Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990.
lBullet Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2016
Open to Public
Inspection
Name of the organization
GENESIS HEALTHCARE SYSTEM
 
Employer identification number
31-1480941
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient
that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC section
(if applicable)		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
noncash assistance		 (h) Purpose of grant
or assistance
(1) UNITED WAY OF MPM COUNTIES
526 PUTNAM AVENUE
ZANESVILLE,OH43701 		31-4379456 501(C)(3) 40,000       GRANTS WERE PAID TO ASSIST IN COMMUNITY IMPACTGRANTS WERE PAID TO ASSIST IN PROVIDING ASSISTANCE FOR COMMUNITY IMPACT PROJECTS
(2) GENESIS HEALTHCARE FOUNDATION
1135 MAPLE AVENUE
ZANESVILLE,OH43701 		31-1629304 501(C)(3) 13,894       GRANT PAID TO FUND GENESIS FOUNDATION CAPITAL CAMPAIGN
(3) AMERICAN HEART ASSOCIATION
PO BOX 4002907
DES MOINES,IA50340 		13-5613797 501(C)(3) 17,000       HEARTCHASE SPONSORSHIP AGREEMENT
(4) AMERICAN CANCER SOCIETY
5555 FRANTZ ROAD
DUBLIN,OH43017 		13-1788491 501(C)(3) 6,500       COUNTY SPONSOR
(5) FOUNDATION FOR APPALACHIAN OHIO
PO BOX 456
NELSONVILLE,OH45764 		31-1620483 501(C)(3) 5,000       COMMUNITY FOUNDATINO FOR PERRY CO ENDOW 200
(6) MUSKINGUM VALLEY HEALTH CENTER
716 ADAIR AVENUE
ZANESVILLE,OH43701 		20-8814374 501(C)(3) 10,000       PATIENT CARE CHARITABLE FUND
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
5
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2016
Page 2

Schedule I (Form 990) 2016
Page 2
Part III
Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Number of
recipients		 (c) Amount of
cash grant		 (d) Amount of
noncash assistance		 (e) Method of valuation (book,
FMV, appraisal, other)		 (f) Description of noncash assistance
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Part IV
Supplemental Information. Provide the information required in Part I, line 2; Part III, column (b); and any other additional information.
Return Reference Explanation
Part I, Line 2: THE UNITED WAY DONATION IS MONITORED THROUGH "METRICS AND DATA" REPORTED TO GHCS AND GHCS APPOINTS ONE "AT-LARGE MEMBER" ANNUALLY TO SERVE ON THE COMMUNITY IMPACT BOARD. THE AMERICAN HEART ASSOCIATION GRANT IS PART OF A 3 YR COMMITMENT FROM 2016-2018 FOR A TOTAL CONTRIBUTION OF $51,000. THIS COMMITMENT WAS AUTHORIZED BY OUR CEO THROUGH A SIGNED AGREEMENT AND IS TO BENEFIT THE LOCAL HEART CHASE PROGRAM OF WHICH GENESIS IS A SPONSOR AND PARTICIPANT. THE AMERICAN CANCER SOCIETY GRANT IS A SPONSORSHIP OF LOCAL ACS EVENTS IN AREA COUNTIES SERVED BY GENESIS. GENESIS ENCOURAGES COMMUNITY AND EMPLOYEE PARTICIPATION IN THESE EVENTS. THE FOUNDATION FOR APPALACHIAN OHIO GRANT IS PART OF GENESIS'S INVESTMENT IN PERRY COUNTY, ONE OF THE SURROUNDING COUNTIES THAT GENESIS SERVES. OUR CEO AND OTHER STAFF MEMBERS ALSO COMMIT TIME AND ENERGY WORKING IN COLLABORATION WITH THE FOUNDATION TO PROMOTE GOOD HEALTH AND WELL-BEING FOR AREA RESIDENTS. THE CONTRIBUTION TO THE MUSKINGUM VALLEY HEALTH CENTER PATIENT CARE CHARITABLE FUND IS JUST ONE OF THE MANY WAYS THAT GENESIS WORKS WITH MVHC TO PROVIDE ACCESS TO PRIMARY AND PREVENTIVE CARE SERVICES FOR UNINSURED AND UNDERINSURED RESIDENTS. OUR CHIEF PHYSICIAN NETWORK OFFICER SERVED ON THE MVHC BOARD DURING 2016. SHE, AS WELL AS SEVERAL PHYSICIANS AND TECHNICAL STAFF MEMBERS, WORKS CLOSELY WITH MVHC TO HELP MEET THE HEALTH NEEDS OF MUSKINGUM COUNTY.
Schedule I (Form 990) 2016



Additional Data


Software ID:  
Software Version: