2026-03-26T14:55:06-05:00 2025-06-30 450250958 EIDE BAILLY LLP 18081 BURT ST STE 200 OMAHA NE 680224722 990 2024-07-01 470544098 WEST HOLT MEMORIAL HOSPITAL WEST 4029252811 406 W NEELY ST ATKINSON NE 68713 JEREMY BAUER CFO 4029252811 2026-03-26 1 1 WENDY R COOLEY CPA P01523804 4023302660 2026-03-24 2024 2025-03-06 01:10:19Z JEREMY BAUER 406 W NEELY ST ATKINSON NE 68713 18533923 0 X WWW.WESTHOLTMED.ORG X 1972 NE CRITICAL ACCESS HOSPITAL AND RURAL HEALTH CLINIC THAT PROVIDES MEDICAL SERVICES. 9 6 122 10 0 0 203846 28396 17359531 18201363 292498 298664 4674 5263 17860549 18533686 0 0 0 0 7230725 7282656 0 0 30504 10227922 10507638 17458647 17790294 401902 743392 18218165 18860597 7490195 7371871 10727970 11488726 X TO PROVIDE COMPREHENSIVE HEALTHCARE WITH RESPECT AND COMPASSION. 0 0 15739842 18201363 WEST HOLT MEMORIAL HOSPITAL (WHMH) IS A 15 LICENSED-BED CRITICAL ACCESS HOSPITAL: SERVICES PROVIDED BY WHMH INCLUDE EMERGENCY SERVICES, LABORATORY, PHYSICAL AND OCCUPATIONAL THERAPY, RESPIRATORY THERAPY, SPEECH THERAPY, DIAGNOSTIC IMAGING TEST, CARDIOLOGY TESTS, EKG, NUCLEAR MEDICINE TESTS, IV THERAPY, SLEEP STUDIES, OP SURGERY, AND A VARIETY OF SPECIALTY CLINICS. DURING 2025, WHMH HAD 665 EMERGENCY ROOM VISITS AND PERFORMED 162 OUTPATIENT SURGERIES. THE LABORATORY PERFORMED 26,829 TESTS, DIAGNOSTIC IMAGING PERFORMED 3,810 TESTS AND PHYSICAL/OCCUPATIONAL/SPEECH THERAPY SERVICES PROVIDED 12,682 TREATMENTS.THE HOSPITAL PROVIDES CHARITY CARE TO PATIENTS WHO ARE FINANCIALLY UNABLE TO PAY FOR THE HEALTHCARE SERVICES THEY RECEIVE. IT IS THE POLICY OF THE HOSPITAL NOT TO PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. ACCORDINGLY, THE HOSPITAL DOES NOT REPORT THESE AMOUNTS IN PATIENT SERVICE REVENUE. THE HOSPITAL DETERMINES THE COSTS ASSOCIATED WITH PROVIDING CHARITY CARE BY AGGREGATING THE DIRECT AND INDIRECT COSTS, INCLUDING SALARIES, BENEFITS, SUPPLIES, AND OTHER OPERATING EXPENSES, BASED ON AN OVERALL COST TO CHARGE RATIO. THE COSTS OF CARING FOR THESE PATIENTS FOR THE YEARS ENDED JUNE 30, 2025 AND 2024, WAS APPROXIMATELY $52,000 AND $99,000, RESPECTIVELY. 15739842 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 24 0 1 122 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0 0 X TAYLOR MCCORMICK 4029252811 406 WEST NEELY STREET ATKINSON NE 68713 TRENT SCHAAF PRESIDENT 2.00 X X 0 0 0 BRYAN RENTSCHLER FIRST VICE PRESIDENT 1.00 X X 0 0 0 TOM DVORAK SECOND VICE PRESIDENT 1.00 X X 0 0 0 BRETT LIESWALD TREASURER 1.00 X X 0 0 0 MARSHA THURLOW SECRETARY 1.00 X X 0 0 0 MATTHEW FRITZ MEMBER 1.00 X 0 0 0 MICHAEL PEEK MEMBER 1.00 X 0 0 0 SUSAN MYERS MEMBER 1.00 X 0 0 0 LORI OLSON MEMBER 1.00 X 0 0 0 JEREMY BAUER CEO 40.00 X 187511 0 45178 TAYLOR MCCORMICK CFO 40.00 X 124850 0 4980 SAMANTHA SHOLES PHYSICIAN 32.00 X 233045 0 46885 LORETTA DANIELS PHYSICIAN ASSISTANT 48.00 X 187784 0 7934 AMY KINKENNON PHARMACIST 40.00 X 160314 0 6459 VANESSA GOTTIER PHARMACIST 40.00 X 137934 0 21709 APRIL DEXTER NURSE PRACTITIONER 32.00 X 140897 0 5609 1172335 0 138754 11 0 1 0 FOCUSONE SOLUTIONS 13609 CALIFORNIA ST OMAHA NE 68154 AGENCY NURSING SERVICES 736415 GREATER SANDHILLS FAMILY HEALTHCARE PO BOX 70 STUART NE 68780 PROVIDER ER COVERAGE 415460 SILVERHAWK AVIATION 1751 WEST KEARNEY AVE LINCOLN NE 68524 TRAVEL SERVICES 150000 MMC MECHANICAL 9751 SOUTH 142ND ST OMAHA NE 68138 CONSTRUCTION FIRM 123216 FAITH REGIONAL HEALTH SERVICES 1500 KOENIGSTEIN AVE NORFOLK NE 68701 IT, SURGERIES, AND OVERREADS 106981 5 13312 15084 28396 PATIENT SERVICE REVENUE 621110 13865180 13865180 RETAIL PHARMACY REVENUE 621110 3601546 3601546 PHARMACY REVENUE 621110 693291 693291 41346 41346 18201363 293679 293679 5500 237 5263 5263 5263 4985 0 4985 4985 4985 18533686 18201363 0 303927 X 378812 378812 150991 150991 5381055 4781783 573286 25986 163888 146419 16840 629 799496 710618 88878 408414 343617 62830 1967 15014 15014 69825 69825 709 709 3570777 3203986 364917 1874 62837 62837 207143 158156 48987 591 476 111 4 155456 123147 32309 2450 2450 21166 21166 170203 160983 9220 1125909 1064921 60988 116355 13760 102595 MEDICAL SUPPLIES 4466023 4395232 70791 MISCELLANEOUS 399213 341874 57295 44 LICENSES & FEES 123967 120263 3704 17790294 15739842 2019948 30504 600 600 7637734 8375557 2032005 2212306 570839 597420 164638 222203 19308075 12762617 7515666 6545458 296683 907053 18218165 18860597 1342036 1635355 5940221 5736516 207938 0 7490195 7371871 X 10431287 11174679 296683 314047 10727970 11488726 18218165 18860597 X 743392 17364 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 709 709 0 PART II-B, LINE 1: WEST HOLT MEMORIAL HOSPITAL PAYS ASSOCATION DUES TO THE NEBRASKA HOSPITAL ASSOCIATION (NHA), OF WHICH A PORTION IS USED BY THE ASSOCIATION FOR LOBBYING PURPOSES. 50632 50632 11040762 6161251 4879511 8039590 6477492 1562098 177091 123874 53217 6545458 X 18533923 237 237 18533686 0 18533686 17790531 237 237 17790294 0 17790294 PART X, LINE 2: THE HOSPITAL ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT JUNE 30, 2025 AND 2024, THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS ACCRUED. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED IN REVENUE FOR FORM 990 237. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED IN REVENUE FOR FORM 990 237. 1 1 X 1 X 1 X 1 1 0 1 1 52000 0 52000 0.00290 1106928 1254947 0 0.00000 1158928 1254947 52000 0.00290 1623 287887 46040 241847 0.01360 2 1000 0 1000 0.00010 3049661 2106872 942789 0.05300 1625 3338548 2152912 1185636 0.06670 1625 4497476 3407859 1237636 0.06960 1 0 0 5721221 5756324 -35103 X 1 1 1 1 WEST HOLT MEMORIAL HOSPITAL 406 W NEELY ST ATKINSON NE 68713 WWW.WESTHOLTMED.ORG 410001 X X X X 1 PROVIDER BASED RURAL HEALTH CLINIC WEST HOLT MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 24 1 1 1 1 X HTTPS://WWW.WESTHOLTMED.ORG/ X 1 24 1 HTTPS://WWW.WESTHOLTMED.ORG/ 0 1 X 100.000000000000 200.000000000000 X X X X X 1 1 X X X X 1 X WWW.WESTHOLTMED.ORG/PATIENTS/PATIENT-RESOURCES X WWW.WESTHOLTMED.ORG/PATIENTS/PATIENT-RESOURCES X WWW.WESTHOLTMED.ORG/PATIENTS/PATIENT-RESOURCES X X X X X 1 X 0 X X X X 1 X 0 0 WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE COMMUNITY STATUS ASSESSMENT WAS CONDUCTED VIA A COMMUNITY SURVEY ON QUALTRICS FROM 9/8/2024 AND CLOSED ON 10/22/2024, ALONG WITH INTERVIEWS WITH KEY HOSPITAL PERSONNEL AND COMMUNITY FOCUS GROUPS FACILITATED BY NORTH CENTRAL DISTRICT HEALTH DEPARTMENT. 36 PARTNERS PARTICIPATED IN A COMMUNITY PARTNER ASSESSMENT SURVEY; INCLUDING 11 SCHOOLS, 1 TRIBAL HEALTH DEPARTMENT, 1 OTHER TRIBAL ENTITY, 8 CITY/COUNTY GOVERNMENT, 7 HOSPITALS, 3 CLINICS, 3 EMERGENCY RESPONSE, 2 NON-PROFIT ORGANIZATIONS, 2 FAITH-BASED, AND 2 OTHER SECTORS THAT LOOKED AT THEIR OWN INDIVIDUAL SYSTEMS, PROCESSES, AND CAPACITIES AND THEIR COLLECTIVE CAPACITY AS A NETWORK/ACROSS ALL COMMUNITY PARTNERS TO ADDRESS HEALTH INEQUITIES. WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 6A: ANTELOPE MEMORIAL HOSPITAL, ROCK COUNTY HOSPITAL, BROWN COUNTY HOSPITAL, NIOBRARA VALLEY HOSPITAL, AVERA-CREIGHTON, OSMOND GENERAL HOSPITAL, CHERRY COUNTY HOSPITAL, AVERA ST. ANTHONY'S O'NEILL, AND CHI HEALTH PLAINVIEW. WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD), MIDTOWN HEALTH, WEST HOLT HEALTH MINISTRIES, ASERACARE HOSPICE, BRIGHT HORIZONS, DHHS, GREATER SANDHILLS FAMILY HEALTHCARE, HCED, SANTEE HEALTH CENTER, AINSWORTH CHAMBER OF COMMERCE, BOYD COUNTY SCHOOLS, BUILDING BLOCKS, CITY OF CREIGHTON, BROWN COUNTY EMERGENCY MANAGEMENT, AND O'NEILL COMMUNITY FOUNDATION. WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: IN THE MOST RECENT CHNA THAT WAS CONDUCTED, THE FOLLOWING NEEDS WERE IDENTIFIED:1. ACCESS TO AFFORDABLE, HIGH-QUALITY HEALTHCARE2. MENTAL HEALTH AND BEHAVIORAL HEALTH NEEDS3. HEALTHY LIVING AND CHRONIC DISEASE PREVENTION4. TRANSPORTATION AND INFRASTRUCTURE CHALLENGES5. SOCIAL DETERMINANTS OF HEALTH AND ECONOMIC STRAIN6. CULTURAL COMPETENCE AND DIVERSE POPULATIONS7. COORDINATED, COLLABORATIVE COMMUNITY INITIATIVESAT THIS TIME, THE ORGANIZATION WILL NOT BE ADDRESSING TRANSPORTATION AND INFRASTRUCTURE CHALLENGES IN THE COMMUNITY. A DIFFERENT ORGANIZATION ALREADY HAS THE "TRANSPORTATION CONTRACT" FOR THE COUNTY. GIVEN THE SCOPE OF THESE CHALLENGES, OUR BUDGET DOES NOT ALLOW FOR THE OPPORTUNITY FOR US TO MAKE THE REQUIRED SIGNIFICANT INVESTMENTS IN THESE AREAS DURING THE CURRENT YEAR. IN THE CURRENT YEAR THE FACILITY HAS TAKEN THE FOLLOWING ACTIONS:- LED A FOOD DRIVE AT THE HOSPITAL THAT COLLECTED 160 ITEMS FOR THE LOCAL FOOD PANTRY TO HELP WITH FOOD INSECURITIES.- PARTICIPATED IN THE CVH LEARNING COLLABORATIVE GROUP LED BY NCDHD TO COORDINATE WITH OTHER FACILITIES IN THE REGION AND COLLABORATE ON COMMUNITY INITIATIVES- OFFERED REDUCED PRICE CASH PAY LABS FOR BETTER ACCESS TO AFFORDABLE LAB DRAWS- PROVIDED ACCESS TO A FREE BLOOD PRESSURE CHECKING DEVICE WHILE ATTENDING AREA TRADE SHOWS- DR. SHOLES BECAME A CERTIFIED DIABETIC EDUCATOR TO IMPROVE ACCESS TO THIS SERVICE FOR COMMUNITY PATIENTS WHILE INCREASING HER SKILLS TO HELP PROMOTE HEALTHY LIVING AND LIFESTYLE CHOICES WEST HOLT MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: IN ADDITION TO INCOME, INQUIRIES ARE MADE RELATED TO ASSETS AND LIABILITIES. THE APPLICATION INCLUDES INQUIRIES REGARDING INCOME, EXPENSES, LOANS, VEHICLES, HOUSE (OWNED OR RENTED), ETC.IN INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL ASSISTANCE, BUT THERE IS NO FINANCIAL APPLICATION FORM ON FILE DUE TO A LACK OF SUPPORTING DOCUMENTATION, FINANCIAL ASSISTANCE MAY STILL BE GRANTED IN CERTAIN SITUATIONS BASED ON PRESUMPTIVE CIRCUMSTANCES. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT OR THROUGH OTHER SOURCES, WHICH COULD PROVIDE SUFFICIENT EVIDENCE TO PROVIDE THE PATIENT WITH FINANCIAL ASSISTANCE. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, WEST HOLT COULD USE OUTSIDE AGENCIES IN DETERMINING ESTIMATED INCOME AMOUNTS FOR THE BASIS OF DETERMINING FINANCIAL ASSISTANCE ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED IN CERTAIN SITUATIONS, AND BASED ON THE APPROVAL OF WEST HOLT'S MANAGEMENT, ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:A) STATE-FUNDED PRESCRIPTION PROGRAMS;B) TRANSIENT, HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC, OR UNIDENTIFIED PERSONS;C) PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC);D) FOOD STAMP ELIGIBILITY;E) ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED (E.G.,MEDICAID SPEND- DOWN);F) CRIME VICTIMS - BILLED CHARGES AFTER STATE OR FEDERAL FUNDS HAVE PAID OR ARE EXHAUSTED;G) LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;H) PATIENT IS DECEASED WITH NO KNOWN ESTATE OR RESPONSIBLE PARTY; ANDI) PATIENT'S HOUSEHOLD INCOME IS AT OR BELOW 100% OF THE IRS FEDERAL POVERTY LEVEL;J) NET WORTH IS LESS THAN 200% OF TOTAL OUTSTANDING MEDICAL BILLS 1 1 - WEST HOLT PHARMACY 313 W PEARL ST ATKINSON NE 68713 RETAIL PHARMACY PART I, LINE 3C: IN ADDITION TO INCOME, INQUIRIES ARE MADE RELATED TO ASSETS AND LIABILITIES. THE APPLICATION INCLUDES INQUIRIES REGARDING INCOME, EXPENSES, LOANS, VEHICLES, HOUSE (OWNED OR RENTED), ETC.IN INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR FINANCIAL ASSISTANCE, BUT THERE IS NO FINANCIAL APPLICATION FORM ON FILE DUE TO A LACK OF SUPPORTING DOCUMENTATION, FINANCIAL ASSISTANCE MAY STILL BE GRANTED IN CERTAIN SITUATIONS BASED ON PRESUMPTIVE CIRCUMSTANCES. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT OR THROUGH OTHER SOURCES, WHICH COULD PROVIDE SUFFICIENT EVIDENCE TO PROVIDE THE PATIENT WITH FINANCIAL ASSISTANCE. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE, WEST HOLT COULD USE OUTSIDE AGENCIES IN DETERMINING ESTIMATED INCOME AMOUNTS FOR THE BASIS OF DETERMINING FINANCIAL ASSISTANCE ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED IN CERTAIN SITUATIONS, AND BASED ON THE APPROVAL OF WEST HOLT'S MANAGEMENT, ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:A) STATE-FUNDED PRESCRIPTION PROGRAMS;B) TRANSIENT, HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC, OR UNIDENTIFIED PERSONS;C) PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC);D) FOOD STAMP ELIGIBILITY;E) ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS THAT ARE UNFUNDED (E.G.,MEDICAID SPEND- DOWN);F) CRIME VICTIMS - BILLED CHARGES AFTER STATE OR FEDERAL FUNDS HAVE PAID OR ARE EXHAUSTED;G) LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS;H) PATIENT IS DECEASED WITH NO KNOWN ESTATE OR RESPONSIBLE PARTY; ANDI) PATIENT'S HOUSEHOLD INCOME IS AT OR BELOW 100% OF THE IRS FEDERAL POVERTY LEVEL;J) NET WORTH IS LESS THAN 200% OF TOTAL OUTSTANDING MEDICAL BILLS PART I, LINE 6A: THE HOSPITAL PREPARES ITS OWN COMMUNITY BENEFIT REPORT WHICH IS INCLUDED IN THE NEBRASKA HOSPITAL ASSOCIATION ANNUAL COMMUNITY BENEFIT REPORT. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID ON LINE 7B WAS CALCULATED USING THE COSTING METHODS TO PREPARE THE COST REPORTS. COMMUNITY HEALTH IMPROVEMENT SERVICES AND HEALTH PROFESSIONS EDUCATION ARE REPORTED BASED ON ACTUAL EXPENSES RECORDED IN THE ORGANIZATION'S GENERAL LEDGER. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE PATIENT FINANCIAL ADVISOR AND CFO REVIEWED THE PATIENT IMPLICIT PRICE CONCESSIONS AND NOTES FROM CREDIT MANAGEMENT. WITH THIS INFORMATION, THEY DETERMINED THAT APPROXIMATELY 10% RESULTED FROM CHARGES TO PATIENTS WHO WOULD QUALIFY FOR CHARITY CARE. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGE 12 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: WEST HOLT MEMORIAL HOSPITAL IS A CRITICAL ACCESS HOSPITAL WITH A MEDICARE SHORTFALL. THIS IS CONSIDERED A COMMUNITY BENEFIT BECAUSE PROVIDING SERVICES TO MEDICARE PATIENTS IS ESSENTIAL TO THE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES.BOTH THE TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES.HOSPITAL SERVICES REIMBURSED ON A FEE SCHEDULE ARE NOT INCLUDED IN THE MEDICARE CALCULATION PER THE 990 INSTRUCTIONS. HAD THIS BEEN REPORTED, THE TOTAL LOSS FROM MEDICARE SERVICES WOULD HAVE BEEN $188,584.MEDICARE FEE SCHEDULE REVENUE $ 136,864MEDICARE ESTIMATED COSTS OF CARE RELATING TO PAYMENTS (325,448)NET (SHORTAGE) $ (188,584) PART III, LINE 9B: INCOMPLETE APPLICATIONS WILL RECEIVE A WRITTEN NOTICE PROVIDING THE PATIENT WITH AT LEAST 30 DAYS TO PROVIDE THE REQUIRED INFORMATION. THE POLICY FURTHER STATES THE HOSPITAL MAY REFER A PATIENT'S BILL TO A COLLECTION AGENCY 120 DAYS FROM THE DATE THE FIRST BILL FOR CARE WAS PROVIDED TO THE PATIENT.THE APPLICATION PERIOD FOR APPLYING FOR FINANCIAL ASSISTANCE BEGINS ON THE DATE CARE IS PROVIDED TO THE PATIENT AND ENDS ON THE LATER OF THE 240TH DAY AFTER THE DATE OF THE FIRST POST-DISCHARGE BILLING STATEMENT IS PROVIDED TO THE PATIENT OR NOT LESS THAN 30 DAYS AFTER THE DATE THE HOSPITAL PROVIDES THE PATIENT THE REQUISITE FINAL NOTICE TO COMMENCE EXTRAORDINARY COLLECTION ACTIONS. IF A PATIENT COMPLETES AN APPLICATION DURING THE 240 DAYS AND IS APPROVED FOR FINANCIAL ASSISTANCE ALL COLLECTION ACTIVITIES STOP. PART VI, LINE 2: THE ORGANIZATION ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES THROUGH ROUTINE COLLECTION OF INFORMATION ABOUT IMPORTANT ASPECTS OF PATIENT CARE PROVIDED IN THE HOSPITAL AND ABOUT THE CLINICAL PERFORMANCE OF ALL INDIVIDUALS WITH CLINICAL PRIVILEGES. THIS INFORMATION IS COLLECTED THROUGH ACTIVITIES OF THE MEDICAL STAFF COMMITTEES, THE OVERALL QUALITY ASSURANCE PROGRAM, AND THROUGH THE MEDICAL STAFF MONITORING ACTIVITIES. THROUGH THIS COLLECTION OF INFORMATION, PERIODIC ASSESSMENTS ARE CONDUCTED TO IDENTIFY OPPORTUNITIES TO IMPROVE PATIENT CARE AND THE PROBLEMS THAT NEED RESOLUTIONS. PART VI, LINE 3: ALL NEW PATIENTS ARE GIVEN A "NEW PATIENT PACKET" THAT CONTAINS WEST HOLT MEDICAL SERVICES BILLING AND COLLECTION POLICY WHICH OUTLINES PATIENT ELIGIBILITY FOR FINANCIAL ASSISTANCE. THERE IS ALSO A FINANCIAL ASSISTANCE SECTION ON WESTHOLTMED.ORG UNDER PATIENT RESOURCES THAT INCLUDES OUR COMPREHENSIVE CHARITY CARE POLICY AND FINANCIAL ASSISTANCE POLICY (ALSO A PLAIN LANGUAGE SUMMARY VERSION). THESE RESOURCES ARE ALSO MADE AVAILABLE FOR ALL PATIENTS IN THE REGISTRATION AREAS OF THE FACILITY. PATIENTS ARE ENCOURAGED TO SPEAK WITH OUR FINANCIAL COUNSELOR AND SOCIAL SERVICES WORKER TO FURTHER EDUCATE THEMSELVES ON ALL AVENUES FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: WEST HOLT MEMORIAL HOSPITAL IS IN THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT AREA WHICH CONSISTS OF 9 COUNTIES IN NORTH CENTRAL NEBRASKA. RESIDENTS BETWEEN THE AGE OF 18-65 ACCOUNT FOR 52.30%, OVER THE AGE OF 65 ACCOUNT FOR 23.58%, AND 24.12% OF THE POPULATION IS UNDER THE AGE OF 18. THE POPULATION DENSITY IN THE AREA IS 3 PEOPLE PER SQUARE MILE AS COMPARED TO THE NEBRASKA RATE OF 26 PEOPLE PER SQUARE MILE. THE PERCENT OF THE POPULATION WITH INCOME BELOW 100% OF THE FEDERAL POVERTY LEVEL IS 14.50%, WHILE THE STATE PERCENTAGE IS 11.10%. THE AREA FACES AN ACUTE SHORTAGE OF PHYSICIANS IN NEARLY EVERY SPECIALTY AREA. GIVEN THE VASTNESS OF THE REGION AND SPARSE POPULATION DENSITY, IT IS NOT UNCOMMON FOR RESIDENTS TO LIVE MANY MILES FROM THE NEAREST HEALTH CARE PROVIDER. PART VI, LINE 5: THE HOSPITAL HAS THE AUTHORITY FOR A 40 MEMBER COMMUNITY BOARD WITH 17 MEMBERS CURRENTLY SERVING. FROM THIS GROUP, 9 MEMBERS SERVE AS THE HOSPITAL BOARD. ONE THIRD OF THE MEMBERS ARE ELECTED EVERY YEAR AT THE ANNUAL MEETING. THIS MEETING IS HELD THE FOURTH MONDAY OF OCTOBER AND IS OPEN TO THE COMMUNITY. THOSE ATTENDING ARE INVITED TO ASK QUESTIONS AND VOICE ANY CONCERNS THEY MAY HAVE. THE HOSPITAL HOSTS A HEALTH FAIR EVERY YEAR. LAB TESTS ARE OFFERED AT A REDUCED RATE AND OUTSIDE VENDORS OFFER INFORMATION FOR THE PARTICIPANTS. THE HOSPITAL OFFERS REDUCED PRICED LAB TESTS AND FREE COLORECTAL CANCER TESTS. X X 0 0 0 0 0 0 0 0 0 SAMANTHA SHOLES PHYSICIAN 233045 0 0 0 0 0 10314 0 38043 0 281402 0 0 0 JEREMY BAUER CEO 187511 0 0 0 0 0 8236 0 38457 0 234204 0 0 0 LORETTA DANIELS PHYSICIAN ASSISTANT 187784 0 0 0 0 0 7516 0 1425 0 196725 0 0 0 AMY KINKENNON PHARMACIST 160314 0 0 0 0 0 6459 0 1560 0 168333 0 0 0 VANESSA GOTTIER PHARMACIST 137934 0 0 0 0 0 5696 0 18108 0 161738 0 0 0 PART I, LINE 3 CEO COMPENSATION IS DETERMINED BY A GROUP CONSISTING OF THE CFO, HR DIRECTOR, AND THE BOARD OF DIRECTORS, AND IS THEN APPROVED BY THE BOARD OF DIRECTORS ON AN ANNUAL BASIS. CFO COMPENSATION IS DETERMINED BY THE CEO AND HR DIRECTOR ON AN ANNUAL BASIS, WITH POSSIBLE PERFORMANCE INCREASES EVALUATED ON A MID-YEAR BASIS. AMY RENTSCHLER SPOUSE OF BOARD FIRST VICE PRESIDENT BRYAN RENTSCHLER 60884 COMPENSATION AND BENEFITS AS EMPLOYEE 0 AMANDA SCHAAF DAUGHTER OF BOARD SECRETARY MARSHA THURLOW 51878 COMPENSATION AND BENEFITS AS EMPLOYEE 0 AMBER FRITZ SPOUSE OF BOARD MEMBER MATTHEW FRITZ 38229 COMPENSATION AND BENEFITS AS EMPLOYEE 0 FORM 990, PART VI, SECTION A, LINE 6 WEST HOLT MEMORIAL HOSPITAL SHALL HAVE ONE CLASS OF MEMBER, CONSISTING OF FORTY INDIVIDUALS, OR FEWER IF THERE ARE LESS THAN 40 QUALIFIED INDIVIDUALS WILLING TO SERVE. MEMBERS MUST BE CITIZENS OF THE UNITED STATES, RESIDENTS OF HOLT COUNTY, NEBRASKA OR AN ADJOINING COUNTY, AND HAVE ATTAINED THE AGE OF MAJORITY. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS OF WEST HOLT MEMORIAL HOSPITAL HAVE THE POWER TO ELECT AND REMOVE INDIVIDUALS TO MEMBERSHIP, ELECT THE DIRECTORS OF THE BOARD OF DIRECTORS, AND MAKE RECOMMENDATIONS TO THE BOARD ON OTHER MATTERS. EACH MEMBER SHALL HAVE ONE VOTE ON EACH MATTER SUBMITTED TO A VOTE OF THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD OF DIRECTORS WILL BE PROVIDED THE FORM 990 PRIOR TO FILING. THE CEO AND CFO WILL REVIEW THE FORM 990 PRIOR TO SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C FOLLOWING THE ELECTION OF THE BOARD OF DIRECTORS, EACH MEMBER IS REQUIRED TO SIGN THE CONFLICT OF INTEREST POLICY AND REFRAIN FROM THOSE SITUATIONS THAT MAY CAUSE NON-COMPLIANCE. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE SHOULD BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER SHOULD NOT VOTE OR USE HIS OR HER PERSONAL INFLUENCE ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15A THE CEO'S COMPENSATION IS DETERMINED BY THE BOARD OF DIRECTORS, HUMAN RESOURCE DIRECTOR, AND CFO. FINAL DETERMINATION AND APPROVAL IS MADE BY THE BOARD OF DIRECTORS. COMPARABILITY DATA IS USED BY CONTACTING COMPDATA CONSULTING AND THE NEBRASKA HOSPITAL ASSOCIATION FOR SALARY RANGES. THE COMPENSATION REVIEW IS COMPLETED ON AN ANNUAL BASIS AND DOCUMENTED IN THE CEO'S PERSONNEL FILE AND THE DECISION AND VOTE IN THE BOARD MINUTES. THE LAST REVIEW WAS COMPLETED JULY 1ST, 2025. THE CFO'S COMPENSATION IS DETERMINED BY THE CEO AND HUMAN RESOURCE DIRECTOR. COMPARABILITY DATA IS USED BY CONTACTING COMPDATA CONSULTING AND THE NEBRASKA HOSPITAL ASSOCIATION FOR SALARY RANGES. THE COMPENSATION REVIEW IS COMPLETED ON AN ANNUAL BASIS AND DOCUMENTED IN THE CFO'S PERSONNEL FILE. THE LAST REVIEW WAS COMPLETED IN JULY 1ST, 2025. FORM 990, PART VI, SECTION C, LINE 19 THE PUBLIC IS WELCOME TO COME TO THE FACILITY TO VIEW THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS AT ANYTIME. FORM 990, PART IX, LINE 11G MACHINE SERVICE FEES: PROGRAM SERVICE EXPENSES 763,214. MANAGEMENT AND GENERAL EXPENSES 194,597. FUNDRAISING EXPENSES 1,874. TOTAL EXPENSES 959,685. ANESTHESIOLOGY FEES: PROGRAM SERVICE EXPENSES 128,915. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 128,915. EMERGENCY ROOM COVERAGE FEES: PROGRAM SERVICE EXPENSES 434,810. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 434,810. OTHER FEES FOR SERVICE: PROGRAM SERVICE EXPENSES 663,799. MANAGEMENT AND GENERAL EXPENSES 170,320. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 834,119. LAB FEES: PROGRAM SERVICE EXPENSES 168,457. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 168,457. NURSING FEES: PROGRAM SERVICE EXPENSES 1,044,791. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,044,791. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN TRUSTS 17,364. FORM 990, PART XI, LINE 2C: THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED SINCE THE PRIOR YEAR.