property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.

Special Rules

For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

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

For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Don't complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year ......... Arrow Bullet

Caution. An organization that isn't covered by the General Rule and/or the Special Rules doesn't 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 its Form 990PF, Part I, line 2, to certify that it doesn't 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) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018) Page 2

Name of organization St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc is

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	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Page 3

Name of organization St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc is		Employer identification number 39-0808480

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) (2018)

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Page 4


Name of organization St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc is			Employer identification number 39-0808480
Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. 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.) $ Use duplicate copies of Part III if additional space is needed.

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

(a)
No. from Part I

(b) Purpose of gift

(d) Description of how gift is held

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

Schedule B (Form 990, 990-EZ, or 990-PF) (2018)

Additional Data

Software ID:	18007697
Software Version:	2018v3.1

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

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

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

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

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

If the organization answered "Yes" on 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" on 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" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

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

Name of the organization

St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc
is

Employer identification number

39-0808480

Part I-A

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

Provide a description of the organization’s direct and indirect political campaign activities in Part IV (see instructions for definition of “political campaign activities")

Political campaign activity expenditures (see instructions) .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities (see instructions) ..................................................................

Part I-B

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

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

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

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

Yes No

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

Yes No

If "Yes," describe in Part IV.

Part I-C

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

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

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

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

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

Yes No

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

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

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

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2018

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 Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

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

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

4-Year Averaging Period Under section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2015	(b) 2016	(c) 2017	(d) 2018	(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) 2018

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 on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

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

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

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

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

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

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

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

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

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

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

Yes

8,367

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

8,367

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

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

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

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

Part III-A

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

Yes

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

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

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

Part III-B

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

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

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

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

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

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

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

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

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

Part IV

Supplemental Information

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, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY	ST. NICHOLAS HOSPITAL (THE HOSPITAL) IS A MEMBER OF THE CATHOLIC HEALTH ASSOCIATION ("CHA"), THE WISCONSIN HEALTH ASSOCIATION ("WHA"), AND THE AMERICAN HOSPITAL ASSOCIATION ("AHA"). AS A MEMBER OF THESE ORGANIZATIONS, THE HOSPITAL PAYS DUES, WITH PART OF THESE DUES BEING ATTRIBUTABLE TO LOBBYING FEES PAID BY THE ORGANIZATIONS. THE AMOUNT LISTED IS THE AMOUNT ATTRIBUTABLE TO THE HOSPITAL FROM ITS DUES PAID. THE ASSOCIATIONS THE HOSPITAL PAYS ARE AS FOLLOWS: - AMERICAN HOSPITAL ASSOCIATION ("AHA") AT 22.73% LOBBYING EXPENSE - CATHOLIC HEALTH ASSOCIATION ("CHA") AT 3.52% LOBBYING EXPENSE - WISCONSIN HOSPITAL ASSOCIATION ("WHA") AT 13.60% LOBBYING EXPENSE THE TOTAL AMOUNT OF ANNUAL DUES PAID TO EACH ASSOCIATION IS MULTIPLIED BY THE PERCENTAGE OF DUES ALLOCATED TO LOBBYING EXPENSE TO CALCULATE THE TOTAL LOBBYING EXPENDITURES PAID.

Return Reference

Explanation

Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY

ST. NICHOLAS HOSPITAL (THE HOSPITAL) IS A MEMBER OF THE CATHOLIC HEALTH ASSOCIATION ("CHA"), THE WISCONSIN HEALTH ASSOCIATION ("WHA"), AND THE AMERICAN HOSPITAL ASSOCIATION ("AHA"). AS A MEMBER OF THESE ORGANIZATIONS, THE HOSPITAL PAYS DUES, WITH PART OF THESE DUES BEING ATTRIBUTABLE TO LOBBYING FEES PAID BY THE ORGANIZATIONS. THE AMOUNT LISTED IS THE AMOUNT ATTRIBUTABLE TO THE HOSPITAL FROM ITS DUES PAID. THE ASSOCIATIONS THE HOSPITAL PAYS ARE AS FOLLOWS: - AMERICAN HOSPITAL ASSOCIATION ("AHA") AT 22.73% LOBBYING EXPENSE - CATHOLIC HEALTH ASSOCIATION ("CHA") AT 3.52% LOBBYING EXPENSE - WISCONSIN HOSPITAL ASSOCIATION ("WHA") AT 13.60% LOBBYING EXPENSE THE TOTAL AMOUNT OF ANNUAL DUES PAID TO EACH ASSOCIATION IS MULTIPLIED BY THE PERCENTAGE OF DUES ALLOCATED TO LOBBYING EXPENSE TO CALCULATE THE TOTAL LOBBYING EXPENDITURES PAID.

Schedule C (Form 990 or 990EZ) 2018

Additional Data

Software ID:	18007697
Software Version:	2018v3.1

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," on 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

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc
is

Employer identification number

39-0808480

Part I

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

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

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

Yes No

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

Yes No

Part II

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

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

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

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

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


a	Total number of conservation easements ......................	2a
b	Total acreage restricted by conservation easements ....................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ...	2d

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

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

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

Yes No

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

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

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

Yes No

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" on Form 990, Part IV, line 8.

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

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

(i)

Revenue included on Form 990, Part VIII, line 1 ......................... SchDMd Bullet

(ii)

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

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

Revenue included on Form 990, Part VIII, line 1 .......................... SchDMd Bullet

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) 2018

Page 2

Part III

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

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):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

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

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

Yes No

Part IV

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

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

Yes No


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

Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...

Yes No

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" on Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	(c)Two years back	(d)Three years back	(e)Four years back

1a	Beginning of year balance ....
b	Contributions ...
c	Net investment earnings, gains, and losses
d	Grants or scholarships ...
e	Other expenditures for facilities and programs ...
f	Administrative expenses ....
g	End of year balance ......

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

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

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

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

Yes

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

3a(i)

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

3a(ii)

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

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

Part VI

Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. 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 .....	1,715,010		1,715,010
b	Buildings ....	52,360,684	20,267,239	32,093,445
c	Leasehold improvements	2,775,738	845,832	1,929,906
d	Equipment ....	41,560,182	29,347,247	12,212,935
e	Other .....	47,185,493	28,766,197	18,419,296
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..				66,370,592

Schedule D (Form 990) 2018

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. 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........
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

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

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability	(b) Book value
(1) Federal income taxes
UNAMORTIZED BOND PREMIUM & ISSUE COSTS NET	500,401
OTHER LONG TERM LIABILITIES	355,620
ACCRUED PENSION	7,443,237
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)	8,299,258
2. Liability for uncertain tax positions. 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) 2018

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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 (losses) 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. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
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

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.

Return Reference

Explanation

Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote

HSHS and the Foundation are Illinois not-for-profit organizations as described in Section 501 (c) (3) of the Internal Revenue Code (the Code) and are exempt from federal income taxes on related income pursuant to Section 501 (a) of the Code. Kiara, Inc. is an Illinois for-profit corporation that recognizes income taxes under the asset-and-liability method. Deferred tax assets and liabilities are recognized for the future tax consequences attributable to differences between the consolidated financial statement carrying amounts of existing assets and liabilities and their respective tax basis and operating loss and tax credit carryforwards. Deferred tax assets and liabilities are measured using the enacted tax rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. The effect on deferred tax assets and liabilities of a change in tax rates is recognized in income in the period that includes the enactment date. In assessing the realizability of deferred tax assets, management considers whether it is more likely than not that some portion or all of the deferred tax assets will not be realized. The ultimate realization of deferred tax assets is dependent upon the generation of future taxable income during the periods in which those temporary differences become deductible. Management considers projected future taxable income and tax planning strategies in making this assessment. Based upon the level of historical taxable losses and projections for future taxable losses over the periods for which the deferred tax assets are deductible, management believes it is more likely than not Kiara, Inc. will not realize the majority of the benefits of these deductible differences. Full valuation allowances have been applied against the deferred tax assets attributable to the net operating loss carryforwards not realized as of June 30, 2019 and 2018 in the accompanying consolidated financial statements due to the uncertainty of realization. HSHS recognizes the tax benefit from an uncertain tax position only if it is more likely than not the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. As of June 30, 2019 and 2018, HSHS does not have any liabilities for unrecognized tax benefits.

Schedule D (Form 990) 2018

Additional Data

Software ID:	18007697
Software Version:	2018v3.1

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

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

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc
is

Employer identification number

39-0808480

Part I

Financial Assistance and Certain Other Community Benefits at Cost

Yes

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

Yes

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

Yes

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

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

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

Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?

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

Yes

100% 150% 200% Other %

Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate

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

Yes

200% 250% 300% 350% 400% Other %

If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.

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

Yes

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

Yes

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

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

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

Yes

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

Yes

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

Financial Assistance and Certain Other Community Benefits at Cost

Financial Assistance and Means-Tested Government Programs		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a	Financial Assistance at cost (from Worksheet 1) . . .			3,583,598	2,467,611	1,115,987	0.98 %
b	Medicaid (from Worksheet 3, column a) . . . . .			13,257,566	5,200,431	8,057,135	7.04 %
c	Costs of other means-tested government programs (from Worksheet 3, column b) . .			589,853	408,523	181,330	0.16 %
d	Total Financial Assistance and Means-Tested Government Programs . . . . .	0	0	17,431,017	8,076,565	9,354,452	8.18 %
Other Benefits
e	Community health improvement services and community benefit operations (from Worksheet 4).			188,884	0	188,884	0.17 %
f	Health professions education (from Worksheet 5) . . .			20,291	0	20,291	0.02 %
g	Subsidized health services (from Worksheet 6) . . . .					0	0 %
h	Research (from Worksheet 7) .					0	0 %
i	Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .			117,713	0	117,713	0.10 %
j	Total. Other Benefits . .	0	0	326,888	0	326,888	0.29 %
k	Total. Add lines 7d and 7j .	0	0	17,757,905	8,076,565	9,681,340	8.46 %

For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2018

Schedule H (Form 990) 2018

Page

Part II

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

		(a) Number of activities or programs (optional)	(b) Persons served (optional)	(c) Total community building expense	(d) Direct offsetting revenue
1	Physical improvements and housing
2	Economic development
3	Community support
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building
7	Community health improvement advocacy
8	Workforce development
9	Other
10	Total	0	0	0	0

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

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

Yes

Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......

2,537,669

Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......

203,395

Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.

Section B. Medicare

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

32,623,322

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

55,112,252

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

-22,488,930

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

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

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

Yes

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

Yes

Part IV

Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership %	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2018

Page

Part VFacility Information

Section A. Hospital Facilities (list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?1Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility)
1	ST NICHOLAS HOSPITAL 3100 SUPERIOR AVE SHEBOYGAN,WI530811948 www.stnicholashospital.org 37	X	X	X

Schedule H (Form 990) 2018

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices

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

	ST NICHOLAS HOSPITAL
Name of hospital facility or letter of facility reporting group

Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A):

Yes

Community Health Needs Assessment

Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C...............

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12......................

Yes

If "Yes," indicate what the CHNA report describes (check all that apply):

A definition of the community served by the hospital facility

Demographics of the community

Existing health care facilities and resources within the community that are available to respond to the health needs of the community

How data was obtained

The significant health needs of the community

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups

The process for identifying and prioritizing community health needs and services to meet the community health needs

The process for consulting with persons representing the community’s interests

The impact of any actions taken to address the significant health needs identified in the hospital facility's prior CHNA(s)

Other (describe in Section C)

Indicate the tax year the hospital facility last conducted a CHNA: 20 17

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted .................

Yes

6 a

Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C..................................

Yes

Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................

Yes

Did the hospital facility make its CHNA report widely available to the public?..............

Yes

If "Yes," indicate how the CHNA report was made widely available (check all that apply):

Hospital facility’s website (list url): https://www.stnicholashospital.org/www-sns/media/SNS-PDFs/About/CHNA-SNS.pdf

Other website (list url):

Made a paper copy available for public inspection without charge at the hospital facility

Other (describe in Section C)

Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. ..............

Yes

Indicate the tax year the hospital facility last adopted an implementation strategy: 20 17

Is the hospital facility's most recently adopted implementation strategy posted on a website?.........

Yes

If "Yes" (list url): https://www.stnicholashospital.org/www-sns/media/SNS-PDFs/About/CHIP-SNS.pdf

If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ......

10b

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.

12a

Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?...............................

12a

If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........

12b

If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

Schedule H (Form 990) 2018

Page 5

Part VFacility Information (continued)

Financial Assistance Policy (FAP)

	ST NICHOLAS HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a written financial assistance policy that:

Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care?

Yes

If “Yes,” indicate the eligibility criteria explained in the FAP:

Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.0% and FPG family income limit for eligibility for discounted care of 400.0%

Income level other than FPG (describe in Section C)

Asset level

Medical indigency

Insurance status

Underinsurance discount

Residency

Other (describe in Section C)

Explained the basis for calculating amounts charged to patients?.................

Yes

Explained the method for applying for financial assistance?...................

Yes

If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):

Described the information the hospital facility may require an individual to provide as part of his or her application

Described the supporting documentation the hospital facility may require an individual to submit as part of his or
her application

Provided the contact information of hospital facility staff who can provide an individual with information about the
FAP and FAP application process

Provided the contact information of nonprofit organizations or government agencies that may be sources of
assistance with FAP applications

Other (describe in Section C)

Was widely publicized within the community served by the hospital facility?........

Yes

If "Yes," indicate how the hospital facility publicized the policy (check all that apply):

The FAP was widely available on a website (list url):

http://www.hshs.org/FAP

The FAP application form was widely available on a website (list url):

http://www.hshs.org/FAP

A plain language summary of the FAP was widely available on a website (list url):
http://www.hshs.org/FAP

The FAP was available upon request and without charge (in public locations in the hospital facility and by mail)

The FAP application form was available upon request and without charge (in public locations in the hospital facility
and by mail)

A plain language summary of the FAP was available upon request and without charge (in public locations in the
hospital facility and by mail)

Individuals were notified about the FAP by being offered a paper copy of the plain language summary of the FAP, by
receiving a conspicuous written notice about the FAP on their billing statements, and via conspicuous public displays or
other measures reasonably calculated to attract patients' attention

Notified members of the community who are most likely to require financial assistance about availability of the FAP

The FAP, FAP application form, and plain language summary of the FAP were translated into the primary language(s)
spoken by LEP populations

Other (describe in Section C)

Schedule H (Form 990) 2018

Page 6

Part VFacility Information (continued)

Billing and Collections

	ST NICHOLAS HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?..................................

Yes

Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring, denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

None of these actions or other similar actions were permitted

Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............

If "Yes," check all actions in which the hospital facility or a third party engaged:

Reporting to credit agency(ies)

Selling an individual’s debt to another party

Deferring , denying, or requiring a payment before providing medically necessary care due to nonpayment of a previous
bill for care covered under the hospital facility's FAP

Actions that require a legal or judicial process

Other similar actions (describe in Section C)

Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):

Provided a written notice about upcoming ECAs (Extraordinary Collection Action) and a plain language summary of the
FAP at least 30 days before initiating those ECAs

Made a reasonable effort to orally notify individuals about the FAP and FAP application process

Processed incomplete and complete FAP applications

Made presumptive eligibility determinations

Other (describe in Section C)

None of these efforts were made

Policy Relating to Emergency Medical Care

Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..................

Yes

If "No," indicate why:

The hospital facility did not provide care for any emergency medical conditions

The hospital facility’s policy was not in writing

The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C)

Other (describe in Section C)

Schedule H (Form 990) 2018

Page 7

Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)

	ST NICHOLAS HOSPITAL
Name of hospital facility or letter of facility reporting group

Yes

Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month period

The hospital facility used a look-back method based on claims allowed by Medicaid, either alone or in combination with
Medicare fee-for-service and all private health insurers that pay claims to the hospital facility during a prior 12-month
period

The hospital facility used a prospective Medicare or Medicaid method

During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ...............................

If "Yes," explain in Section C.

During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ...........................

If "Yes," explain in Section C.

Schedule H (Form 990) 2018

Page 8

Part V

Facility Information (continued)

Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference	Explanation
Schedule H, Part V, Section B, Line 3E	Yes, the significant health needs are a prioritized description of the significant health needs of the community and were identified through the CHNA process.
Schedule H, Part V, Section B, Line 5 Facility , 1	Facility , 1 - HSHS St. Nicholas Hospital. Hospital Sisters Health System and HSHS St. Nicholas Hospital are committed to promoting and defending human dignity, caring for persons living in poverty and other vulnerable persons, promoting the common good and stewarding resources. We believe that the CHNA process must be informed by input from the poor and vulnerable populations we seek to serve. To ensure that the needs of these groups were adequately represented, we included representatives from Sheboygan County Health and Human Services (Public Health, Aging & Disability Resource Center, and Child & Family Services); various Sheboygan County departments including Head Start, Probation & Parole, Victim/Witness Services, Veterans Services; Love, Inc.; Sheboygan County Interfaith Organization; local school districts; Sheboygan County Interfaith; Partners for Community Development; Family Resource Center of Sheboygan County; and Safe Harbor in the FY2018 CHNA process. These organizations serve the under-resourced in our community, including low-income seniors, children living in poverty, families who struggle with shelter and food insecurity, veterans, and victims of domestic violence. Representatives of these organizations, who work directly with their constituents, have extensive knowledge and quantifiable data regarding the needs of their service populations. Actively including these organizations in the CHNA process was critical to ensure that the needs of the most vulnerable persons in our communities were being shared and addressed in the CHNA process and included in the development of related implementation strategies. Internal HSHS St. Nicholas Hospital spent more than a year developing the CHNA, identifying and prioritizing community health needs for its service area and formulating an implementation plan to guide ongoing population health initiatives with like-missioned partners and collaborators. These planning and development activities included the following internal and external steps: Convene the HSHS Eastern Wisconsin Division community benefit team. Determine internal capacity for the collaborative process. Allocate monetary resources to support the community-wide effort. Share results of the "Call to Action" event and World Cafe meetings in order to develop the implementation plan. Present to hospital leadership to seek approval for colleagues to track and document community benefit efforts in CBISA Share the results of the CHNA and obtain feedback for the implementation plan from the Hospital Advisory Committee. Present the CHNA and implementation plan to the hospital Board for approval External HSHS St. Nicholas Hospital also leveraged existing relationships to gain additional insights into community health needs in the hospital's service area. External components and steps included: Identify the methodology to be used for this update. Utilize local community health survey, a comprehensive phone-based survey, which gathers data on adult behavioral and lifestyle habits and the respondent's household information. This report was sponsored by the collaborative group and funded by HSHS St. Nicholas Hospital, Lakeshore Community Health Care and Aurora Health Care. Data was analyzed and prepared by JKV Research, LLC. Data collection was conducted by Management Decisions Incorporated. Interview 32 key community stakeholders for the key interview summary report. This report is prepared by the Center for Urban Population Health (CUPH). Engage CUPH to complete a secondary data report. Convene a planning committee to host the "Call to Action" event. Work with the CHNA committee to determine priorities prior to the "Call to Action" event. Host a Call to Action event on September 28, 2017 to encourage key community stakeholders to actively participate in the CHNA process. Prior to the event, attendees had the opportunity to review preliminary community health data (secondary data report, key informant report, healthy survey report and a data report snapshot). One hundred and fifteen individuals attended the Call to Action event. As part of the Call to Action, a presentation was given by members of the CHNA steering committee and Healthy Sheboygan County Council Co-Leaders. The large group was divided into small groups to discuss root causes and potential goals within the priority action areas. The framework for this activity was the Tearless Logic Model, a tool from the Global Journal of Community Psychology Practice that breaks the logic model process down into a series of manageable, jargon-free questions. As part of the evaluation process, attendees were asked to complete an initial survey. Using survey date, event organizers compiled a list of what is currently occurring within our community related to each priority area. After the event, the CHNA steering committee evaluated the feedback from the facilitated discussions to refine the priority areas and determine goals for the World Cafe discussions. Host three World Cafe discussions for each of the identified priority action areas: Responsible substance use (November 6, 2017); Healthy nutrition and physical activity (November 7, 2017); and Positive mental health (November 13, 2017). Invitations were extended to members of the HSC 2020 committees and "Call to Action" attendees, who were also encouraged to share the invitation with others who would be interested in participating; 87 individuals attended the cafes. The purpose of the World Cafe discussions was for participants to propose effective implementation strategies to address the identified needs: Responsible substance use * Enhance primary prevention and education * Create a responsible substance use culture * Create a recovery community Positive mental health * Build a trauma informed/resilient community * Increase access to mental health services * Prevent suicide Healthy nutrition and physical activity * Create a culture of health eating * Increase access to healthy foods to address food security * Promote a lifestyle of physical activity * Promote best practice worksite wellness Analyze data collected at "Call to Action" and World Cafe events. Work with the CHNA committee and subject matter experts to develop action plans for community action groups. Work with the CHNA committee on 2018 follow-up meeting to review community health improvement plan.
Schedule H, Part V, Section B, Line 6a Facility , 1	Facility , 1 - St. Vincent Hospital. AURORA SHEBOYGAN MEDICAL CENTER
Schedule H, Part V, Section B, Line 6b Facility , 1	Facility , 1 - HSHS St. Nicholas Hospital. HSHS St. Nicholas Hospital partnered with several community organizations, including Healthy Sheboygan County 2020, Lakeshore Community Health Center, Sheboygan County Division of Public Health, United Way of Sheboygan County, and University of Wisconsin-Extension - Sheboygan County to complete the Community Health Needs Assessment.
Schedule H, Part V, Section B, Line 11 Facility , 1	Facility , 1 - HSHS ST. NICHOLAS HOSPITAL. HSHS St. Nicholas Hospital provides a range of Community Benefit activities and programs that furthers our mission and long-standing commitment to our community. In many cases, these Community Benefit initiatives, which often relieve a burden that would otherwise be carried by government, would not exist without the leadership role played by HSHS St. Nicholas Hospital. HSHS St. Nicholas Hospital's FY2018 Community Health Needs Assessment (CHNA) surfaced the following health focus areas to be addressed in collaboration with Aurora Sheboygan Memorial Medical Center, clinics, and community organizations: Mental Health Goal: In partnership with the Health and Human Services Divisions of Public Health, Healthy Sheboygan County 2020 and other organizations, promote positive mental health. Long-term performance indicators: * By June 30, 2021, decrease the average number of mentally unhealthy days reported in the past 30 days from 3.3 to 3.0 (Source: 2016 County Health Rankings) * By June 30, 2021, decrease Sheboygan County's suicide rate from 13.0 per 100,000 to 12.5 per 100,000. (Source: Wisconsin Dept. of Health Services, Division of Public Health, Office of Health Informatics. Wisconsin Interactive Statistics on Health (WISH) data query system). The Healthy People 2020 target for the United States is 10.2 per 100,000. Mental Health Strategy One: Build a trauma informed/resilient community HSHS St. Nicholas Hospital (SNS), in partnership with Sheboygan County Health and Human Services, and other organizations, will promote and support education on trauma-informed care. The hospital refocused the strategy to align with Healthy Sheboygan County 2020 (HSC 2020) and expanded the focus to include building a resilient community. The HSC 2020 Building a Resilient Community Action Team is using the Strengthening Families model to operationalize resiliency with protective factors as guide to action with a focus on youth. In alignment with the focus on building resiliency within the youth of our community, SNS supported the following strategies, which align with the promotion of positive mental health: Above and Beyond Museum Family Access Membership SNS will provide funds to support the launch the Above and Beyond Children's Museum Family Access Membership to increase access to museum resources by children in our community. The family access program supports positive activities, promotes youth mental health, and aligns with the HSC2020 Building a Resilient Community Action Team. FY2019 Outcomes: In June 2019, the hospital provided funding ($2,000) to the Above and Beyond Children's Museum for the Family Access Membership Program. SNS partnered with the Kohler Company Foundation to support initiation of this program. Mindfulness in the School Program SNS provided a three-year grant (FY2017-FY2019) to Mental Health America (MHA) in Sheboygan County to expand their Mindful Classroom Initiative. MHA utilizes a social-emotional, evidence-based curriculum developed by Growing Minds in classrooms in Sheboygan County. During this 10-week program, students learn how to train their attention and focus, use their five senses mindfully, be more aware in the present moment, and pause to make meaningful choices. Students also learn to recognize their thoughts and emotions, which enhance social skills and the quality of relationships they experience with others. These skills also create calmer classrooms and more productive learning environments. FY2019 Outcomes: During the fall of 2018, 23 classrooms and more than 446 students in Sheboygan County participated in MHA's Sheboygan County Mindful Classroom Initiative. Feedback from students and teachers indicate the program is having a positive impact: "I think mindfulness is amazing. It calms me down and makes me feel better. Thanks for teaching it to us!" - 5th grade student. "I appreciated the opportunity to learn new tools for my toolbox to help my students as well as my own children. Your time spent with us has made a great impact already and will continue long after you leave us. Gifts that continue to give after they are given are amazing. We will continue to be blessed because of the time you have spent with us. Thank you for being awesome and investing in our future." - 4th grade teacher Outcome measurements were calculated based on teacher and student pre and post-self-report surveys: * 80 percent of students now notice when their minds wander (35 percent increase). * 80 percent of students reported they could focus better in the classroom (41 percent increase). * 71 percent of students reported they take a pause before reacting to situations (57 percent increase). * 78 percent of students reported the ability to calm down easier (56 percent increase). * 82 percent of students reported noticing their emotions (a 45 percent increase). * 78 percent of students reported they're able to find ways to relax when stressed (a 55 percent increase). * 100 percent of educators reported calmer classrooms after participating in MCI. * 100 percent of educators reported MCI was beneficial to their students. Mental Health Strategy Two: Promote and support suicide prevention: Question Persuade Refer (QPR) QPR is the most widely taught gatekeeper training in the world and is designed to help participants gain an awareness of statistics, known risk factors, and recognizable behaviors. It shares a proven three-step process for suicide intervention. Training is 60 to 90 minutes. While QPR is not intended to be a form of counseling or treatment, it is intended to offer hope through positive action. Four SNS/Prevea staff members are trained as QPR instructors, who are part of a community cadre of 20 QPR trainers. In 2018, these 20 trainers provided 20 trainings to more than 400 individuals, including hospital staff, church lay persons, community health care providers, and college students. FY2019 Outcomes: At each session attendees complete pre and post sessions evaluation. Feedback from participants indicate that QPR is having a positive impact: This was empowering. Thank you for equipping me to be a force for good in Sheboygan; Excellent and thorough presentation on a very sensitive subject; and I had some previous knowledge, but this made me feel a lot more confident with my current ability to help someone in crisis. Pre and post survey outcomes included: * 83 percent of attendees can now identify the warnings signs of suicide (overall increase of 40 percent). * 84 percent of attendees now know what questions to ask when someone is suicidal (overall increase of 64 percent) and 84 percent reported they know how to ask these questions (overall increase of 71 percent). * 87 percent of attendees know where to go for help and what resources to provide should someone share they are suicidal (overall increase of 48 percent). * 91 percent of attendees reported QPR training helped dispel myths or misconceptions about suicide. There is Hope Walk SNS Community Benefit provided financial and in-kind donations (printing, educational booth/event staffing) to support the Mental Health America in Sheboygan County's 13th annual There is Hope walk, that promotes suicide prevention. FY2019 Outcomes: Nearly 600 people attended, and the event raised approximately $40,000 for community suicide prevention programming. Mental Health Board Hospital staff actively participated on the Board of Mental Health of America in Sheboygan County (MHA); serve on the Personnel and Finance Committee. FY2019 Outcomes: Hospital staff served more than 35 hours on the MHA Board. Service included hiring a new Executive Director and actively serving as a member of the advisory committee for Open Door, a drop-in center for individuals with mental health challenges run by MHA. Mental Health Strategy Three: Increase Access to Mental Health Services HSHS St. Nicholas Hospital will actively support Mental Health American (MHA) to maintain a comprehensive list of mental health providers in the county on the MHA website. The hospital will explore opportunities to partner with MHA and other community organizations to define the access to mental health services issues within our community. Mental Health/AODA Resource Fair As part of HSC 2020 Access Action Team strategies a Mental Health/AODA Resource Fair was held on May 14, 2019 and SNS was an active member of the planning committee along providing funding for the event. FY2019 Outcomes: More than 200 community members including 115 participants, 86 individual professionals from 47 vendor organizations, and 17 volunteers partnered to learn about resources to improve their own lives, the lives of loved ones, or of those colleagues they work with to build healthier communities to live and play in. Participant evaluations indicated that 100% of the attendees learned about new resources;
Schedule H, Part V, Section B, Line 11 Facility , 2	Facility , 2 - HSHS St Nicholas Hospital. 74% of participants planned to follow up with a resource they learned about at the fair; and 63% of participants stated their attitudes or behaviors changed by attending the fair. Mental Health/AODA Gap Analysis The Mental Health Access Action Team continues work on the mental health gap analysis which will also include AODA focusing on the development of tools to assess the different groups (key informants, focus groups and community). The goal is to gather stakeholders and present findings and work on next steps identified from the report in the first quarter of 2020. FY2019 Outcomes: SNS has partnered with the Center for Urban Population Health (CUPH) to assist in the strategic planning, implementation, and writing of the report. SNS is an active member of the planning group for this initiative. Support initiation of new dual - licensed position at Federally Qualified Health Center Please refer to the detailed description under AODA. Alcohol and Other Drug Abuse (AODA) Goal: In partnership with the Health and Human Services Division of Public Health, Healthy Sheboygan 2020, and other organizations, create a responsible substance use culture. Long Term Performance Indicators: By June 30, 2021, decrease binge drinking among adults by three percent to 25 percent. By June 30, 2021, decrease the number of opioid deaths by five percent. By June 30, 2021 decrease the number of opioids prescribed in our community by ten percent. AODA Strategy One: Enhance primary prevention and education- medication storage and disposal Medication Take Back Events SNS is an active member of the planning group for the community-wide Medication Take Back event which is held at five county locations two times each year. The hospital host and staff the Sheboygan site. FY2019 Outcomes: At the October 2018 collection, more than 400 pounds were collected from the five locations with over 250 pounds being collected at HSHS St. Nicholas Hospital. In April 2019, collections from the five locations totaled more almost 450 pounds with over 240 pounds being collected at HSHS St. Nicholas Hospital. During these events, approximately 200 people dropped off medication for disposal at the hospital site. Hospital employees from Community Benefit, Plant Services and The Green Team staff this event. The hospital also supported these medication take back events by developing marketing materials and funding ads in local newspapers to share information with our partners and throughout our community. As part of a grant, Healthy Sheboygan County 2020 was able to obtain medication lock/bags to increase medication safety within our community. They partnered with community agencies to distribute the lock boxes/bags to increase medication safety within our community. HSHS St. Nicholas was an active part of the action team who planned and distributed the boxes/bags. Providers from Prevea Behavioral Care participated in this program and had boxes/bags for patients. AODA Strategy Two: Enhance primary prevention and education - Narcan (Naloxone) With grant funding, Healthy Sheboygan County 2020 hosted two Narcan training sessions with the support of the Aids Resource Center of Wisconsin and HSHS St. Nicholas Hospital. The general public, members of community organizations and medical providers were invited to attend the sessions. FY2019 Outcomes: Hosted one Narcan training session at Lakeland University and one at Lakeshore Community Health Care; in total, 32 people attended the two training sessions. Of the completed evaluations received, 93 percent of attendees felt the presentation was easy to understand, and more than 70 percent of attendees felt the information will be of immediate use to them. Feedback received included: "Easy to comprehend and understand"; and "The training was very easy to follow, and the information was delivered in a way that made the topic less intimidating." AODA Strategy Three: Enhance primary prevention and education - Alcohol Healthy Sheboygan County 2020's Responsible Substance Use Action Team has included alcohol as a substance that they are addressing. HSHS St. Nicholas Hospital is an active member of this team. Initial discussion focused on the development of strategies which target and align with the capacity and readiness for change within our community. FY2019 Outcomes: Based on these discussion and strategies are being developed to address binge drinking and underage drinking. Current efforts include the development of a Festival Toolkit to decrease access to alcohol at community events for underage individuals. AODA Strategy Four: Enhance primary prevention and education - Prescription medication Healthy Sheboygan County 2020 (HSC 2020) in cooperation with The Sheboygan County Aging and Disability Resource Center held a community conversation about the opioid epidemic. The discussion and presentation focused on the factors that led to the opioid problem, how to recognize signs of opioid and prescription drug abuse and explore simple ways for community members to get involved in prevention efforts. HSHS St. Nicholas staff and a member of the Sheboygan County Drug Meg Unit presented. FY2019 Outcomes: Ten community members attended the community conversation. In addition to the presentation, a medication take back event was held at the Resource Center. AODA Strategy Five: Increase access to treatment The hospital will provide funding for the initiation of new dual- licensed position in behavioral health and substance abuse at Lakeshore Community Health Care, a Federally Qualified Health Center, to increase access to services for the uninsured and underinsured in the community. FY2019 Outcomes: Funding was provided for a new dual licensed behavioral health/substance abuse position at Lakeshore Community Health Center. This position will be incorporated into their teams which consist of medical, behavioral health and case management. This model was created based on extensive research on evidence-based strategies for providing effective care to the identified needs of their target population and broader community. AODA Strategy Six: Create a recovery community The hospital will partner with community agencies to promote and increase access to recovery support for individuals with substance misuse and abuse issues. FY2019 Outcomes: Starting on October 1, 2018, HSHS St. Nicholas Emergency Department began to offer ED2Recovery services to patients who are seen in our emergency department with a diagnosis of opioid use disorder. ED2Recovery connects people with program staff living in recovery from opioid addiction trained to offer support. Program staff are known as peer specialists or recovery coaches. Hospital staff contacts ED2Recovery staff when they have a candidate for the program. ED2Recovery staff introduces the patient to resources designed to help the person find a path to wellness prior to their release from the hospital. ED2 Recovery peer specialists regularly checks on the person after they leave the hospital to support them reaching their goals. AODA Strategy Seven: Advocate and support policy change related to alcohol and drug abuse The four hospitals in HSHS's Eastern Wisconsin Division including HSHS St. Nicholas Hospital continue to focus our Joint Advocacy/Community Benefit efforts on the opioid epidemic. FY2019 Outcomes: The hospital continued to advocate on behalf of our communities to let our elected officials know that opioid and methamphetamine abuse continue to be major issues. In addition, HSHS St. Nicholas Hospital colleagues attended the annual WHA Advocacy Day. More specifically, the hospital has raised the awareness regarding the following issues and offered innovative solutions to addressing the problem: Opioid epidemic: How can we work together to combat opioid abuse; 340B funding: If CAH and DSH hospitals can continue with these savings, we can use these funds to improve education and awareness around the opioid epidemic; Telemedicine: Removing regulatory burden. By doing so we can better reach the patients that need our help; and Behavioral health: Provider payment increases and regulatory reform. This is key to providing comprehensive care for those that suffer from opioid addictions. In addition to the above efforts other ways in which we are working to increase access to services include the hospital's funding support for the initiation of the dual licensed behavioral health/substance abuse professional at Lakeshore Community Health Care and the active participation of staff in the Mental Health/AODA Gap Analysis described above. Mental Health/AODA Gap Analysis Please refer to the detailed description under Mental Health. Obesity and Nutrition Goal: In partnership with Health and Human Services Division of Public Health, Healthy Sheboygan County 2020 and other organizations, promote healthy nutrition and physical activity.
Schedule H, Part V, Section B, Line 11 Facility , 3	Facility , 3 - HSHS St. Nicholas Hospital. Long-term performance indicators By June 30, 2021, increase consumption of fruits to two servings on an average day by three percent. By June 30, 2021 increase consumption of vegetables to two servings per day on an average day by three percent. By June 30, 2021, increase physical activity in a typical week by three percent. Obesity and Nutrition Strategy One: Create a culture of healthy eating The hospital, in partnership with Healthy Sheboygan County 2020 and the Sheboygan County Food Bank (SCFB), will promote and provide healthy food choices in food pantries, empowering the people who use the food pantries to make the best nutritional choices for themselves and their families. The hospital will plant an onsite garden and donate all produce to the Sheboygan County Food Bank. The food bank provides food to 12 community food pantries. The hospital will partner with HSC 2020 and the SCFB to develop a produce collection program -- Produce for Pantries -- for employers within our community. FY2019 Outcomes: Expanded the Produce for Pantries to include the two major hospital systems, two county school districts and multiple locations/departments within the Kohler Company in FY2019 to increase the amount of fresh produce at SCFB pantries for food pantry clients. Fifteen food pantries within our community received produce as part of this program in FY2019. HSHS St. Nicholas Hospital also provided in-kind marketing for the promotional materials and funding for the equipment. In addition to collecting donations from hospital staff, the hospital planted a raised bed garden and donated the produce to the Produce for Pantries program. During the 2018 summer growing season almost 100 pounds of produce was donated. Obesity and Nutrition Strategy Two: Increase access to healthy foods to address food insecurity Double Your Bucks (DYB) Adequate food and nutrition was identified as one of the priority health needs of our community. The Healthy Sheboygan County 2020 food and nutrition action planning group has been working with the local farmer's market to encourage customers using EBT for Food Share (electronic transfer, formerly known as food stamps) to purchase fruits and vegetables. The planning group worked to enable vendors to accept EBT. FY2019 Outcomes: With funding from HSHS St. Nichols Hospital, the "double your bucks" (DYB) program was started during the 2016 Farmers Market to double the purchasing power of EBT when used for fruits and vegetables up to a $10 twice a month. Due to the positive response from customers, DYB is available every market day - twice a week vs. two times a month. Of customers surveyed by the Farmer's Market staff, 75% consumed on average three servings of vegetables during the summer Farmers Market, which translates to DYB participants achieving the recommended goal for HSC 2020 vegetable consumption. The funds supported the Farmers Market Intern which increased capacity and access to enhance DYB program impact. Sheboygan County Food Bank The hospital will partner with Sheboygan County Food Bank to support their efforts to provide healthy food options for their food pantries network. FY2019 Outcomes: The hospital provided monetary support to help SCFB purchase a large freezer and committed to providing ongoing support for two years to help them "fill the freezer." The purchase of the freezer increased SCFB's capacity to receive donations of perishables such as meat, fresh fruits, and vegetable to be distributed to their network of food pantries. In addition, hospital staff actively serve on the SCFB Board including membership on the newly formed Anti-Hunger Coalition which is working closely with Healthy Sheboygan County 2020 Nutrition groups. Obesity and Nutrition Strategy Three: Promote a lifespan of physical activity The hospital will develop a partnership with HSC 2020 and other community agencies to promote and increase physical activity. FY2019 Outcomes: The hospital continues to be actively engaged in Healthy Sheboygan County 2020 and is part of the ongoing discussion to convene a cross-sector group to develop strategies that will promote and increase physical activity for community members. Obesity and Nutrition Strategy Four: Promote best practice worksite wellness Wellness Council of America (WELCOA) Well County /Workplace Designation The Sheboygan County Activity and Nutrition Coalition (SCAN) Committee partnered with the Wellness Council of Wisconsin to engage and challenge local businesses to improve the health & wellbeing of the workforce in Sheboygan County. The coalition established a goal to achieve 'Sheboygan Well County' designation from the Wellness Council of America (WELCOA) by 2020. Sponsored locally by the Wellness Council of Wisconsin, Well City USA challenges local businesses and community leaders to work together and engage entire communities in improving the health and wellbeing of their workforces. Well City USA status is achieved when a minimum of 20 organizations that collectively employ at least 20% of a community's workforce become designated Well Workplaces within a three-year period. Each employer must complete WELCOA's Well Workplace Award application to document their progress in developing their worksite wellness initiatives. FY2019 Outcomes: HSC 2020 SCAN and HSHS St. Nicholas Hospital/Prevea continue work to achieve the designations of a Well County and a Well Workplace. Prevea staff actively serve on HSC 2020 Well County Group. Due to changes in the application process, the due date for the application has been extended until March 2020. We continue to work on the application which includes data gathering from the Health Risk Assessments and initiation of health coaching. As an outcome of the prioritization process, the following community health needs were also identified, but will not be addressed directly by the hospital for the reasons indicated: Jobs/Income and wages: Being a provider of health care services through inpatient and outpatient services, the hospital does not have the expertise or resources to take the lead on addressing this priority in the region. However, in our role as an employer, the hospital is involved in many initiatives to support employment within our community. Injury and violence: The hospital is not directly involved in initiatives dealing with the prevention of injuries and violence. HSHS St. Nicholas Hospital is a member of the local child death review committee which reviews childhood deaths in our county and works with other local organizations to administer programs and services to address this issue. Housing: Being a provider of health care services through inpatient and outpatient services, the hospital does not have the expertise or resources to address housing in the region. HSHS St. Nicholas Hospital does provide support to various community agencies that work directly within this scope. Examples include collection drives that provide the basics, including food for the local food bank and personal hygiene items for our local women's shelter.
Schedule H, Part V, Section B, Line 13 Facility , 1	Facility , 1 - St. Nicholas Hospital. Presumptive eligibility provides individuals participating in one of the following categories with a 100% write off. These programs are granted by outside organizations based on screening criteria of less than 200% of the FPG. 1. Homelessness 2. Deceased with no estate 3. Mental incapacitation with no one to act on patient's behalf 4. Medicaid eligibility, but not on date of service or for non-covered services 5. Incarceration in a penal institution 6. Enrollment in the following assistance programs for low-income individuals: 6a. Temporary Assistance for Needy Families (TANF) 6b. Illinois Housing Development Authority's Rental Housing Support Program 7. Wisconsin Department of Health Services Housing Assistance Program 8. Participation in Women, Infants and Children programs (WIC); 9. Supplemental Nutrition Assistance Program (SNAP) eligibility; 10. Illinois Free Lunch and Breakfast Program; 11. Wisconsin Free Lunch Program; 12. Low Income Home Energy Assistance Program (LIHEAP); 13. Wisconsin Home Energy Assistance Program (WHEAP); 14. Enrollment in an organized community-based program providing access to medical care that assesses and documents limited low-income financial status as criteria; 15. Receipt of grant assistance for medical services

Schedule H (Form 990) 2018

Page 9

Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, from largest to smallest) How many non-hospital health care facilities did the organization operate during the tax year?0
Name and address		Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10

Schedule H (Form 990) 2018

Page 10

Part VI

Supplemental Information

Provide the following information.

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

Form and Line Reference	Explanation
Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation	2537669
Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance	CHARITY CARE IS CALCULATED BY DETERMINING THE TOTAL AMOUNT FROM PATIENT BILLING THAT IS WRITTEN OFF TO CHARITY CARE CHARGE CODES OR ALLOWANCES. THIS AMOUNT MATCHES THE NUMBER THAT IS REPORTED ON OUR FY2019 AUDITED FINANCIAL STATEMENTS. THE TOTAL CHARITY CARE DOLLAR AMOUNT IS THEN REDUCED TO COST BY APPLYING THE HOSPITAL'S COST TO CHARGE RATIO AS CALCULATED ON IRS SCHEDULE H - WORKSHEET J.
Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount	Self-pay patients are screened for verification of no insurance coverage. Once verification of no coverage has been completed, the guarantors will be screened for charity or uninsured discounts based on income levels. Those guarantors who do not qualify for charity through the screening process will be asked to provide proof of income in the form of a recent pay stub and/or recent tax return to determine the level of uninsured discounting. If no proof of income is provided or a guarantor's income is greater than 201% of the federal poverty level, the appropriate discount according to the established criteria up to 400% of the federal poverty level will be applied. The amount of money not collected from those self-pay patients who are not eligible for charity care is reported as bad debt. Allowances for Doubtful Accounts have been recorded based on an historical matrix, using collectability percentages by payor and aging category in accordance with HSHS Executive Policy #F-23, Valuation of Net Accounts Receivable. Percentages are based on historical experience at the hospital and adjusted for known limitations. The Hospital reports bad debt in accordance with Generally Accepted Accounting Principles (GAAP).
Schedule H, Part III, Line 3 Bad Debt Expense Methodology	HSHS St. Nicholas Hospital strongly believes that its charity care, and the related community benefit obtained from such care, is understated because of those patients who potentially qualify for charity care but do not wish to apply for it. In addition, some care is not classified as charity because of missing documentation on patient resources. Thus, the hospital's bad debt includes a portion that could be classified as charity care if application for such care was sought and/or completed.
Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote	The text of the footnote to the organization's financial statements that describes bad debt expense can be found on page 19 of the HSHS Consolidated Audit Report. Please also reference Footnote 2Q on page 14 for an explanation of how the financials account for bad debt.
Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs	HSHS St. Nicholas Hospital continually strives to provide excellent patient care in the most cost effective fashion. Nonetheless, the Medicare program, in many cases, does not provide payment that covers the full cost of the care provided. Since it is the mission of the hospital to respond to community need, hospital management continually advocates for improved Medicare payment so that the cost of quality care to those patients who are not able to afford it is not compromised and is fairly subsidized by all payers. THE HOSPITAL COMPUTES THE UNPAID COSTS OF PROVIDING CARE TO MEDICARE PATIENTS BY COMPARING THE COST OF THE SERVICES TO THE REIMBURSEMENT RECEIVED FROM MEDICARE DURING THE YEAR. THE COST OF MEDICARE SERVICES IS CALCULATED BY APPLYING THE RATIO OF PATIENT CARE COST TO CHARGES TO THE ANNUAL MEDICARE CHARGES. THE PATIENT CARE COST IS DETERMINED BY REDUCING THE TOTAL ANNUAL OPERATING EXPENSE BY BAD DEBT EXPENSES, MEDICAID PROVIDER TAXES AND COMMUNITY BENEFIT EXPENSE. THE DIFFERENCE BETWEEN THE REIMBURSEMENT RECEIVED AND THE CALCULATED COST OF THE SERVICES IS REPORTED AS THE MEDICARE SHORTFALL. The hospital's Medicare shortfall at cost for FY2019 was nearly $22.5 million.
Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance	Every effort is made prior to, during, and after provision of medical services to determine whether a patient is eligible for charity/community care and to assist the patient in completing the application and providing adequate documentation. If the patient qualifies for charity/community care for the full balance of their account, the entire amount is written off to charity/community care and hence no debt collection is pursued. If the patient qualifies for charity/community care for a portion of their account balance, that portion is written off to charity/community care, with the patient being responsible for the remainder of the balance. Additionally, reasonable effort will be made to obtain third-party or government payer reimbursement on behalf of the patient. If those efforts are not fruitful, an offer will be extended to the patient to make installment payments on their balance. Only at such point that the patient defaults on installment payments or refuses to cooperate with the hospital's efforts to be reimbursed will the account be sent to collections. The hospital will make reasonable efforts to determine whether a patient is eligible under the financial assistance policy before it engages in an ECA. To the extent a patient is determined to be eligible for financial assistance under the FAP, the hospital will take all reasonably available measures to reverse any ECA taken against the patient to obtain payment for the care.
Schedule H, Part V, Section B, Line 16a FAP website	- ST. NICHOLAS HOSPITAL: Line 16a URL: http://www.hshs.org/FAP;
Schedule H, Part V, Section B, Line 16b FAP Application website	- ST. NICHOLAS HOSPITAL: Line 16b URL: http://www.hshs.org/FAP;
Schedule H, Part V, Section B, Line 16c FAP plain language summary website	- ST. NICHOLAS HOSPITAL: Line 16c URL: http://www.hshs.org/FAP;
Schedule H, Part VI, Line 2 Needs assessment	HSHS St. Nicholas Hospital is continually assessing the health care needs of the community through several avenues, including the Hospital Advisory Council which is representative of the community that the hospital serves. The Council meets regularly to discuss hospital services and the ability of the hospital to meet community health care needs. Agendas are purposely organized to include time for feedback from members on what they are hearing in the community. In addition, hospital colleagues represent the hospital on a variety of community groups which provides an opportunity to reach and serve the medically underserved, low income and minority populations within our community. Through this representation, the hospital becomes aware of emerging needs and is able to offer to address or support others to address these needs. In addition, feedback is solicited in patient surveys and the Patient Family Engagement Council. The hospital maintains a close relationship with the public health department which is also a good resource regarding the health of our community.
Schedule H, Part VI, Line 3 Patient education of eligibility for assistance	HSHS St. Nicholas Hospital's community care (financial assistance program) brochures and applications are available on its website in both English and Spanish. The community care (financial assistance program) brochures and program are available to all patients regardless of whether they are insured or uninsured and are prominently displayed within the hospital Emergency Department and lobby waiting areas. The hospital also partners with Lakeshore Community Health Care, the local Federally Qualified Health Center, to make their patients aware of the hospital's financial Assistance program when the FQHC refers patients to SNS. The financial assistance program application may be obtained in the Patient Access department. Each hospital billing statement includes instructions for patients who need financial assistance. These patients are directed to follow up with our Patient Accounts Customer service. Applications are mailed based on screening. Point of Service uninsured patients: * Registration provides the Community Care application packet for any uninsured patients that present to our Emergency Department. * The scheduled appointments are contacted by a Financial Counselor either prior to service or upon arrival for their appointment. After normal business hours, the Registrar will provide the Community Care packet. * Inpatients are visited in their room by a Financial Counselor during normal business hours. All patients presenting and discharged during off-hours are contacted by a Financial Counselor based on a Self-Pay work queue. Patients are screened for the hospital's financial assistance program eligibility and for possible assistance through other government agency programs. Financial Counselors work with the patients through the Community Care application process and make referrals to the hospital contacted agency for assistance with eligibility and application process for any government programs. The contracted agency actively reaches out to patients who may need additional assistance or advocacy to apply for benefits, appeal denials, or who need transportation to government agencies to apply for benefits. Our on-site vendor, HRS Erase, provides personal visits to patients to screen for government programs. In addition, there are plans for the representative from HRS Erase to become a Certified Application Counselor for market place insurance, so the hospital can offer this service onsite. A system called Search America is sometimes utilized after failed follow-up attempts to reach the patient have been made to determine if the patient has the ability to pay. This system displays a federal poverty level determination and provides credit information which allow the user to see the probability of a patient's ability to pay. After assessing the information, a presumptive determination is made as to whether the patient qualifies for charity based on charity guidelines or if collection efforts are continued.
Schedule H, Part VI, Line 4 Community information	HSHS St. Nicholas Hospital (SNS) is an acute community hospital located in Sheboygan Wisconsin. The city is located on the western shore of Lake Michigan at the mouth of the Sheboygan River, about 55 miles north of Milwaukee and 60 mi south of Green Bay. The county totals 513 square miles and is bordered by Lake Michigan to the east, Manitowoc and Calumet counties to the north, Fond du Lac County to the west, and Washington and Ozaukee counties to the south. Sheboygan County has an estimated population of 115, 290 (2017). The city of Sheboygan is the largest city in the county with a population of 48,288 (2017). Two other cities, Sheboygan Falls and Plymouth have populations of 7,775 and 8,445 respectively (2017). The remainder of the county consists of small villages and rural residential settings. In Sheboygan County, over 36,000 people, which is approximately 30 percent of the County's total population, live outside cities and villages. Many rural residents face barriers related to access to housing, transportation, and foods that are safe, healthy, and affordable. These barriers can impact all residents, thought they are particularly problematic for those already struggling financially. There are two non-profit, general medical and surgical hospitals servicing the county. There are several outpatient clinics affiliated with the health systems which operate the two hospitals (HSHS/Prevea and Aurora Healthcare). Ascension and Holy Family Memorial also operate clinics within our county along with a small number of independent providers. In addition, there is a federally qualified healthcare center (Lakeshore Community Health Care) which provides medical, dental and behavioral health services. Sheboygan County contains a HPSA (health professional shortage area) for Medical, Dental, and Behavioral Health as well as a MUA (medically underserved area), per HRSA (Health Resources and Services Administration). HSHS St. Nicholas does not exclude Medically Underserved Areas, low income or minority population from its service area. The service area's racial profile is primarily white (85.6 percent), higher than the state (86.2 percent) and nation (72.4 percent). The largest minority populations in the service area are Hispanic or Latino (5.98 percent) and Hmong (5.25 percent) with other races making up the remaining 3 percent of the population. Wisconsin is home to the third largest Hmong population in the nation. Sheboygan County with has one of the largest Hmong populations in the state. When compared to other counties, Sheboygan County has a relatively high number of residents that are native Hmong speakers. Studies have shown that language and cultural barriers can have negative impact on an individual's health. Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care. The median age of residents is 41.4 years which is older than the state median age of 39.4 years. The Hospital service area population is aging as much of the nation is as the population of Sheboygan County aged 60 and older comprises approximately 34% of the county population, or 50,907 individuals. Along with the aging population come increased health care costs with chronic disease. Studies indicate that the health of the aging population can be maintained, and chronic diseases reduced by promoting healthy behaviors and expanding prevention services. The median income of Sheboygan County residents is $53,713 which is approximately $300 dollars more than the Wisconsin median income of $53,357. 9.2% of population of is below the federal poverty guideline. A total of 18.9% of the hospital's and community's patients are uninsured or Medicaid recipients (6.2% uninsured and 12.7 % Medicaid). Socioeconomics is one of the most influential determinants in an individual's level of access to health care. Individuals with a lower socioeconomic status in the U.S. have lower levels of general health, insurance, in addition to less access to care. (American Journal of Public, Health 2000). Several large manufacturing firms, service industry, agriculture, and agriculture-related business are located in Sheboygan County and provide most of the employment opportunities.
Schedule H, Part VI, Line 5 Promotion of community health	As a healing ministry of the Catholic Church and an affiliate of Hospital Sisters Health System (HSHS), HSHS St. Nicholas Hospital is committed to delivering high quality, compassionate, and cost-effective health care services to all. Founded in 1890, the hospital brings a healing presence and improves the health of our community, especially those persons who are sick, poor, and disadvantaged. Because of the hospital's mission and heritage, the hospital is dedicated to promoting the health of Sheboygan County and surrounding areas. The hospital is governed by a Board of Directors, most of whom reside in the hospital's primary service area and are neither employees nor independent contractors of the hospital (nor family members thereof). The Board ensures that HSHS St. Nicholas is responding to community need. In FY2019 for example, Community Benefit staff presented to the Board on Community Involvement updating them on current initiatives related to the identified health focus areas. Additionally, our hospital Advisory Council, HSHS St. Nicholas Foundation and the Partners of St. Nicholas Hospital, whose volunteer members assist in many areas of the hospital, provide the hospital with additional connections to and insights into the larger community and its health care needs. Consistent with its exempt purpose, HSHS St. Nicholas Hospital has an open medical staff with privileges available to all qualified physicians in the area. The hospital also operates an emergency department that is open 24 hours to all persons regardless of their ability to pay. As a not-for-profit hospital, HSHS St. Nicholas Hospital reinvests surplus funds to support the mission of the organization and health of the community rather than distributing surplus funds as profits to shareholders or individuals. Funds not committed to ongoing operations are generally used to upgrade facilities, secure new technologies, improve patient care, and support initiatives designed to promote health and ensure access for all. Medical Office Building In April 2018, SNS and Prevea Health broke ground on a new medical office building on the hospital campus. The five-story building will house Prevea physicians and specialists, along with a lab. It also has the potential for other capabilities, such as imaging, to meet the health care demands of the market. Currently, Prevea Health's physician offices are scattered loosely outside and around the SNS campus, which makes coordination of care between the hospital and physicians a bit more complex than needed. With the new medical office building located directly on the hospital campus, providers and patients will be just steps away from the hospital allowing for more seamless coordination and better patient care experiences. In providing this space on the SNS campus for Prevea Health, SNS is securing its place in the market and on the move to gain market share. The medical office building is scheduled for completion in August 2019. Radiation Oncology Department Renovation During FY19, the Radiation Oncology Department started a renovation project to improve the opportunities for cancer care we can provide for our community. This included remodeling of the physical space to provide a more welcoming and comfortable environment for patients and staff. In addition, a TrueBeam linear accelerator will be installed replacing the current therapy equipment allowing the Hospital to utilize state-of-the-art radiation therapy equipment. The True Beam delivers highly-precise doses of radiation to the tumor(s) which can result in shorter treatments and improved patient experiences. The project is due to be completed Fall 2019. HSHS St. Nicholas Hospital also devotes significant resources to access for patients who cannot afford care, along with other community benefit. In FY2019, HSHS St. Nicholas Hospital provided more than $9.7 million in Community Benefit services, including financial assistance at cost, unpaid costs of Medicaid and other public programs, and a range of diverse programs designed to enhance access and improve community health. Additionally, in FY2019, HSHS St. Nicholas Hospital provided $203k (at cost) in uncompensated care to patients who did not qualify for charity care or public assistance and more than $22 million (at cost) in excess of Medicare payment for health care services. HSHS St. Nicholas Hospital provides a range of Community Benefit initiatives and programs that further our mission and long-standing commitment to our community. In many cases, these Community Benefits would not exist without the leadership role played by HSHS St. Nicholas Hospital and they often relieve a burden that would otherwise be carried by government.
Schedule H, Part VI, Line 6 Affiliated health care system	Headquartered in Springfield, Illinois, Hospital Sisters Health System (HSHS) is a highly integrated, multi-institutional health care system comprised of 16 hospitals and more than 200 physician practice sites in Illinois and Wisconsin. HSHS is sponsored by Hospital Sisters Ministries (HSM), which is a public juridic person of the Roman Catholic Church. HSHS continues the health care ministries begun by its founders, the Hospital Sisters of St. Francis, more than 140 years ago, in rural and midsized communities throughout Illinois and Wisconsin. HSHS provides compassionate, holistic, high quality, and cost-effective health care through its acute care hospitals, physician practices, home health programs, palliative and hospice programs, and community outreach services. In addition, HSHS affiliated hospitals include critical access facilities that offer essential health services that otherwise would not be available in many communities. Our mission calls us to reveal and embody Christ's healing love for all people, and we extend our high quality Franciscan health care ministry beyond the walls of our hospitals by providing community health improvement services with special emphasis on the poor and vulnerable. In addition to providing community health improvement services to the broader community, HSHS cares for everyone who comes to its facilities, regardless of their ability to pay. In tandem with a variety of cross sector community partners, HSHS's Community Benefit initiatives are strategically planned and professionally implemented to improve access to health care services; enhance the health of the community; advance medical or general health care knowledge; and relieve or reduce the burden of government to improve health. In FY2019, HSHS collectively provided $211.7 million in Community Benefit (9.2% of total hospital expenses). This amount included $27.7 million provided for Financial Assistance (a.k.a. Charity Care) and $142.3 million for unreimbursed care provided as part of the Medicaid program. In addition, HSHS hospitals committed significant resources to treat Medicare patients. The cost of providing services to primarily elderly beneficiaries of the Medicare program - in excess of governmental and managed care contract payments - was $279.9 million. HSHS hospitals also recorded $41.1 million in uncollectible accounts. While HSHS does not count the latter two amounts as Community Benefit, they nonetheless reflect our commitment to serving all persons in need of care. In addition to the dollars invested in our Community Benefit programs, HSHS continues to reinvest any surplus revenue from operations and investments into new medical technology, facility infrastructure and health care services in our communities. By doing so, we ensure our ability to meet the ongoing demand for high quality, efficient and easily accessible health care.
Schedule H, Part VI, Line 7 State filing of community benefit report	WI

