efile Public Visual Render
ObjectId: 202022309349301942 - Submission: 2020-08-17
TIN: 39-0837206
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
Attach to Form 990.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
18
Open to Public Inspection
Name of the organization
LAKEVIEW MEDICAL CENTER INC
OF RICE LAKE
Employer identification number
39-0837206
Part I
Questions Regarding Compensation
Yes
No
1a
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)
b
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
.........
1b
Yes
2
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?
..
2
Yes
3
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
4
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:
a
Receive a severance payment or change-of-control payment?
.............
4a
Yes
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
.........
4b
Yes
c
Participate in, or receive payment from, an equity-based compensation arrangement?
.........
4c
No
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.
5
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:
a
The organization?
....................
5a
Yes
b
Any related organization?
.......................
5b
Yes
If "Yes," on line 5a or 5b, describe in Part III.
6
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:
a
The organization?
..................
6a
Yes
b
Any related organization?
......................
6b
Yes
If "Yes," on line 6a or 6b, describe in Part III.
7
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
............
7
No
8
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
..........................
8
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)?
.........................
9
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2018
Page 2
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
(i)
Base
compensation
(ii)
Bonus & incentive
compensation
(iii)
Other
reportable compensation
1
Tom Lundquist MD
Board Member
(i)
(ii)
0
-------------
209,061
0
-------------
9,761
0
-------------
4,362
0
-------------
29,497
0
-------------
25,534
0
-------------
278,215
0
-------------
0
2
Scott Polenz
Board Member
(i)
(ii)
0
-------------
257,715
0
-------------
0
0
-------------
5,982
0
-------------
29,497
0
-------------
24,143
0
-------------
317,337
0
-------------
0
3
Neelakantan Namboodiri MD
Board Member
(i)
(ii)
0
-------------
344,222
0
-------------
0
0
-------------
17,328
0
-------------
29,497
0
-------------
20,809
0
-------------
411,856
0
-------------
0
4
Bradley Groseth
Chief Admin Officer
(i)
(ii)
0
-------------
289,116
0
-------------
7,500
0
-------------
630
0
-------------
2,080
0
-------------
31,339
0
-------------
330,665
0
-------------
0
5
Narayana Murali MD
MCHS Chief Strategy Officer
(i)
(ii)
0
-------------
720,583
0
-------------
112,500
0
-------------
21,632
0
-------------
29,497
0
-------------
28,594
0
-------------
912,806
0
-------------
0
6
Jerard Jensen
MCHS General Counsel
(i)
(ii)
0
-------------
741,937
0
-------------
112,500
0
-------------
19,789
0
-------------
29,497
0
-------------
26,636
0
-------------
930,359
0
-------------
0
7
Gordon Edwards
MCHS CFO/COO
(i)
(ii)
0
-------------
570,052
0
-------------
90,000
0
-------------
42,207
0
-------------
29,497
0
-------------
29,848
0
-------------
761,604
0
-------------
0
8
Susan Turney MD
MCHS CEO
(i)
(ii)
0
-------------
1,686,332
0
-------------
510,000
0
-------------
258,560
0
-------------
270,897
0
-------------
22,398
0
-------------
2,748,187
0
-------------
154,255
9
Ned Wolf
Former LMC CEO
(i)
(ii)
0
-------------
333,897
0
-------------
0
0
-------------
32,949
0
-------------
29,497
0
-------------
30,543
0
-------------
426,886
0
-------------
0
10
Cindy Arts-Strenke
Former LMC COO
(i)
(ii)
0
-------------
201,186
0
-------------
0
0
-------------
1,290
0
-------------
29,007
0
-------------
19,614
0
-------------
251,097
0
-------------
0
11
Daniel Ramsey
Former MCHS COO
(i)
(ii)
0
-------------
-456
0
-------------
0
0
-------------
557,469
0
-------------
0
0
-------------
456
0
-------------
557,469
0
-------------
0
12
Steven Kulick
Chief Experience Officer
(i)
(ii)
0
-------------
216,878
0
-------------
0
0
-------------
8,702
0
-------------
1,769
0
-------------
9,678
0
-------------
237,027
0
-------------
0
Schedule J (Form 990) 2018
Page 3
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
Form 990 Sch J Part I Line 1a
THE ORGANIZATION MAY OCCASIONALLY REIMBURSE OR PROVIDE A HOUSING ALLOWANCE FOR KEY EXECUTIVES IN ORDER TO ASSIST WITH RELOCATING TO THE AREA. THE ORGANIZATION MAY ALSO CONTRIBUTE TO OR REIMBURSE FOR HEALTH AND SOCIAL CLUB DUES AS DEEMED NECESSARY IN ORDER TO SUPPORT A BUSINESS NEED.
Form 990 Sch J Part I Line 3
THE MARSHFIELD CLINIC HEALTH SYSTEM'S (MCHS) INDEPENDENT COMPENSATION COMMITTEE (THE COMMITTEE) HAS FINAL AUTHORITY FOR APPROVING COMPENSATION AND BENEFITS OF ALL DISQUALIFIED PERSONS EMPLOYED BY ANY OF THE ORGANIZATIONS IN THE SYSTEM. THE COMMITTEE USES COMBINATIONS OF THE FOLLOWING TO EVALUATE COMPENSATION: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE, AND WRITTEN EMPLOYMENT CONTRACTS.
Form 990 Sch J Part I Line 4a
SEVERANCE DANIEL RAMSEY - $557,469
Form 990 Sch J Part I Line 4b
457(F) PLAN SUSAN TURNEY, MD - $165,215
Form 990 Sch J Part I Line 5a & 5b
SEVERAL INDIVIDUALS MAY RECEIVE INCENTIVE COMPENSATION BASED ON A VARIETY OF FACTORS, INCLUDING NOT ONLY FINANCIAL MEASURES SUCH AS REVENUE GROWTH OR EARNINGS, BUT ALSO QUALITY, SERVICE, MARKET EXPANSION, COMMUNITY & EMPLOYEE ENGAGEMENT, AND OTHER OUTCOMES OR EXPECTATIONS SET BY THE BOARD AND/OR CEO. ANY PERFORMANCE BONUS IS SUBJECT TO REVIEW BY THE SYSTEM'S INDEPENDENT COMPENSATION COMMITTEE FOR REASONABLENESS.
Form 990 Sch J Part I Line 6a & 6b
SEVERAL INDIVIDUALS MAY RECEIVE INCENTIVE COMPENSATION BASED ON A VARIETY OF FACTORS, INCLUDING NOT ONLY FINANCIAL MEASURES SUCH AS REVENUE GROWTH OR EARNINGS, BUT ALSO QUALITY, SERVICE, MARKET EXPANSION, COMMUNITY & EMPLOYEE ENGAGEMENT, AND OTHER OUTCOMES OR EXPECTATIONS SET BY THE BOARD AND/OR CEO. ANY PERFORMANCE BONUS IS SUBJECT TO REVIEW BY THE SYSTEM'S INDEPENDENT COMPENSATION COMMITTEE FOR REASONABLENESS.
Schedule J (Form 990) 2018
Additional Data
Software ID:
Software Version: