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Nonprofiteer
← ST MARYS HOSPITAL FOUNDATION

Form 990 for tax year 2022

Filed by ST MARYS HOSPITAL FOUNDATION.

Totals

Total revenue
$261,212
Total expenses
$265,772
Contributions and grants received
$248,093
Grants paid
$172,133
Program service revenue
$0
Investment income
$9,559
Other revenue
$3,560
Total assets, end of year
$855,954
Total liabilities, end of year
$6,625
Net assets or fund balances, end of year
$849,329
Program services expenses (Part IX)
$172,561
Management and general expenses
$32,889
Fundraising expenses
$60,322
Program service expenses (Part III)
$172,561

Program services were 64.9% of total expenses calculated — Part IX's program-services column over total expenses, both as filed.

Line items

Every line the filer filed in Parts VIII, IX and X, as filed and in filed order. Blank columns are left out, and the lines are not forced to add up to the totals above.

Revenue

Part VIII, the statement of revenue.

  • 1c · Fundraising events

    $35,904

  • 1e · Government grants (contributions)

    $500

  • 1f · All other contributions, gifts and grants

    $211,689

  • 1g · Noncash contributions included above

    $138,000

  • 2f · All other program service revenue

    total $0 · related or exempt $0 · unrelated business $0 · excluded $0

  • 3 · Investment income

    total $5,932 · excluded $5,932

  • 6c · Rental income or loss

    real property $0 · personal property $0

  • 7a · Gross sales of assets other than inventory

    securities $3,627

  • 7c · Gain or loss

    securities $3,627 · other assets $0

  • 7d · Net gain or loss

    total $3,627 · excluded $3,627

  • 8a · Fundraising events: gross income

    $10,496

  • 8a · Fundraising events: contributions included on line 1c

    $35,904

  • 8b · Fundraising events: direct expenses

    $8,407

  • 8c · Net income from fundraising events

    total $2,089 · excluded $2,089

  • 9a · Gaming: gross income

    $3,171

  • 9b · Gaming: direct expenses

    $1,700

  • 9c · Net income from gaming

    total $1,471 · excluded $1,471

  • 11d · All other revenue

    total $0 · related or exempt $0 · unrelated business $0 · excluded $0

  • 11e · Other revenue, total

    $0

Functional expenses

Part IX, the statement of functional expenses.

  • 1 · Grants to domestic organizations and governments

    total $172,133 · program services $172,133

  • 7 · Other salaries and wages

    total $46,210 · management and general $15,403 · fundraising $30,807

  • 9 · Other employee benefits

    total $18,465 · management and general $6,155 · fundraising $12,310

  • 11b · Fees: legal

    total $1,450 · management and general $1,450

  • 11g · Fees: other

    total $800 · program services $0 · management and general $0 · fundraising $800

  • 12 · Advertising and promotion

    total $1,680 · management and general $1,680

  • 13 · Office expenses

    total -$3,824 · management and general -$1,275 · fundraising -$2,549

  • 14 · Information technology

    total $28,216 · management and general $9,405 · fundraising $18,811

  • 17 · Travel

    total $214 · management and general $71 · fundraising $143

  • 24a · Other expenses: Bank service charges

    total $398 · program services $398

  • 24b · Other expenses: licenses and taxes

    total $30 · program services $30

  • 24e · All other expenses

    total $0 · program services $0 · management and general $0 · fundraising $0

Balance sheet

Part X, book values.

  • 1 · Cash, non-interest-bearing

    end of year $385,817

  • 2 · Savings and temporary cash investments

    beginning of year $456,559 · end of year $303,272

  • 3 · Pledges and grants receivable

    beginning of year $449,447 · end of year $166,865

  • 5 · Loans and receivables from officers and key people

    beginning of year $0 · end of year $0

  • 6 · Loans and receivables from disqualified persons

    beginning of year $0 · end of year $0

  • 10a · Land, buildings and equipment: cost or other basis

    $0

  • 10b · Land, buildings and equipment: accumulated depreciation

    $0

  • 10c · Land, buildings and equipment, net

    beginning of year $0 · end of year $0

  • 12 · Investments: other securities

    beginning of year $0

  • 13 · Investments: program-related

    beginning of year $0

  • 15 · Other assets

    beginning of year $0 · end of year $0

  • 22 · Loans and payables to officers and key people

    beginning of year $0 · end of year $0

  • 25 · Other liabilities

    beginning of year $0 · end of year $6,625

  • 27 · Net assets without donor restrictions

    beginning of year $293,555 · end of year $333,949

  • 28 · Net assets with donor restrictions

    beginning of year $612,451 · end of year $515,380

Mission and programs · 2022

Mission

Through our exceptional health care services, we reveal the healing presence of God.

Activities or mission (Part I)

To provide support to SSM Health St. Mary's Hospital - Centralia in support of their mission to continue the healing ministry of Jesus Christ by improving regional quality health services for everyone.

  • PROVIDED SUPPORT TO VARIOUS PROGRAMS AND EQUIPMENT PURCHASES FOR SSM HEALTH ST MARY'S HOSPITAL - CENTRALIA. PLEASE SEE SCHEDULE O FOR A COMPLETE DESCRIPTION OF PROGRAM SERVICE ACCOMPLISHMENTS.

    Expenses $172,561 · Grants $172,133

As filed on the 2022 return.

Listed in Part VII

  • Damon Harbison

    Trustee & Hospital President

    Total calculated
    $608,529
    From this org
    $0
    From related orgs
    $426,972
    Other
    $181,557
    Hours/week
    1 + 42 related

    Schedule J breakdown matched by us

    Base
    $0 + $288,253 related
    Bonus
    $0 + $114,517 related
    Other
    $0 + $24,202 related
    Deferred
    $0 + $132,756 related
    Nontaxable benefits
    $0 + $48,801 related
    Filer's total
    $0 + $608,529 related

  • Gary Unverfehrt

    Trustee & Vice Chairperson

    Total calculated
    $0
    Hours/week
    1

  • Kim McMillan

    Trustee & Chairperson

    Total calculated
    $0
    Hours/week
    1

  • Victoria Sayles

    Trustee & Secretary/Treasurer

    Total calculated
    $0
    Hours/week
    1

  • Dean Lampe

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Dr Maryann Langenfeld

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Dr Rajendra Shroff

    Trustee & Physician

    Total calculated
    $177,134
    From this org
    $0
    From related orgs
    $139,364
    Other
    $37,770
    Hours/week
    1

    Schedule J breakdown matched by us

    Base
    $0 + $139,326 related
    Bonus
    $0
    Other
    $0 + $38 related
    Deferred
    $0 + $8,508 related
    Nontaxable benefits
    $0 + $29,262 related
    Filer's total
    $0 + $177,135 related

  • Greg Dodson

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Gregg Winn

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Jack Graham

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Keith Kessler

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • LaVerne Brink

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Lisa Lampe

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Patty Williams

    Trustee

    Total calculated
    $0
    Hours/week
    1 + 4 related

  • Rev Ron Johnson

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Susan Robbins

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Wes Monken

    Trustee

    Total calculated
    $0
    Hours/week
    1

  • Douglas Long

    Assistant Secretary, General Counsel at SSM Health

    Total calculated
    $2,040,754
    From this org
    $0
    From related orgs
    $1,354,027
    Other
    $686,727
    Hours/week
    1 + 72.2 related

    Schedule J breakdown matched by us

    Base
    $0 + $724,576 related
    Bonus
    $0 + $460,492 related
    Other
    $0 + $168,959 related
    Deferred
    $0 + $664,054 related
    Nontaxable benefits
    $0 + $22,673 related
    Filer's total
    $0 + $2,040,753 related

  • John Snodsmith

    Regional VP, Finance

    Total calculated
    $385,946
    From this org
    $0
    From related orgs
    $296,045
    Other
    $89,901
    Hours/week
    1 + 43 related

    Schedule J breakdown matched by us

    Base
    $0 + $256,300 related
    Bonus
    $0 + $38,894 related
    Other
    $0 + $852 related
    Deferred
    $0 + $61,875 related
    Nontaxable benefits
    $0 + $28,026 related
    Filer's total
    $0 + $385,946 related

  • Kay Zibby-Damron

    Executive Director

    Total calculated
    $121,037
    From this org
    $0
    From related orgs
    $100,283
    Other
    $20,754
    Hours/week
    20 + 20 related

  • Karen Rewerts

    Former Officer, VP-Financial Operations

    Total calculated
    $1,067,699
    From this org
    $0
    From related orgs
    $805,591
    Other
    $262,108
    Hours/week
    0 + 43 related

    Schedule J breakdown matched by us

    Base
    $0 + $589,253 related
    Bonus
    $0 + $159,192 related
    Other
    $0 + $57,145 related
    Deferred
    $0 + $231,797 related
    Nontaxable benefits
    $0 + $30,312 related
    Filer's total
    $0 + $1,067,699 related

