Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
|
Total |
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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. | ||||||
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 | ||||||
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.") . | 728 | 55 | 783 | |||
| 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 | 15,032,184 | 16,820,972 | 15,423,499 | 14,765,989 | 14,887,505 | 76,930,149 |
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513 ..... | 66,646 | 50,571 | 40,358 | 36,639 | 23,038 | 217,252 |
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | 0 | |||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge | 0 | |||||
| 6 | Total. Add lines 1 through 5 | 15,098,830 | 16,872,271 | 15,463,912 | 14,802,628 | 14,910,543 | 77,148,184 |
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | 0 | |||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | 386,642 | 136,017 | 308,054 | 179,414 | 238,885 | 1,249,012 |
| c | Add lines 7a and 7b.. | 386,642 | 136,017 | 308,054 | 179,414 | 238,885 | 1,249,012 |
| 8 | Public support. (Subtract line 7c from line 6.) | 75,899,172 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 15,098,830 | 16,872,271 | 15,463,912 | 14,802,628 | 14,910,543 | 77,148,184 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 8 | 8 | ||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | |||||
| c | Add lines 10a and 10b. | 8 | 8 | ||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | 0 | |||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | 0 | |||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 15,098,830 | 16,872,279 | 15,463,912 | 14,802,628 | 14,910,543 | 77,148,192 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 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) |
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| 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 | ||||
| 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 |
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|
2
Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions. |
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| 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) |
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| 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. |
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|
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. |
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|
7 Excess distributions carryover to 2019. Add lines 3j and 4c. |
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| 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..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
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| Software ID: | 18007218 |
| Software Version: | 2018v3.1 |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder | The business and affairs of Wellmont Wexford House (the Corporation) shallbe governed exclusively by the Board of Directors. The Corporation's Boardof Directors is designated by Wellmont Health System, the sole member ofthe Corporation.In addition to such rights of approval and consent as may be reserved tothe sole member of the Corporation pursuant to applicable law, transactionsof the following matters by the Corporation shall require the priorapproval of Wellmont Health System:A) Implementation of the Corporation's annual budget,B) Incurring any loan or other indebtedness for borrowed money,C) Acquisition of any equipment or personal property for a purchase price in excess of $50,000 or the acquisition of any real estate, regardless of purchase price,D) The undertaking of certain contractual commitments,E) Entering into any plan of merger or consolidation,F) Acquisition of substantially all of the assets of any other legal entity, andG) Institution of any litigation by or on behalf of the Corporation. |
| Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body | The Board of Directors are appointed by the Wellmont Health System Board ofDirectors. |
| Form 990, Part VI, Line 7b: Describe Decisions of Governing Body Approval by Members or Shareholders | Certain decisions of the board are, pursuant to charter, subject toapproval of the members. No ordinary, day-to-day decisions are subject tomember approval. |
| Form 990, Part VI, Line 9: Officer, Director, Trustee, Key Employee Mailing Address | Tim Attebery1905 American WayKingsport, TN 37660Dale Poe1905 American WayKingsport, TN 37660 |
| Form 990, Part VI, Line 11b: Form 990 Review Process | The Executive Director of Wellmont Wexford House reviewed the Wellmont Wexford House Form 990 with the Wellmont Wexford House Board of Directors prior to filing. The return was made available to each board member in an electronic format prior the review. |
| Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts | Ballad Health has a conflict of interest policy for all members of the Board of Directors, the Executive Chair/President, Executive Vice Presidents, Senior Vice Presidents,and Vice Presidents, and applies to all Ballad organizations. All persons covered by this policy are required to complete a conflict of interest disclosure on an annual basis. Should a conflict arise, it is the responsibility of the conflicted individual to update his or her disclosure immediately. All meetings of the board and board committees have a standing agenda item first on the agenda titled "Conflicts of Interest". If a member of the board or board committee has a conflict of interest involving any issue on the board agenda, he or she must declare the conflict of interest during the period allotted for disclosure. If any issue arises during a meeting in which the board member has a conflict of interest, he or she must immediately declare the conflict. While each member of the board or board committees are responsible for disclosing conflicts of interest, it is also the responsibility of any board member aware of a conflict which has not been disclosed to ensure the board is made aware. The presiding officer of a board or board committee meeting may ask a conflicted member to excuse themselves from the meeting during the discussion related to the issue with which the conflict of interest applies. Under no circumstances shall a member vote on a matter that gives rise to a potential conflict. |
| Form 990, Part VI, Line 19: Other Organization Documents Publicly Available | Governing documents and conflict of interest policy are made available upon request to the appropriate parties requesting them. Financial statements are made available upon request to appropriate parties requesting them, and they are made available to those parties who own indebtedness of the company on a quarterly basis. |
| Other Changes In Net Assets Or Fund Balances - Other Increases | Capital contribution from parent = $421415 |
| Form 990, Part VI, Line 15a - Compensation Process for Top Official | On an annual basis, Ballad Health's Human Resources (HR) Department evaluates compensation for all executives at a position level of Assistant Vice President and above. The review includes Ballad Health's CEO-Northwest Market, who also serves as board president of Wellmont Wexford House. HR's evaluation is based on market data obtained from independent third-party consultants for positions with similar responsibilities at similarly situated organizations. Based on this comparable data, Ballad Health's President and CEO evaluates the data and submits his recommendations to Ballad Health's Board of Directors for their final review and approval. In addition, Ballad Health offers an incentive plan to executives based on targeted achievement metrics set in advance of the pay year. Established metrics include: quality and access measures, evidence-based care scores, and value based purchasing, etc.Similar to Ballad Health's CEO-Northwest Market, Wellmont Wexford House's Executive Director receives compensation that complies with Ballad Health's salary policy. Her pay is set at a market percentile specific to her position as Executive Director of Wellmont Wexford House. |
| Form 990, Part VI, Line 15b - Compensation for Officers | Similar to Ballad Health's CEO-Northwest Market, other officers reported on Wellmont Wexford House's Part VII receive compensation that complies with Ballad Health's salary policy and undergoes the same review and approval process by Ballad Health's Board of Directors as described in 15a. |
| Software ID: | 18007218 |
| Software Version: | 2018v3.1 |