Schedule H (Form 990) 2018

Additional Data

Software ID:	18007697
Software Version:	2018v3.1

- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

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

Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990.
SchJMediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc
is

Employer identification number

39-0808480

Part I

Questions Regarding Compensation

Yes

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

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

Travel for companions Payments for business use of personal residence

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

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

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

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

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.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

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

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

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

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

Yes

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

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

Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.

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

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

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

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

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

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

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

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

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

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

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

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

Cat. No. 50053T

Schedule J (Form 990) 2018

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 on 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 in column (B) reported as deferred on prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
1ANDREW J BAGNALL FORMER PRES/CEO WESTERN WI DIV	(i) (ii)	0 ------------- 398,881	0 ------------- 15,779	0 ------------- 196,643	0 ------------- 77,839	0 ------------- 30,673	0 ------------- 719,815	0 ------------- 51,004
2THERESE B PANDL INTERIM PRES/ CEO EASTERN WISCONSIN DIVISION	(i) (ii)	0 ------------- 702,210	0 ------------- 46,929	0 ------------- 175,248	0 ------------- 144,623	0 ------------- 29,679	0 ------------- 1,098,689	0 ------------- 139,297
3Justin Selle President & CEO as of 8/20/18	(i) (ii)	0 ------------- 92,523	0 ------------- 0	0 ------------- 66,195	0 ------------- 9,554	0 ------------- 9,589	0 ------------- 177,861	0 ------------- 0
4MICHAEL W COTTRELL BOARD MEMBER/HSHS CFO	(i) (ii)	0 ------------- 657,185	0 ------------- 15,342	0 ------------- 155,634	0 ------------- 158,581	0 ------------- 31,165	0 ------------- 1,017,907	0 ------------- 127,730
5ANN M CARR TREASURER	(i) (ii)	0 ------------- 268,272	0 ------------- 4,360	0 ------------- 57,197	0 ------------- 89,873	0 ------------- 20,590	0 ------------- 440,292	0 ------------- 28,431
6MARY MARTIN CHIEF NURSING OFFICER	(i) (ii)	186,213 ------------- 0	4,005 ------------- 0	470 ------------- 0	28,842 ------------- 0	27,638 ------------- 0	247,168 ------------- 0	0 ------------- 0
7GREG SIMIA DIVISION CFO	(i) (ii)	0 ------------- 415,076	0 ------------- 0	0 ------------- 41,380	0 ------------- 60,580	0 ------------- 28,644	0 ------------- 545,680	0 ------------- 0
8ANDREA M ANGOTTI PHARMACIST	(i) (ii)	156,152 ------------- 0	1,261 ------------- 0	780 ------------- 0	56,905 ------------- 0	23,393 ------------- 0	238,491 ------------- 0	0 ------------- 0
9SHALON EDSON DIRECTOR - CLINICAL	(i) (ii)	128,377 ------------- 0	0 ------------- 0	450 ------------- 0	13,641 ------------- 0	9,002 ------------- 0	151,470 ------------- 0	0 ------------- 0
10MELISSA PALECEK PHARMACY MANAGER	(i) (ii)	154,926 ------------- 0	0 ------------- 0	0 ------------- 0	13,771 ------------- 0	935 ------------- 0	169,632 ------------- 0	0 ------------- 0
11CEANNE SIMMELINK PHARMACIST	(i) (ii)	126,897 ------------- 0	0 ------------- 0	858 ------------- 0	7,475 ------------- 0	27,897 ------------- 0	163,127 ------------- 0	0 ------------- 0

Schedule J (Form 990) 2018

Page 3

Part III

Supplemental Information

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.

Return Reference

Explanation

Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation

PLEASE SEE RESPONSE TO FORM 990, PART VI, LINE 15A IN SCHEDULE O.

Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan

HSHS EXECUTIVES ELIGIBLE TO PARTICIPATE IN SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) ARE DEFINED IN THE SERP PLAN DOCUMENTS;. THE SERP WAS ESTABLISHED TO PROVIDE ADDITIONAL RETIREMENT BENEFITS TO ENSURE REASONABLE MARKET COMPETITIVE BENEFITS IN ACCORDANCE WITH THE HSHS EXECUTIVE COMPENSATION PHILOSOPHY ESTABLISHED BY THE HSHS COMPENSATION COMMITTEE. THE PLAN PROVIDES A DEFINED RETIREMENT CONTRIBUTION TO PARTICIPANTS COMMENCING ON JANUARY 1, 2008, EQUAL TO A PERCENTAGE OF COMPENSATION AS DEFINED IN THE SERP PLAN DOCUMENTS FOR THE PLAN YEAR. PARTICIPANTS CONSTRUCTIVELY RECEIVE A DISTRIBUTION FROM THE PLAN NO LATER THAN MARCH 15TH OF THE CALENDAR YEAR FOLLOWING THE CALENDAR YEAR IN WHICH AN AMOUNT IS VESTED and TAXABLE PURSUANT TO A VESTING SCHEDULE AS SPECIFIED IN THE PLAN DOCUMENT. THE ACTUAL DISTRIBUTION OF THE VESTED BENEFIT UNDER THE PLAN IS PAID IN A SINGLE LUMP SUM TO THE PARTICIPANT OR THE PARTICIPANT'S BENEFICIARY UPON THE EARLIER OF THE PARTICIPANT'S TERMINATION OF EMPLOYMENT, DEATH, OR TOTAL AND PERMANENT DISABILITY. THE FOLLOWING INTERESTED PERSONS CONSTRUCTIVELY RECEIVED DEFERRALS TO THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) IN 2018; THESE DEFERRALS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (C). ANDREW J BAGNALL -- $52,032 ANN M. CARR -- $29,653 MICHAEL W. COTTRELL -- $84,073 THERESE B. PANDL -- $89,819 THE FOLLOWING INTERESTED PERSONS RECEIVED DISTRIBUTIONS FROM THE SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) IN 2018; THESE PAYMENTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(III) AND SCHEDULE J, PART II, COLUMN (F), AS APPLICABLE. ANDREW J BAGNALL -- $51,004 ANN M. CARR -- $28,431 MICHAEL W. COTTRELL -- $127,730 THERESE B. PANDL -- $139,297

Schedule J (Form 990) 2018

Additional Data

Software ID:	18007697
Software Version:	2018v3.1

- 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 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2018

Open to Public
Inspection

Name of the organization

St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc
is

Employer identification number

39-0808480

Return Reference	Explanation
Form 990, Part III, Line 4a SURGICAL SERVICES	ST. NICHOLAS HOSPITAL SURGICAL SERVICES ARE COMPRISED OF THE MAIN OR, STERILE PROCESSING, SCHEDULING, PACU, ANESTHESIA, ONE DAY SURGERY (ODS) AND THE SHEBOYGAN SURGERY CENTER (SSC). THE MAIN OR HAS 6 OPERATING SUITES, A C-SECTION SUITE AND A PROCEDURE ROOM. THE SSC HAS 3 OR SUITES AND 2 PROCEDURE ROOMS. SERVICES ARE AVAILABLE 24/7 ONLY AT THE MAIN HOSPITAL. IN FY2019 THERE WERE NEARLY 5,100 SURGICAL PROCEDURES PERFORMED. SURGICAL PROCEDURES INCLUDE GENERAL, ORTHOPEDIC, ENT, PODIATRY, PAIN MANAGEMENT, OPHTHALMOLOGY, GASTROENTEROLGY, PULMONOLOGY, UROLOGY, TRAUMA AND GYNECOLOGY. ANESTHESIA AND STERILE PROCESSING ALSO PROVIDE HOSPITAL-WIDE SERVICES TO INPATIENT NURSING, LABOR AND DELIVERY AND THE EMERGENCY DEPARTMENT. ODS SUPPORTS INFUSION AND INTERVENTIONAL RADIOLOGY PATIENTS BESIDES THE SURGICAL CASES.
Form 990, Part III, Line 4b RADIOLOGY SERVICES	ST. NICHOLAS HOSPITAL IMAGING SERVICES PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY CARE. DURING FY2019 THE DEPARTMENT PERFORMED APPROXIMATELY 30,500 INPATIENT AND OUTPATIENT EXAMS AND PROCEDURES ANNUALLY. PATIENTS HAVE ACCESS TO THE LATEST TECHNOLOGY IN RADIOLOGY, COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING (MRI), NUCLEAR MEDICINE, POSITRON EMISSION TOMOGRAPHY (PET) AND ULTRASOUND. THE STAFF CONSISTS OF BOARD CERTIFIED RADIOLOGISTS AS WELL AS LICENSED AND CERTIFIED TECHNOLOGISTS, NURSES AND SONOGRAPHERS. THE MODALITIES ARE ACCREDITED AND UTILIZE STATE-OF-THE ART EQUIPMENT TO AFFORD THE RADIOLOGISTS OPTIMAL IMAGES FOR INTERPRETATION. THE DEPARTMENT AND HOSPITAL ARE ACCREDITED BY THE JOINT COMMISSION.
Form 990, Part III, Line 4c EMERGENCY SERVICES	ST. NICHOLAS HOSPITAL OPERATES A LEVEL IV TRAUMA CENTER/EMERGENCY DEPARTMENT THAT IS OPEN 24/7 AND STAFFED BY BOARD-CERTIFIED EMERGENCY MEDICINE PHYSICIAN SPECIALISTS. STAFF MEMBERS ARE TRAINED IN ADVANCED CARDIAC LIFE SUPPORT, EMERGENCY NURSING FOR PEDIATRICS AND TRAUMA NURSING. IN FY2019 THERE WERE NEARLY 13,500 VISITS TO THE EMERGENCY CENTER. LIKE ALL HOSPITAL SERVICES, EMERGENCY CARE IS PROVIDED REGARDLESS OF RACE, CREED, OR ABILITY TO PAY, AND FINANCIAL ASSISTANCE IS AVAILABLE AFTER CARE IS PROVIDED FOR THOSE IN NEED.
Form 990, Part III, Line 4d Description of other program services	(Expenses $ 80,330,929 including grants of $)(Revenue $ 71,024,267) OTHER PROGRAM SERVICES ST. NICHOLAS HOSPITAL PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT MEDICAL SERVICES TO THE COMMUNITY. BESIDES THE THREE LARGEST PROGRAM SERVICES IDENTIFIED IN PART III, ST. NICHOLAS HOSPITAL PROVIDES ADDITIONAL SERVICES INCLUDING A MEDICAL/SURGICAL FLOOR, INTENSIVE CARE UNIT, WOMEN AND INFANT SERVICES, HOME HEALTH AND HOSPICE CARE, CARDIAC SERVICES, WOUND CARE, RADIATION THERAPY, ORTHOPEDIC SERVICES, RENAL DIALYSIS, SLEEP CENTER SERVICES, AND A VARIETY OF ADDITIONAL MEDICAL SERVICES. ST. NICHOLAS HOSPITAL PROVIDES AN ARRAY OF COMMUNITY HEALTH SERVICES INCLUDING, BUT NOT EXCLUSIVE TO THE FOLLOWING, DIABETIC SCREENINGS, FLU SHOTS, FOOT CLINICS AND A VARIETY OF COMMUNITY EDUCATION CLASSES. IN ADDITION, ST. NICHOLAS HOSPITAL PARTNERS WITH SEVERAL PHYSICIAN GROUPS AND OTHER JOINT VENTURES THAT PROVIDE NEEDED MEDICAL SERVICES TO THE COMMUNITY.
Form 990, Part IV, Line 24a TAX EXEMPT BONDS	ST. NICHOLAS HOSPITAL HOLDS A LIABILITY ON ITS BOOKS FOR TAX-EXEMPT BONDS, WHICH IS AN ALLOCATION FROM ITS SOLE CORPORATE MEMBER, HOSPITAL SISTERS SERVICES, INC. ("HSSI"). AS A RESULT, THIS QUESTION WAS ANSWERED NO, AND SCHEDULE K WILL BE COMPLETED ON THE HSSI FORM 990.
Form 990, Part IV, Line 10 Endowment Funds	The organization maintains temporarily and permanently restricted net assets on its balance sheet. Such funds are held by Hospital Sisters of St. Francis Foundation, Inc., a related tax-exempt organization. While these funds are held to further one or more exempt purposes of the filing organization, they are not maintained exclusively for the filing organization. The board of directors of Hospital Sisters of St. Francis Foundation, Inc. maintains ownership and ultimately authority and discretion over the use of these funds. Based on the above, the related amounts have not been reported as endowment funds on Part V of Schedule D.
Form 990, Part VI, Line 13 WHISTLEBLOWER POLICY	PROVISIONS WITHIN THE CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY PROVIDE PROTECTIONS FOR WHISTLEBLOWER TYPE ACTIVITIES.
Form 990, Part VI, Line 16b JOINT VENTURES	HOSPITAL SISTERS HEALTH SYSTEM ADOPTED A JOINT VENTURE COMPLIANCE PROGRAM POLICY EFFECTIVE ON JANUARY 1, 2012 FOR ALL SYSTEM HOSPITALS, INCLUDING ST. NICHOLAS HOSPITAL. THE OVERALL PURPOSE OF THE POLICY IS TO PROVIDE PRACTICAL GUIDELINES FOR ETHICAL BUSINESS CONDUCT, TO ACHIEVE COMPLIANCE, AND TO DETECT AND PREVENT VIOLATIONS OF APPLICABLE LAWS. THE POLICY REQUIRES ST. NICHOLAS HOSPITAL, AND ALL HSHS HOSPITALS, TO EVALUATE THEIR PARTICIPATION IN JOINT VENTURE ARRANGEMENTS, INCLUDING UNDER APPLICABLE FEDERAL TAX LAWS, AND TO SAFEGUARD ST. NICHOLAS HOSPITAL'S TAX EXEMPT STATUS WITH RESPECT TO ANY JOINT VENTURE ARRANGEMENTS.
Form 990, Part VI, Line 1a Delegate broad authority to a committee	PER ARTICLE 5.5 OF THE ORGANIZATION'S BY-LAWS, THE GOVERNING BODY DELEGATES BROAD AUTHORITY TO AN EXECUTIVE COMMITTEE. THE EXECUTIVE COMMITTEE SHALL BE VESTED WITH AND MAY IN ITS DISCRETION EXERCISE THE FULL POWERS, DUTIES, RESPONSIBILITIES, AND AUTHORITY OF THE BOARD EXCEPT WHERE PROHIBITED BY LAW AND SUBJECT TO ANY LIMITATIONS IMPOSED BY THE BYLAWS OR THE BOARD OF DIRECTORS. AS PROVIDED IN THE BY-LAWS, THE EXECUTIVE COMMITTEE SHALL CONSIST OF NO MORE THAN SIX MEMBERS, INCLUDING THE CHAIRPERSON OF THE BOARD, THE VICE CHAIRPERSON, THE PRESIDENT AND AT LEAST TWO OTHER MEMBERS SELECTED FROM AMONG THE DIRECTORS BY THE BOARD.
Form 990, Part VI, Line 6 Classes of members or stockholders	THE SOLE CORPORATE MEMBER OF ST. NICHOLAS HOSPITAL (THE CORPORATION) IS HOSPITAL SISTERS SERVICES, INC. ("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE.
Form 990, Part VI, Line 7a Members or stockholders electing members of governing body	PURSUANT TO SECTION 2.3 OF THE CORPORATION'S BYLAWS, THE ORGANIZATION'S MEMBER, HOSPITAL SISTERS SERVICES, INC. ("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, HAS THE RIGHT TO APPOINT AND REMOVE THE CORPORATION'S BOARD OF DIRECTORS.
Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders	RESPONSIBILITY FOR THE POLICY AND OPERATIONS OF ST. NICHOLAS HOSPITAL (THE "CORPORATION") IS VESTED IN ITS BOARD OF DIRECTORS, EXCEPT WITH RESPECT TO SPECIFIC POWERS RESERVED IN THE CORPORATION'S BYLAWS TO THE CORPORATION'S MEMBER, HOSPITAL SISTERS SERVICES, INC. ("HSSI"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501 (C) (3) OF THE INTERNAL REVENUE CODE. THE MEMBER OF HSSI IS HOSPITAL SISTERS HEALTH SYSTEM ("HSHS"), AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501 (C) (3) OF THE INTERNAL REVENUE CODE. THE GOVERNANCE AND OPERATIONS OF THE CORPORATION ARE SUBJECT TO HSSI'S RIGHT TO EXERCISE THESE RESERVED POWERS WITH RESPECT TO THE CORPORATION AND ORGANIZATIONS OF WHICH THE CORPORATION IS EITHER, DIRECTLY OR INDIRECTLY, A CONTROLLING MEMBER OR A CONTROLLLING SHAREHOLDER ("AFFILIATES"). HSSI'S RIGHT TO EXERCISE CERTAIN OF THESE RESERVED POWERS IS, IN TURN, SUBJECT TO THE APPROVAL OF HSHS AND HSHS' MEMBERS. THE RESERVED POWERS INCLUDE ALL RIGHTS GRANTED TO HSSI BY LAW AND THE RIGHT TO: (A) ADOPT, APPROVE AMENDMENTS TO, OR AMNED ANY STATEMENT OF PHILOSOPHY, MISSION, MISSION INTEGRATION OR VALUES, OR ANY NAME, LOGO, OR MARK OF THE CORPORATION OR OF ANY AFFILIATE; (B) ADOPT, APPROVE AMENDMENTS TO, OR AMEND THE ARTICLES OF INCORPORATION OF THE CORPORATION OR OF ANY AFFLILIATE; (C) ADOPT, APPROVE AMENDMENTS TO, OR AMEND THE BYLAWS OF THE CORPORATION OR OF ANY AFFILIATE; (D) APPOINT AND REMOVE THE BOARD OF DIRECTORS, ANY ONE OR MORE OF THE DIRECTORS OF THE CORPORATION OR OF ANY AFFILIATE, AND THE CHAIRPERSON AND PRESIDENT OF THE CORPORATION OR OF ANY AFFILIATE; (E) APPROVE THE RECOMMENDATION OF THE BOARD OF DIRECTORS TO APPOINT OR REMOVE THE BOARD OF DIRECTORS, ANY ONE OR MORE DIRECTORS OF THE CORPORATION OR OF ANY AFFILIATE, OR THE CHAIRPERSON AND PRESIDENT OF THE CORPORATION OR OF ANY AFFILIATE. (F) WITH RESPECT TO THE CORPORATION OR ANY AFFILIATE, APPROVE THE PURCHASE, SALE, ALIENATION, EXCHNAGE, LEASE, OR ENCUMBRANCE OF ANY REAL PROPERTY OF THE CORPORATION OR OF ANY AFFILIATE, WHICH PROPERTY HAS A VALUE IN EXCESS OF LIMITS SET FROM TIME TO TIME BY HSSI; (G) APPROVE THE OPERATING AND CAPITAL BUDGETS OF THE CORPORATION OR OF ANY AFFILIATE, AND ANY DEVIATIONS BY THE CORPORATION OR OF ANY AFFILATE FROM SUCH BUDGETS IN AN AMOUNT OR PERCENTAGE SPECIFIED BY HSSI FROM TIME TO TIME; (H) APPROVE THE STRAEGIC PLAN AND GOALS OF THE CORPORATION OR OF ANY AFFILIATE; (I) APPROVE THE SALE OF SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION OR OF ANY AFFILIATE; (J) APPROVE THE MERGER OR DISSOLUTION OF THE CORPORATION OR OF ANY AFFILIATE; (K) ADOPT OR AMEND THE PLAN FOR MINISTRY EDUCATION AND GOVERNANCE FOR THE CORPORATION AND ITS AFFILIATES; (L) APPROVE THE CORPORATION'S MISSION ACCOUNTABILITY REPORTS AND THOSE OF ANY AFFILIATE; (M) APPROVE THE FINANCIAL POLICIES AND PROCEDURES OF THE CORPORATION OR OF ANY AFFILIATE, AND APPROVE ANY DEVIATIONS FROM SUCH POLICIES AND PROCEDURES BY THE CORPORAITON OR ANY AFFILIATE; AND (N) ADOPT POLICIES TO IMPLEMENT THE RESERVED POWERS OF HSSI.
Form 990, Part VI, Line 11b Review of form 990 by governing body	THE HOSPITAL EMPLOYS CROWE LLP TO ASSIST IN THE OVERALL REVIEW AND ELECTRONIC SUBMISSION OF ITS FORM 990. CROWE LLP PROVIDES GUIDANCE IN IDENTIFYING CRITICAL ERRORS IN THE RETURN SUBMISSION AND FEEDBACK ON QUANTITATIVE AND QUALITATIVE RESPONSES. ADDITIONALLY, THE HOSPITAL CFO PERFORMS A THOROUGH REVIEW OF THE RETURN AND REVIEWS IT WITH THE HOSPITAL CEO AND/OR SENIOR LEADERS BEFORE PRESENTING IT IN ITS ENTIRETY TO THE HOSPITAL BOARD FOR QUESTIONING AND REVIEW PRIOR TO THE RETURN'S SIGNING AND SUBMISSION TO THE IRS.
Form 990, Part VI, Line 12c Conflict of interest policy	THE ORGANIZATION IS SUBJECT TO THE CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY ("POLICY") OF HOSPITAL SISTERS HEALTH SYSTEM, AN ILLINOIS NOT FOR PROFIT CORPORATION EXEMPT FROM FEDERAL TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. A REVISED CORPORATE COMPLIANCE PROGRAM AND CONFLICT OF INTEREST POLICY HAVE BEEN IMPLEMENTED SINCE JANUARY, 2009 TO MANAGE CONFLICTS OF INTEREST USING A SYSTEM-WIDE PROTOCOL FOR DISCLOSURE STATEMENTS. IN ACCORDANCE WITH THE ORGANIZATON'S CONFLICT OF INTEREST POLICY, ALL COVERED PERSONS HAVE A DUTY TO COMPLY WITH THE CONFLICT OF INTEREST POLICY FOR ANY CONTRACT, TRANSACTION, RELATIONSHIP, OR ACTIVITY CONTEMPLATED, ENTERED INTO, OR CONDUCTED AT HSHS OR ITS AFFILIATES. THE POLICY DEFINES COVERED PERSONS AS BOARD MEMBERS, BOARD COMMITTEE MEMBERS, OFFICERS, BOARD DESIGNEES, SENIOR MANAGEMENT, MEMBERS OF ANY COMMITTEE THAT OVERSEES THE APPROVAL OF PHARMACEUTICALS AND MEDICAL DEVICES, AND ANY OTHER INDIVIDUAL WHO HOLDS A POSITION OF TRUST. ON AN ANNUAL BASIS, HSHS DISCLOSES A COPY OF THE CONFLICT OF INTEREST POLICY (AND ALL CORRESPONDING PROCEDURES, GUIDELINES, FORMS, AND TOOLS) TO ALL COVERED PERSONS AND ADVISES ALL COVERED PERSONS IN WRITING OF ANY SUBSTANTIVE CHANGES TO THIS POLICY AND SUCH RELATED MATERIALS. COVERED PERSONS ARE REQUIRED TO REVIEW AND COMPLETE THE CORRESPONDING CONFLICT OF INTEREST STATEMENT. THE SYSTEM OFFICE VICE PRESIDENT - SYSTEM RESPONSIBILITY, VICE PRESIDENT - RISK & COMPLIANCE, OR MEMBERS OF THE AUDIT AND INTEGRITY COMMITTEE ("COMMITTEE") ARE AVAILABLE TO ANSWER ANY QUESTIONS A COVERED PERSON MAY HAVE. IN ADDITION, IF, AT ANY TIME AFTER SUBMITTING AN ANNUAL CONFLICT OF INTEREST STATEMENT, A COVERED PERSON BECOMES AWARE OF AN INTEREST THAT HE OR SHE WOULD HAVE HAD TO DISCLOSE AT THE ANNUAL INTERVAL, THE COVERED PERSON IS REQUIRED PROMPTLY TO DISCLOSE THE INTEREST TO THE COMMITTEE USING THE HSHS CONFLICT OF INTEREST DISCLOSURE STATEMENT. COMPLETED CONFLICT OF INTEREST STATEMENTS ARE SUBMITTED TO THE COMMITTEE, WHICH IS RESPONSIBLE FOR IDENTIFYING, ASSESSING, AND MANAGING CONFLICTS OF INTEREST THAT ARISE IN THE COURSE OF CONDUCTING THE AFFAIRS OF HSHS AND ITS AFFILIATES. IF THE COMMITTEE DETERMINES THAT A CONFLICT OF INTEREST EXISTS, THE CONFLICT OF INTEREST POLICY REQUIRES HSHS NOT TO ENGAGE IN, OR ENTER INTO A PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY UNLESS THE COMMITTEE OR, WHERE NECESSARY, THE BOARD OF DIRECTORS (ACTING THROUGH ITS DISINTERESTED MEMBERS), HAS INVESTIGATED ALTERNATIVES TO THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY AND, IN THE ABSENCE OF ALTERNATIVES THAT ARE IN THE BEST INTERESTS OF HSHS, HAS DETERMINED: 1. THAT, REGARDLESS OF WHETHER THE COVERED PERSON PARTICIPATES IN THE IMPLEMENTATION OF THE PROPOSED CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY; 2. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS IN THE BEST INTERESTS OF HSHS; 3. THE CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY IS FAIR AND REASONABLE FROM THE PERSPECTIVE OF HSHS; AND 4. HSHS CANNOT OBTAIN A MORE ADVANTAGEOUS CONTRACT, TRANSACTION, ARRANGEMENT, OR ACTIVITY WITH REASONABLE EFFORTS UNDER THE CIRCUMSTANCES. IN DETERMINING WHETHER A CONTRACT, TRANSACTION OR ARRANGEMENT IS FAIR AND REASONABLE TO HSHS, THE COMMITTEE SHALL CONSIDER, WHERE APPLICABLE: 1. APPRAISALS OR OTHER INDEPENDENT VALUATIONS OF THE FAIR MARKET VALUE OF THE CONTRACT, TRANSACTION, OR ARRANGEMENT; 2. INFORMATION REGARDING COMPARABLE CONTRACTS, TRANSACTIONS, OR ARRANGEMENTS BETWEEN UNRELATED PARTIES; 3. OFFERS FROM COMPARABLE COMPETING ENTITIES; AND/OR 4. STUDIES OF COMPARABLE COMPENSATION ARRANGEMENTS. IN ANY CASE IN WHICH THE COMMITTEE FINDS, AFTER TAKING THE STEPS DESCRIBED ABOVE, THAT HSHS SHOULD PARTICIPATE IN A PROPOSED TRANSACTION OR ARRANGEMENT DESPITE THE EXISTENCE OF A CONFLICT OF INTEREST, THE COMMITTEE SHALL DEVELOP, IMPLEMENT, MONITOR, AND ENFORCE COMPLIANCE WITH A CONFLICT MANAGEMENT PLAN FOR MANAGING THE CONFLICT OF INTEREST AS IT CONSIDERS NECESSARY FOR SUCH FINDINGS TO REMAIN VALID THROUGHOUT THE LIFE OF THE CONTRACT, TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY. ALL CONFLICT MANAGEMENT PLANS SHALL: 1. STATE THAT THE COMMITTEE WILL OVERSEE, MONITOR, AND ENFORCE COMPLIANCE WITH THE PLAN THROUGHOUT THE COURSE OF THE STUDY AND SPECIFY MEANS FOR DOING SO, INCLUDING, WITHOUT LIMITATION, THAT THE APPROPRIATE INDIVIDUALS MUST PROVIDE THE COMMITTEE WITH WRITTEN REPORTS PERTAINING TO COMPLIANCE WITH THE CONFLICT MANAGEMENT PLAN, THAT THE COMMITTEE SHALL HAVE THE RIGHT TO AUDIT THE STUDY FOR SUCH COMPLIANCE AND THE RIGHT TO IMPOSE SANCTIONS FOR NON-COMPLIANCE; 2. STATE THAT THE PLAN MUST BE SHARED WITH COVERED PERSON WHOSE INTERESTS IT WAS DEVELOPED TO MANAGE; 3. STATE THAT THE PLAN MUST BE SHARED WITH, AND PERIODIC REPORTS ON COMPLIANCE WITH THE PLAN MUST BE PROVIDED TO, THE BOARD, SENIOR MANAGEMENT, AND/OR GOVERNMENT AGENCIES; AND 4. PROVIDE FOR SUCH OTHER MANAGEMENT STEPS AND MECHANISMS THE COMMITTEE CONSIDERS NECESSARY AND APPROPRIATE. IN ADDITION TO THE COMMITTEE, THE SYSTEM OFFICE VICE PRESIDENTS OF SYSTEM RESPONSIBILITY AND RISK & COMPLIANCE MAY RETAIN SUCH INDEPENDENT ADVISORS OR EXPERTS AS DEEMED NECESSARY TO ASSIST IN MAKING ITS DETERMINATIONS AND DECISIONS. IF THE COMMITTEE DETERMINES THAT THE CONTEMPLATED TRANSACTION, RELATIONSHIP, ARRANGEMENT, OR ACTIVITY CANNOT PROCEED DUE TO A CONFLICT OF INTEREST, THE COMMITTEE SHALL INFORM THE APPLICABLE COVERED PERSON OR DECISION-MAKING BODY OF SUCH DETERMINATION WITHIN ONE WEEK OF THE COMMITTEE MEETING AT WHICH THE CONTEMPLATED TRANSACTION WAS DISCUSSED. THE COMMITTEE SHALL DOCUMENT ITS REJECTION OF THE CONTEMPLATED TRANSACTION IN THE COMMITTEE'S MEETING MINUTES.
Form 990, Part VI, Line 15a Process to establish compensation of top management official	THE COMPENSATION COMMITTEE (COMMITTEE) IS COMPRISED OF INDEPENDENT MEMBERS OF THE BOARD OF DIRECTORS. THE COMMITTEE DEVELOPS A COMPENSATION PHILOSOPHY FOR THE SYSTEM AND ALL AFFILIATES. THE COMMITTEE SELECTS AND HIRES THE INDEPENDENT COMPENSATION CONSULTANT TO DEVELOP COMPARABILITY DATA AND ADVISE THE COMMITTEE DURING ITS DELIBERATIONS REGARDING ALL ELEMENTS OF TOTAL COMPENSATION FOR ALL HSHS EXECUTIVES, (the top management official, other officers and key employees). INTEGRATED HEALTHCARE STRATEGIES ("IHS"), THE CONSULTANTS UTILIZED BY THE COMMITTEE, USE DATA FROM MULTIPLE TAX-EXEMPT PEER GROUP SOURCES (derived from a full market review conducted every other year) TO DETERMINE SALARY RANGES, INCENTIVE OPPORTUNITY RANGES AND BENEFITS FOR THE HSHS executives. IHS THEN ASSISTS THE COMMITTEE IN PREPARING CONTEMPORANEOUS DOCUMENTATION OF ALL ACTIONS. EACH COMMITTEE MEETING IS CONDUCTED WITH THE INTENT TO CREATE A REBUTTABLE PRESUMPTION OF REASONABLENESS FOR ALL ELEMENTS OF EXECUTIVE TOTAL COMPENSATION. THE CHAIRMAN MAKES THIS DECLARATION AND ALSO INQUIRES IF THERE ARE ANY CONFLICTS OF INTEREST BY ANY ATTENDEES. ANY CONFLICTS ARE DISCLOSED AND THE COMMITTEE THEN ACTS IN A MANNER TO AVOID ANY CONFLICTED INDIVIDUAL PARTICIPATING IN ANY MANNER WHERE A CONFLICT MIGHT EXIST. AT THE END OF THE MEETING, THE COMMITTEE PREPARES CONTEMPORANEOUS MINUTES THAT RECORD ALL ACTIONS TAKEN DURING THE MEETING. The process for reviewing compensation by the compensation committee is completed each fiscal year.
Form 990, Part VI, Line 15b Process to establish compensation of other employees	PLEASE SEE RESPONSE TO FORM 990, PART VI, LINE 15A.
Form 990, Part VI, Line 19 Required documents available to the public	BOARD-APPROVED FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. THE GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE GENERAL PUBLIC AT THIS TIME.
Form 990, Part IX, Line 11g Other Fees	PROFESSIONAL FEES - Total Expense: 1904331, Program Service Expense: 1539469, Management and General Expenses: 364862, Fundraising Expenses: ; ISC FEES - Total Expense: 4879659, Program Service Expense: 0, Management and General Expenses: 4879659, Fundraising Expenses: ; CONTRACT LABOR - Total Expense: 1515011, Program Service Expense: 1492543, Management and General Expenses: 22468, Fundraising Expenses: ; PURCHASED SERVICES - Total Expense: 31620333, Program Service Expense: 29428069, Management and General Expenses: 2192264, Fundraising Expenses: ; Shared Services - Total Expense: 1272983, Program Service Expense: , Management and General Expenses: 1272983, Fundraising Expenses: ;
Form 990, Part X, Line 11 POOLED INVESTMENT ACCOUNT	ST. NICHOLAS HOSPITAL'S CASH RESERVES ARE INVESTED IN A POOLED INVESTMENT ACCOUNT. PARTICIPATION IN THE POOLED FUND IS LIMITED TO THE 501(C)(3) HOSPITALS AND RELATED HEALTH SERVICES ORGANIZATIONS SPONSORED BY THE HOSPITAL SISTERS HEALTH SYSTEM. THE POOLED ACCOUNT CONSISTS OF CASH, AND EQUITY AND DEBT SECURITIES THAT ARE PUBLICLY TRADED. IN ACCORDANCE WITH THE PROVISIONS OF SFAS NO. 124 "ACCOUNTING FOR CERTAIN INVESTMENTS HELD BY NOT-FOR-PROFIT ORGANIZATIONS," INVESTMENTS IN EQUITY SECURITIES WITH READILY DETERMINABLE VALUES, AND ALL INVESTMENTS IN DEBT SECURITIES, ARE REPORTED AT FAIR VALUE ON THE BALANCE SHEET. INCOME, REALIZED AND UNREALIZED GAINS AND LOSSES ARE POOLED AND ALLOCATED TO THE PARTICIPANTS. INDIVIDUAL COMPONENTS OF ASSETS AND REVENUE ARE NOT IDENTIFIED TO THE PARTICIPANTS.
Form 990, Part XI, Line 9 Other changes in net assets or fund balances	CHANGE IN PENSION - -5167262; CHANGE IN TEMPORARILY RESTRICTED NET ASSETS - -177603; CHANGE IN FAIR VALUE OF INTEREST RATE SWAPS - -364929;

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

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2018

Additional Data

Software ID:	18007697
Software Version:	2018v3.1

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

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

Attach to Form 990.
MediumBullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2018

Open to Public Inspection

Name of the organization

St Nicholas Hospital of the Hospital Sisters of the Third Order of St Franc
is

Employer identification number

39-0808480

Part I

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

(a) Name, address, and EIN (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
(1) KIARA CLINICAL INTEGRATION NETWORK LLC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 26-1417684	HEALTHCARE	IL	-1,945,270	3,230,896	HSSI
(2) PHYSICIAN CLINICAL INTEGRATION NETWORK LLC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1668647	HEALTHCARE	IL	563,783	11,970,191	KCIN
(3) HSHS ACO LLC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 32-0465666	HEALTHCARE & SOCIAL ASSISTANCE	IL	-381,285	458,242	KCIN

Part II

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1)HOSPITAL SISTERS HEALTH SYSTEM 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1058692	HEALTHCARE	IL	501(c)(3)	Type III-FI	NA		No
(2)HOSPITAL SISTERS OF ST FRANCIS FOUNDATION 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1186514	HEALTHCARE	IL	501(c)(3)	7	HSHS	Yes
(3)HOSPITAL SISTERS HEALTHCARE WEST INC 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS,WI54729 51-0157933	HEALTHCARE	WI	501(c)(3)	Type I	HSSI	Yes
(4)SACRED HEART HOSPITAL 990 WEST CLAIREMONT AVENUE EAU CLAIRE,WI54701 39-0807060	HEALTHCARE	WI	501(c)(3)	3	HSSI	Yes
(5)ST ANTHONY'S HOSPITAL 503 N MAPLE STREET EFFINGHAM,IL62401 37-0661233	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(6)ST ELIZABETH'S HOSPITAL ONE ST ELIZABETHS BLVD OFALLON,IL62269 37-0663567	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(7)ST JOHN'S HOSPITAL 800 EAST CARPENTER STREET SPRINGFIELD,IL62769 37-0661238	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(8)ST JOSEPH'S HOSPITAL 9515 HOLY CROSS LANE BREESE,IL62230 37-1208459	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(9)ST JOSEPH'S HOSPITAL 2661 COUNTY HIGHWAY 1 CHIPPEWA FALLS,WI54729 39-0810545	HEALTHCARE	WI	501(c)(3)	3	HSSI	Yes
(10)ST MARY'S HOSPITAL 1800 E LAKE SHORE DRIVE DECATUR,IL62521 37-0661244	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(11)ST MARY'S HOSPITAL 111 SPRING STREET STREATOR,IL61364 36-2169181	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(12)ST MARY'S MEDICAL CENTER 1762 SHAWANO AVENUE GREEN BAY,WI54303 39-0818682	HEALTHCARE	WI	501(c)(3)	3	HSSI	Yes
(13)ST VINCENT HOSPITAL 835 S VAN BUREN GREEN BAY,WI51301 39-0817529	HEALTHCARE	WI	501(c)(3)	3	HSSI	Yes
(14)ST JOSEPH'S HOSPITAL 12866 TROXLER AVENUE HIGHLAND,IL62249 37-0663568	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(15)ST FRANCIS HOSPITAL 1215 FRANCISCAN DRIVE LITCHFIELD,IL62056 37-0661236	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(16)HOSPITAL SISTERS SERVICES INC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1163402	HEALTHCARE	IL	501(c)(3)	Type III-FI	HSHS	Yes
(17)HSHS MEDICAL GROUP INC 3215 EXECUTIVE PARK DRIVE SPRINGFIELD,IL62703 26-3956318	HEALTHCARE	IL	501(c)(3)	Type III-FI	HSSI	Yes
(18)HSHS WISCONSIN MEDICAL GROUP INC 3215 EXECUTIVE PARK DRIVE SPRINGFIELD,IL62703 26-4515959	HEALTHCARE	WI	501(c)(3)	Type III-FI	HSSI	Yes
(19)ORANGE CROSS AMBULANCE INC 919 ASHLAND AVENUE SHEBOYGAN,WI53081 39-1860942	HEALTHCARE	WI	501(c)(3)	10	ST NICHOLAS	Yes
(20)UNITY LIMITED PARTNERSHIP 2366 OAK RIDGE CIRCLE DE PERE,WI54115 39-1750729	HEALTHCARE	WI	501(c)(3)	10	HSSI	Yes
(21)PRAIRIE EDUCATION & RESEARCH COOPERATIVE 317 NORTH 5TH STREET SPRINGFIELD,IL62701 37-1157915	HEALTHCARE	IL	501(c)(3)	4	HSSI	Yes
(22)ST CLARE MEMORIAL HOSPITAL 855 S MAIN STREET OCONTO FALLS,WI54154 39-0848401	HEALTHCARE	WI	501(c)(3)	3	HSSI	Yes
(23)HSHS HOLY FAMILY HOSPITAL 200 HEALTHCARE DRIVE GREENVILLE,IL62246 37-0792770	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(24)UTLAUT MEMORIAL FOUNDATION 200 HEALTHCARE DRIVE GREENVILLE,IL62246 37-1140166	FUNDRAISING	IL	501(c)(3)	Type II	HSSI	Yes
(25)HSHS GOOD SHEPHERD HOSPITAL INC 200 SOUTH CEDAR STREET SHELBYVILLE,IL62565 37-0512290	HEALTHCARE	IL	501(c)(3)	3	HSSI	Yes
(26)SHELBY MEMORIAL HOSPITAL EMPLOYEE BENEFIT TRUST 200 SOUTH CEDAR STREET SHELBYVILLE,IL62565 37-1778753	TRUST	IL	501(a)		GSS	Yes

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

Cat. No. 50135Y

Schedule R (Form 990) 2018

Page 2

Part III

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Predominant income(related, unrelated, excluded from tax under sections 512-514)	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?		(k) Percentage ownership
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity		(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No
(1) PAIN CENTER OF WISCONSIN 4131 W LOOMIS ROAD SUITE 300 GREENFIELD,WI53221 26-3155343	HEALTHCARE	WI	ST VINCENT	Related	742,948	556,009		No			No	50 %
(2) PAIN CENTER OF WISCONSIN - OCONTO FALLS LLC 4131 W LOOMIS ROAD SUITE 300 GREENFIELD,WI53221 36-4717036	HEALTHCARE	WI	ST CLARE	Related	26,375	142,266		No			No	50 %
(3) CARPENTER STREET HOTEL LLC 525 NORTH SIXTH STREET SPRINGFIELD,IL62702 36-4128127	HOTEL	IL	LASANTE INC	N/A								0 %
(4) SPRINGFIELD URGENT CARE REAL ESTATE LLC PO BOX 19456 SPRINGFIELD,IL627949456 03-0413258	RENTAL REAL ESTATE	IL	LASANTE INC	N/A								0 %
(5) PRAIRIE HEART INSTITUTE MANAGEMENT COMPANY LLC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 26-1479945	MEDICAL	IL	HSHS	Related	-6,697	9,753		No		Yes		100 %
(6) SOUTHWEST ILLINOIS HEALTH SERVICES REAL ESTATE LLP 4000 NORTH ILLINOIS STREET SWANSEA,IL62226 82-3633320	REAL ESTATE	IL	ST ELIZABETH'S	Related	337,078	1,174,120		No			No	50 %
(7) PRAIRIE HEART INSTITUTE ST JOHN'S 800 EAST CARPENTER STREET SPRINGFIELD,IL62769 37-1321197	HEALTHCARE	IL	HSHS	Related	0	0		No			No	100 %

Part IV

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

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(h) Percentage ownership	(i) Section 512(b)(13) controlled entity?
(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		Yes	No
(1) KIARA INC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1163401	HEALTHCARE	IL	HSHS	C Corporation			100 %	Yes
(2) LASANTE WISCONSIN INC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 39-1572196	HEALTHCARE	IL	KIARA INC	C Corporation				Yes
(3) LASANTE INC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 37-1163400	HEALTHCARE	IL	KIARA INC	C Corporation				Yes
(4) PRAIRIE CARDIOVASCULAR 619 EAST MASON SUITE 4P57 SPRINGFIELD,IL62701 37-1071858	HEALTHCARE	IL	KIARA INC	C Corporation				Yes
(5) PREVEA HEALTH SERVICES INC 2710 EXECUTIVE DRIVE GREEN BAY,WI54304 39-1839351	HEALTHCARE	WI	HSSI	C Corporation			50 %	Yes
(6) PREVEA CLINIC INC 2710 EXECUTVE DRIVE GREEN BAY,WI54304 39-1839349	HEALTHCARE	WI	PHSI	C Corporation				Yes
(7) RENAISSANCE QUALITY INSURANCE LTD PO BOX 1159 GRAND CAYMANKY11102 CJ 98-0669953	SELF-INSURANCE	CJ	HSSI	C Corporation			100 %	Yes
(8) OJV INC 4936 LAVERNA ROAD SPRINGFIELD,IL62707 46-0873384	HEALTHCARE	IL	LASANTE INC	C Corporation				Yes

Schedule R (Form 990) 2018

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on 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

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 .....................

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

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

Yes

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

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

f Dividends from related organization(s) ............................

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

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

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

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

Yes

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

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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 related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved

Schedule R (Form 990) 2018

Page 4

Part VI

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

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

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

Schedule R (Form 990) 2018

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference

Explanation

Schedule R, Part V, Line 2 TRANSACTIONS WITH RELATED ENTITIES

ANY TRANSACTIONS LISTED ON SCHEDULE R, PART V, LINE 1 AND NOT ON SCHEDULE R, PART V, LINE 2 ARE BETWEEN RELATED 501(C)(3) AND DO NOT REQUIRE REPORTING ON THIS SECTION.

Schedule R, Part VII Related Organizations

Due to the increasingly complex organization structure of Hospital Sisters Health System and Affiliates, the filing organization has elected to report all organizations within Hospital Sisters Health System as related, regardless of ownership interest or "control" as defined by the instructions to Schedule R. The intent of this reporting is to promote transparency and increase consistency across the numerous Form 990 submissions by Hospital Sisters Health System and Affiliates.

Schedule R (Form 990) 2018

Additional Data

Software ID:	18007697
Software Version:	2018v3.1

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	2,089,474	35,215
9	Program service revenue (Part VIII, line 2g) .........	113,375,359	121,162,569
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	1,247,119	115,482
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	56,757	-177,698
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)	116,768,709	121,135,568
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		0
14	Benefits paid to or for members (Part IX, column (A), line 4).....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	27,415,594	28,664,303
16a	Professional fundraising fees (Part IX, column (A), line 11e) .....		0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	81,505,554	88,249,072
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	108,921,148	116,913,375
19	Revenue less expenses. Subtract line 18 from line 12.......	7,847,561	4,222,193
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	133,451,695	139,336,891
21	Total liabilities (Part X, line 26).............	31,666,681	39,355,352
22	Net assets or fund balances. Subtract line 21 from line 20.....	101,785,014	99,981,539

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 11,099,290 including grants of $ ) (Revenue $ 25,630,893 )
	SURGICAL SERVICES - SEE SCHEDULE O

4b	(Code: ) (Expenses $ 3,303,113 including grants of $ ) (Revenue $ 15,585,901 )
	RADIOLOGY SERVICES - SEE SCHEDULE O

4c	(Code: ) (Expenses $ 2,126,250 including grants of $ ) (Revenue $ 8,851,558 )
	EMERGENCY SERVICES - SEE SCHEDULE O

	(Code: ) (Expenses $ 80,330,929 including grants of $ ) (Revenue $ 71,024,267 )
	OTHER PROGRAM SERVICES ST. NICHOLAS HOSPITAL PROVIDES COMPREHENSIVE INPATIENT AND OUTPATIENT MEDICAL SERVICES TO THE COMMUNITY. BESIDES THE THREE LARGEST PROGRAM SERVICES IDENTIFIED IN PART III, ST. NICHOLAS HOSPITAL PROVIDES ADDITIONAL SERVICES INCLUDING A MEDICAL/SURGICAL FLOOR, INTENSIVE CARE UNIT, WOMEN AND INFANT SERVICES, HOME HEALTH AND HOSPICE CARE, CARDIAC SERVICES, WOUND CARE, RADIATION THERAPY, ORTHOPEDIC SERVICES, RENAL DIALYSIS, SLEEP CENTER SERVICES, AND A VARIETY OF ADDITIONAL MEDICAL SERVICES. ST. NICHOLAS HOSPITAL PROVIDES AN ARRAY OF COMMUNITY HEALTH SERVICES INCLUDING, BUT NOT EXCLUSIVE TO THE FOLLOWING, DIABETIC SCREENINGS, FLU SHOTS, FOOT CLINICS AND A VARIETY OF COMMUNITY EDUCATION CLASSES. IN ADDITION, ST. NICHOLAS HOSPITAL PARTNERS WITH SEVERAL PHYSICIAN GROUPS AND OTHER JOINT VENTURES THAT PROVIDE NEEDED MEDICAL SERVICES TO THE COMMUNITY.

4d	Other program services (Describe in Schedule O.)
	(Expenses $ 80,330,929 including grants of $ ) (Revenue $ 71,024,267 )
4e	Total program service expenses96,859,582

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)			(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) ANDREA M ANGOTTI PHARMACIST	40.0 .......................0	X		158,193	0	80,298
(19) SHALON EDSON DIRECTOR - CLINICAL	40.0 .......................0	X		128,827	0	22,643
(20) Tayna Konitzer Divisional Director	40.0 .......................0	X		118,001	0	29,122
(21) MELISSA PALECEK PHARMACY MANAGER	40.0 .......................0	X		154,926	0	14,706
(22) CEANNE SIMMELINK PHARMACIST	40.0 .......................0	X		127,755	0	35,372
(23) ANDREW J BAGNALL FORMER PRES/CEO WESTERN WI DIV	0.0 .......................40.0		X	0	611,303	108,512

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)...........	878,390	3,308,854	930,011

1	Briefly describe the organization’s mission or most significant activities: TO CARRY FORWARD THE HEALING MINISTRY OF THE HOSPITAL SISTERS OF ST. FRANCIS AS PART OF THE HEALTH MINISTRY OF THE ROMAN CATHOLIC CHURCH.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	14
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	12
5	Total number of individuals employed in calendar year 2018 (Part V, line 2a) ......	5	503
6	Total number of volunteers (estimate if necessary) .............	6	149
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	69,950
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	0

1a	Federated campaigns..		1a
b	Membership dues..		1b
c	Fundraising events..		1c
d	Related organizations		1d	35,215
e	Government grants (contributions)		1e

f	All other contributions, gifts, grants, and similar amounts not included above		1f

g	Noncash contributions included in lines 1a - 1f:$
h Total. Add lines 1a-1f.......		35,215

		Business Code
2a	NET PATIENT SERVICE REVENUE	621990	121,092,619	121,092,619
b	LABORATORY OUTREACH REVENUE	621500	69,950		69,950
c
d
e
f	All other program service revenue.		0	0	0	0
g	Total. Add lines 2a–2f ....		121,162,569

3 Investment income (including dividends, interest, and othersimilar amounts) ......			420,383			420,383
4 Income from investment of tax-exempt bond proceeds
5 Royalties...........
		(ii) Personal	(i) Real
6a	Gross rents		1,256,406
b	Less: rental expenses		1,765,062
c	Rental income or (loss)	0	-508,656
d	Net rental income or (loss)......			-508,656			-508,656
		(ii) Other	(i) Securities
7a	Gross amount from sales of assets other than inventory	3,166,792	337,207
b	Less: cost or other basis and sales expenses	3,808,900
c	Gain or (loss)	-642,108	337,207
d	Net gain or (loss).....			-304,901			-304,901
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..
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..
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..
Business Code			Miscellaneous Revenue
11a	OTHER OPERATING REVENUE		900099	275,160			275,160
b	Gift Shop and Auxiliary Revenue		453220	55,798			55,798
c
d	All other revenue ....			0	0	0	0
e	Total. Add lines 11a–11d ......			330,958
12	Total revenue. See Instructions......			121,135,568	121,092,619	69,950	-62,216

1	Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21
2	Grants and other assistance to domestic individuals. See Part IV, line 22
3	Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, line 15 and 16.
4	Benefits paid to or for members
5	Compensation of current officers, directors, trustees, and key employees ....	205,985	153,582	52,403
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	22,557,135	16,818,696	5,738,439
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	-188,640	-140,650	-47,990
9	Other employee benefits .......	4,624,799	3,448,250	1,176,549
10	Payroll taxes ...........	1,465,024	1,092,322	372,702
11	Fees for services (non-employees):
a	Management ......
b	Legal .........
c	Accounting ...........
d	Lobbying ...........
e	Professional fundraising services. See Part IV, line 17
f	Investment management fees ......	419,702		419,702
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O)	41,192,317	32,460,081	8,732,236	0
12	Advertising and promotion ....
13	Office expenses .......	66,863	62,014	4,849
14	Information technology ......
15	Royalties ..
16	Occupancy ...........	3,373,872	2,346,979	1,026,893
17	Travel ............	245,142	230,494	14,648
18	Payments of travel or entertainment expenses for any federal, state, or local public officials .
19	Conferences, conventions, and meetings ....	430,463	418,706	11,757
20	Interest ...........	-22,814		-22,814
21	Payments to affiliates .......
22	Depreciation, depletion, and amortization ..	3,361,775	2,376,556	985,219
23	Insurance ...	252,803	252,803
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	SUPPLIES - MED/SURG/O2/DRUGS	16,059,709	15,812,474	247,235
b	PREVEA INVESTMENT	13,867,674	13,867,674
c	BAD DEBT EXPENSE	2,537,669	2,537,669
d	MEDICAID ASSESSMENT TAX	2,040,796	2,040,796
e	All other expenses	4,423,101	3,081,136	1,341,965	0
25	Total functional expenses. Add lines 1 through 24e	116,913,375	96,859,582	20,053,793	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).

1	Cash–non-interest-bearing ........			1,450	1	1,450
2	Savings and temporary cash investments .........			3,530,583	2	2,028,758
3	Pledges and grants receivable, net ......				3
4	Accounts receivable, net .............			13,573,003	4	14,775,017
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L .............
				0	5	0
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	0
7	Notes and loans receivable, net ....				7
8	Inventories for sale or use ........			1,992,023	8	2,316,049
9	Prepaid expenses and deferred charges ......			412,955	9	373,643
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	145,597,107
b	Less: accumulated depreciation	10b	79,226,515	50,987,194	10c	66,370,592
11	Investments—publicly traded securities .			60,564,986	11	50,363,860
12	Investments—other securities. See Part IV, line 11 .....			0	12
13	Investments—program-related. See Part IV, line 11 ..			1,083,558	13	1,164,651
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			1,305,943	15	1,942,871
16	Total assets. Add lines 1 through 15 (must equal line 34)...			133,451,695	16	139,336,891

17	Accounts payable and accrued expenses .....	9,467,164	17	15,715,399
18	Grants payable ...		18
19	Deferred revenue .........	157,695	19	112,381
20	Tax-exempt bond liabilities .........	16,202,092	20	15,228,314
21	Escrow or custodial account liability. Complete Part IV of Schedule D		21
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	0
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	5,839,730	25	8,299,258
26	Total liabilities. Add lines 17 through 25..	31,666,681	26	39,355,352

	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets	94,173,829	27	92,496,895
28	Temporarily restricted net assets ...........	5,914,770	28	5,788,229
29	Permanently restricted net assets	1,696,415	29	1,696,415
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund ...		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	101,785,014	33	99,981,539
34	Total liabilities and net assets/fund balances ........	133,451,695	34	139,336,891