  • Matt Kinsella

    Former Officer

    Total calculated
    $770,808
    From this org
    $0
    From related orgs
    $571,367
    Other
    $199,441
    Hours/week
    0 + 40 related

    Schedule J breakdown matched by us

    Base
    $0 + $395,809 related
    Bonus
    $0 + $165,836 related
    Other
    $0 + $9,722 related
    Deferred
    $0 + $163,175 related
    Nontaxable benefits
    $0 + $36,266 related
    Filer's total
    $0 + $770,809 related

Compensation is as filed in Part VII: reportable pay from this organization and from related organizations, other compensation, and hours per week. The total, marked calculated, is our sum of the three dollar columns, with a blank column counted as $0; the form itself has no total. On a Form 990-EZ the columns are Part IV's instead, and on a Form 990-PF Part VIII's — compensation, contributions to benefit plans, and expense account — and the total sums those. A Schedule J breakdown is as filed: base pay, bonus, other, deferred compensation and nontaxable benefits from this organization, with any from related organizations beside each, and the filer's own total. It is shown with the Part VII listing of the same name on the same return. The form gives no key between the two, so that pairing is ours, and is marked matched by us.

Schedule J

Answered yes

  • 4b · Supplemental nonqualified retirement plan

Answered no

  • 4a · Severance or change-of-control payment
  • 4c · Equity-based compensation arrangement
  • 5a · Pay contingent on this organization's revenues
  • 5b · Pay contingent on a related organization's revenues
  • 6a · Pay contingent on this organization's net earnings
  • 6b · Pay contingent on a related organization's net earnings
  • 7 · Other non-fixed payments
  • 8 · Paid under the initial-contract exception

The filer's explanations (Part III)

Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation
The Foundation's top management official (Executive Director) is compensated by a related organization that utilized the following to determine compensation: (1) independent compensation consultant; (2) compensation survey or study; (3) approval by the board or compensation committee.
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
Pension Restoration Plan: SSM Health (SSMH) provides this supplemental defined benefit nonqualified retirement plan to any employee who is a participant in the SSMH qualified defined benefit plan who earns over the Internal Revenue Service compensation limit. The plan "restores" the benefits to these employees that would have been provided under the SSMH qualified plan if the regulations did not impose compensation limits. An individual can take a distribution from the plan at (1) age 65 or older if the individual is still employed by SSMH or (2) age 55 or older if the individual is no longer employed by SSMH. No individuals listed on Part VII of Form 990 received distributions from the plan in 2022. Capital Accumulation Plan: SSMH provides this supplemental nonqualified retirement plan to executive level employees. The organization contributed a percentage of the employee's base salary into their choice of a select list of investments. The deposits and earnings of the plan are owned by SSMH and are tax-deferred until a distribution is made to the employee. In addition, the plan has special safeguards in place to protect the funds from contingencies, other than insolvency. For contributions made to the plan in 2014 or after, the distribution will occur after the completion of four plan years for all executives that are still actively employed on the distribution date. Any active participant 65 years or older will receive the contribution in the current year. THE FOLLOWING INDIVIDUALS LISTED ON PART VII OF THE FORM 990 RECEIVED DEFERRALS FROM THIS PLAN IN 2022: Damon Harbison $29,687 John Snodsmith $12,062 Matthew Kinsella $39,627 Karen Rewerts $57,962 DOUGLAS LONG $159,815 The following individuals listed on Part VII of the Form 990 received distributions from this plan in 2022. All distributions received from the plan in the current year were included in the individual's taxable compensation. Damon Harbison $23,551 Matt Kinsella $8,819 Karen Rewerts $51,943

Part I's answers as filed. A line not listed was left unanswered; on lines 1a and 3 that means the box was not checked.

Grants on this return

Related organizations on this return

Schedule R Part II: tax-exempt organizations related to the filer by control. It does not record shared board members or money.

Taxable family on this return

Schedule R Parts I, III and IV, as filed. These record ownership and control, not shared board members or money moved.

Related partnerships

Part III: related organizations taxable as a partnership, with the filer's share.

  • SSM St Joseph Endoscopy Center LLC

    N/A · Surgery Services · MO

    Directly controlled by NA

  • St Clare Imaging Services LLC

    N/A · Diag. Services · WI

    Directly controlled by NA

  • Mt Vernon Radiation Therapy Center LLC

    N/A · Radiation Therapy · IL

    Directly controlled by NA

  • Sleep & Neurology Center of Southern Illinois LLC

    N/A · Diag. Services · IL

    Directly controlled by NA

  • CHOWSMGSI Office Building LLC

    N/A · MOB · IL

    Directly controlled by NA

  • Oza Cancer Center LLC

    N/A · MOB · IL

    Directly controlled by NA

  • Shawnee Real Estate Holdings LLC

    N/A · MOB · OK

    Directly controlled by NA

  • Dean Clinic & St Mary's Hospital Accountable Care Organization LLC

    N/A · Accountable Care Organization · WI

    Directly controlled by NA

  • Wisconsin Integrated Information Technology and Telemedicine Systems LLC

    N/A · Information Technology Services · WI

    Directly controlled by NA

  • Wingra Building Group

    N/A · MOB · WI

    Directly controlled by NA

  • Janesville Riverview Clinic Building Partnership

    N/A · MOB · WI

    Directly controlled by NA

  • 1110 N Classen Blvd LLC

    N/A · MOB · OK

    Directly controlled by NA

  • SSM St Clare Surgical Center LLC

    N/A · Surgery Services · MO

    Directly controlled by NA

  • Windmill LLP

    N/A · Investments · MO

    Directly controlled by NA

  • Navitus Health Solutions LLC

    N/A · Pharmacy Benefits · WI

    Directly controlled by NA

  • SSM Select Rehab St Louis LLC

    N/A · Health Care · DE

    Directly controlled by NA

  • Epiphany Rx LLC

    N/A · Pharmacy Benefits · DE

    Directly controlled by NA

  • Bain Capital Global Direct Lending 2021 (L Offshore) LP

    N/A · Investments · DE

    Directly controlled by NA

  • Bloom Tree Long-Only Fund QP LP fka Bloom Tree Ponderosa Funds QP LP

    N/A · Investments · DE

    Directly controlled by NA

  • Carlyle Property Investors LP

    N/A · Investments · DE

    Directly controlled by NA

  • NECICF II AIV2-B LP

    N/A · Investments · DE

    Directly controlled by NA

Related corporations and trusts

Part IV: related organizations taxable as a corporation or trust.

  • SSM Managed Care Organization LLC

    C Corporation · Health Promotion · MO

    Directly controlled by NA

  • FPP INC & Subs

    C Corporation · Health Care · MO

    Directly controlled by NA

  • Diversified Health Services Corp

    C Corporation · Medical Equipment · MO

    Directly controlled by NA

  • SSM Properties Inc

    C Corporation · Property Services · MO

    Directly controlled by NA

  • HealthFirst Physician Management Services

    C Corporation · Medical Services · OK

    Directly controlled by NA

  • SSMHC Liability Trust II

    C Corporation · Insurance · MO

    Directly controlled by NA

  • SSM Medical Group Inc

    C Corporation · Physician Offices · MO

    Directly controlled by NA

  • SSMHC Insurance Company

    C Corporation · Insurance · CJ

    Directly controlled by NA

  • Physicians Services Corp of Southern Illinois Inc

    C Corporation · Health Care · IL

    Directly controlled by NA

  • Dean Health Systems Inc

    C Corporation · Physician Offices · WI

    Directly controlled by NA

  • Dean Health Insurance Inc

    C Corporation · Insurance · WI

    Directly controlled by NA

  • Dean Retail Services Inc

    C Corporation · Property Services · WI

    Directly controlled by NA

  • Oza Oncology Inc

    S Corporation · Physician Offices · IL

    Directly controlled by NA

  • SSM Health Janesville Campus Condominium Association Inc

    C Corporation · Condo association · WI

    Directly controlled by NA

  • SSM Health Pharmacy LLC

    C Corporation · Pharmacy · MO

    Directly controlled by NA

  • Navitus Holdings LLC

    C Corporation · Pharmacy · WI

    Directly controlled by NA

  • MS Community JV LLC

    C Corporation · Insurance · DE

    Directly controlled by NA

  • Quality Drug Corporation

    C Corporation · Pharmacy benefits · CA

    Directly controlled by NA

  • St Mary's Hospital Campus Condominium Owners Association Inc

    C Corporation · Condo association · WI

    Directly controlled by NA

  • Partners Group PMC Private Credit LP

    C Corporation · Investment · CJ

    Directly controlled by NA

Provenance

Return type
form_990
Tax year
2022
Filed
16 November 2023
IRS schema version
2022v5.0
Source object
202313199349330281

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