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ObjectId: 202422279349303602 - Submission: 2024-08-14
TIN: 59-3322533
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
22
Open to Public Inspection
Name of the organization
South Lake Hospital Inc
Employer identification number
59-3322533
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 on 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 on 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
No
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
No
b
Any related organization?
.......................
5b
No
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
No
b
Any related organization?
......................
6b
No
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) 2022
Page 2
Schedule J (Form 990) 2022
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, 1099-MISC compensation, and/or 1099-NEC
(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
Mildred Denise Beam
Former Board Member, Vice-Chair (Term End 12/2019)
(i)
(ii)
0
-------------
453,393
0
-------------
321,294
0
-------------
50,356
0
-------------
98,569
0
-------------
16,887
0
-------------
940,499
0
-------------
45,950
2
John A Moore
Former Board Member, Chairman (Term end 9/2020)
(i)
(ii)
0
-------------
462,943
0
-------------
130,213
0
-------------
81,769
0
-------------
94,972
0
-------------
31,881
0
-------------
801,778
0
-------------
71,666
3
Cary J Dtona
Board Member Secretary/Treasurer
(i)
(ii)
0
-------------
408,767
0
-------------
207,190
0
-------------
77,346
0
-------------
81,096
0
-------------
29,080
0
-------------
803,479
0
-------------
65,567
4
Lance E Sewell
Board Member, Chairman/President
(i)
(ii)
0
-------------
370,477
0
-------------
164,042
0
-------------
23,765
0
-------------
75,621
0
-------------
35,102
0
-------------
669,007
0
-------------
19,661
5
Lushantha Sajotha Gunasekera
Former Board Member (Term End 12/2019)
(i)
(ii)
0
-------------
389,320
0
-------------
633,193
0
-------------
810
0
-------------
10,675
0
-------------
34,734
0
-------------
1,068,732
0
-------------
0
6
Mahmoud Fuad Bakeer MD
Board Member
(i)
(ii)
295,141
-------------
0
75,197
-------------
0
147,620
-------------
0
33,973
-------------
0
30,340
-------------
0
582,271
-------------
0
8,920
-------------
0
7
Bonnie J Onofre
Board Member
(i)
(ii)
207,938
-------------
0
51,791
-------------
0
17,002
-------------
0
12,514
-------------
0
9,811
-------------
0
299,056
-------------
0
0
-------------
0
8
Bernadette Spong
Former CFO (Term end 6/2022)
(i)
(ii)
0
-------------
820,020
0
-------------
1,024,421
0
-------------
411,422
0
-------------
4,509
0
-------------
29,286
0
-------------
2,289,658
0
-------------
182,114
9
Leslie Flake
Chief Financial Officer, OH
(i)
(ii)
0
-------------
466,049
0
-------------
230,298
0
-------------
44,865
0
-------------
72,291
0
-------------
5,923
0
-------------
819,426
0
-------------
0
10
Bonnie Bennett
Adm, Patient Care
(i)
(ii)
153,738
-------------
0
23,393
-------------
0
10,237
-------------
0
19,677
-------------
0
12,311
-------------
0
219,356
-------------
0
291
-------------
0
11
Jeanette M Bonstrom
Dir, Pharmacy Services
(i)
(ii)
176,431
-------------
0
18,138
-------------
0
3,296
-------------
0
6,097
-------------
0
19,215
-------------
0
223,177
-------------
0
0
-------------
0
12
Jennifer Grafton
AVP, OH & CFO, SLH
(i)
(ii)
211,656
-------------
0
56,397
-------------
0
323
-------------
0
28,761
-------------
0
36,302
-------------
0
333,439
-------------
0
0
-------------
0
13
Paul Mark Johns
AVP, OH & COO, SLH
(i)
(ii)
215,234
-------------
0
55,277
-------------
0
32,404
-------------
0
12,392
-------------
0
22,131
-------------
0
337,438
-------------
0
15,482
-------------
0
14
Diane Bowen Jones
Clin Assistant Nurse Manager
(i)
(ii)
161,394
-------------
0
23,972
-------------
0
3,915
-------------
0
5,374
-------------
0
30,443
-------------
0
225,098
-------------
0
0
-------------
0
Schedule J (Form 990) 2022
Page 3
Schedule J (Form 990) 2022
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
Schedule J, Part I, Line 1a First-class or charter travel
DURING FY2023, OFFICERS, BOARD MEMBERS AND KEY EMPLOYEES OF SOUTH LAKE HOSPITAL, INC. WERE PERMITTED TO FLY FIRST-CLASS OR WERE PERMITTED TO USE A CHARTERED FLIGHT SERVICE AT THE REQUEST OF ORLANDO HEALTH. THE TRAVEL WAS ENTIRELY BUSINESS RELATED FOR OFFICERS, BOARD MEMBERS, AND KEY EMPLOYEES.
Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation
ORLANDO HEALTH, INC. IS A COMMON PAYMASTER AND COMMON PAY AGENT FOR ORLANDO HEALTH MEDICAL GROUP, INC. (EIN: 59-3259553), ORLANDO HEALTH FOUNDATION, INC. (EIN: 59-2244943), ORLANDO HEALTH CENTRAL, INC. (EIN: 80-0764192), SOUTH LAKE HOSPITAL, INC. (EIN: 59-3322533), OSCEOLASC, LLC (EIN: 20-3728235), OHI WEST, INC. (EIN: 84-5074208), OHI WEST MEDICAL GROUP, LLC (EIN: 85-2733660) AND ORLANDO PHYSICIANS NETWORK, INC. (EIN: 59-3110868) AND THEIR EMPLOYEES ARE INCLUDED ON THE ORLANDO HEALTH, INC. 941. THE ORLANDO HEALTH, INC. INDEPENDENT COMPENSATION COMMITTEE APPROVES ALL OFFICER COMPENSATION ARRANGEMENTS, WHICH REPORTS TO THE ORLANDO HEALTH BOARD OF DIRECTORS AND FOLLOWS IRS GUIDELINES.
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
THE FOLLOWING INDIVIDUALS PARTICIPATED IN A SUPPLEMENTAL QUALIFIED RETIREMENT PLAN. DEFERRAL DEPOSITS: Mildred Beam $92,832 John Moore $82,576 Leslie Flake $72,291 Cary Dtona $68,791 Lance Sewell $66,847 Mahmoud Fuad Bakeer, MD $21,140 Jennifer Grafton $15,855 Bonnie Bennett $10,990 DEFERRAL DISTRIBUTIONS MADE TO THE FOLLOWING: Bernadette Spong $182,114 John Moore $71,666 Mildred Beam $45,950 Cary Dtona $65,567 Lance Sewell $19,661 Paul Johns $15,482 Mahmoud Fuad Bakeer, MD $8,920 Bonnie Bennett $291 457(b) Deferred Compensation Plan: Eligibility to participate in this plan is determined by job classification. The plan accepts pre-tax employee contributions only, and the amount of the contribution is determined by the employee. Participants are automatically vested in the plan, since there are no company contributions. The Team Member Retirement Plan Oversight Committee oversees the plan and determines the investment options with the assistance of a third-party investment advisory firm. Execu-FLEX 457(f) and Director/Admin 457(f) Plans: Eligibility to participate in these plans is determined by job classification. Annual contributions to the plan or payments to participants will be based on a percentage of the participant's based salary as of November 1st of the prior plan year. Vesting occurs for each annual contribution three years after the contribution occurs. Once the participant reaches age 62, they are fully vested in the plan and begin to receive additional wages in lieu of contributions. The Team Member Retirement Plan Oversight Committee oversees the plan and determines the investment options with the assistance of a third-party investment advisory firm.
Schedule J (Form 990) 2022
Additional Data
Software ID:
22016089
Software Version:
2022v5.0