2023-11-14T14:00:17-06:00 2022-12-31 161226221 FUSTCHARLES LLP 220 S WARREN STREET SYRACUSE NY 13202 990 2022-01-01 454913668 SAMARITAN SENIOR VILLAGE INC SAMA 3157855702 22691 CAMPUS DRIVE WATERTOWN NY 13601 MAXINE BRIGGS CFO 3157853605 2023-11-13 1 MAXINE BRIGGS 999009999 0 PATRICK CAPELLA P01359200 3154463600 2023-11-13 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z MAXINE BRIGGS 830 WASHINGTON STREET WATERTOWN NY 13601 19617831 0 X WWW.SAMARITANHEALTH.COM X 2011 NY TO PROVIDE HIGH QUALITY,COMPREHENSIVE,SAFE AND COMPASSIONATE HEALTH CARE SERVICES AT MULTIPLE LEVELS FOR THE LOCAL ELDERLY POPULATION. 15 13 456 16 0 0 1410267 0 19220256 19428909 0 0 392111 188922 21022634 19617831 0 0 0 0 14442030 13425395 0 0 0 9741152 9510937 24183182 22936332 -3160548 -3318501 52947409 49373530 26714281 26678515 26233128 22695015 TO PROVIDE HIGH QUALITY,COMPREHENSIVE,SAFE AND COMPASSIONATE HEALTH CARE SERVICES AT MULTIPLE LEVELS FOR THE LOCAL ELDERLY POPULATION. 0 0 21558923 19617831 PROFESSIONAL CARE OF RESIDENTS IN A 168 BED SKILLED NURSING FACILITY AND 120 BED ASSISTED LIVING FACILITY. 53,610 RESIDENT SKILLED NURSING DAYS AND 37,465 RESIDENT ASSISTED LIVING DAYS OF CARE WERE RENDERED DURING 2022. 21558923 1 0 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 14 0 1 456 1 0 0 0 0 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 1 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X MAXINE BRIGGS 3157853605 104 PADDOCK STREET WATERTOWN NY 13601 THOMAS CARMAN PRESIDENT/CEO 0.50 43.50 X X 0 880166 57874 MAXINE BRIGGS CFO/TREASURER 0.50 42.50 X X 0 453847 46030 JAN TURCOTTE MD SMC CHAIR 0.50 2.50 X 0 0 0 MELANIE PARKER-GEURTSEN SMC BOARD CHAIR EX-OFFCIO 0.50 3.00 X 0 0 0 MARY WARDWELL-DONAHUE FORMER VICE CHAIR/CURRENT CHAIR 0.50 3.50 X X 0 0 0 JORDAN JONES FORMER SECRETARY/CURRENT VICE CHAIR 0.50 3.00 X X 0 0 0 SAMUEL PURINGTON CHAIR / IMMEDIATE PAST CHAIR 0.50 2.50 X X 0 0 0 TRACY VALENTINE TRUSTEE / CURRENT SECRETARY 0.50 1.00 X X 0 0 0 MELISSA SCHMITT AUXILLARY REPRESENTATIVE/ EX-OFFICIO VOTING 0.50 1.00 X 0 0 0 ADDISON F VARS III IMMEDIATE PAST CHAIR/TRUSTEE 0.50 2.50 X 0 0 0 JOAN TREADWELL-WOODS TRUSTEE 0.50 3.50 X 0 0 0 FRANCEE CALARCO TRUSTEE 0.50 1.00 X 0 0 0 PETER WALTON TRUSTEE 0.50 1.00 X 0 0 0 BARRY ORMSBY TRUSTEE 0.50 1.00 X 0 0 0 LINDA O'CONNOR TRUSTEE 0.50 1.00 X 0 0 0 POLLY MATARESE TRUSTEE 0.50 1.00 X 0 0 0 CARL MCLAUGHLIN TRUSTEE 0.50 1.00 X 0 0 0 DANIEL VILLA TRUSTEE 0.50 X 0 0 0 VICKI SMITHERS LTC NURSE MANAGER 40.00 X 144475 0 27750 MARY K VANTASSEL SSV NURSING ADMIN 40.00 X 113266 0 27081 NEVA BOSSARD SSV NURSING ADMIN 40.00 X 116199 0 22102 SHAUNA CAMPANARO SSV NURSING ADMIN 40.00 X 119046 0 14659 SUSAN MARY PEPE SSV NURSING ADMIN 40.00 X 103384 0 14560 596370 1334013 210056 6 0 1 1 MEDIFIS INC PO BOX 5068 NEW YORK NY 100875068 ACENCY STAFF 578266 SERVICES EMPLOYEES BENEFIT FUND PO BOX 1240 SYRACUSE NY 13201 BENEFITS 570597 MOHAWK HEATHCARE SERVICES PO BOX 27 UTICA NY 13503 PURCHASED SERVICES 248766 POINT CLICK CARE TECHNOLOGIES INC 5570 EXPLOYER DRIVE MISSISSAUGA ON CA L4W OC4 SOFTWARE 141204 4 NET RESIDENT REVENUE 623000 19428909 19428909 19428909 TELEVISION 623000 42437 42437 CAFETERIA 623000 18101 18101 128384 128384 188922 19617831 19617831 0 0 10933054 10795620 137434 284563 281540 3023 1398785 1381202 17583 808993 798824 10169 29704 29704 21053 16776 4277 12000 12000 359249 359249 11038 2093 8945 3053 2932 121 650334 577875 72459 1779068 1779068 298034 298034 PURCHASED SERVICE 2294207 1699888 594319 SUPPLIES 2113008 1923667 189341 BAD DEBT 1013687 1013687 NYS ASSESSMENT 926502 926502 22936332 21558923 1377409 0 -1916 1500 2023656 642002 2499484 2157973 59280 48100 84917 117689 64248684 17963384 48018011 46285300 263977 120966 52947409 49373530 996868 2089589 23400477 21120173 2316936 3468753 26714281 26678515 X 26045967 22507854 187161 187161 26233128 22695015 52947409 49373530 X -3318501 -219612 X X 0 1 X 1 0 X 187161 187161 187161 187161 187161 187161 187161 187161 652789 465625 187161 1.00000 0 0 297775 297775 58804540 14026924 44777616 5106446 3936460 1169986 39923 39923 46285300 OTHER LIABILITIES 218748 MEDICARE ADVANCE 113817 RESIDENT FUNDS 120966 DUE TO AFFILIATE 770982 THIRD PARTY PAYABLE 2004479 PENSION PLANS 239761 3468753 X PART V, LINE 4: THE BALANCE IN THE ENDOWMENT FUND IS THE UNSPENT CONSTRUCTION FUNDS TO DATE. PART X, LINE 2: SAMARITAN QUALIFIES AS A TAX-EXEMPT, NOT-FOR-PROFIT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2022 AND 2021, SAMARITAN DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2019 THROUGH 2022. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT NET PERIODIC BENEFIT COST PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT X X X X X 0 1 0 0 0 0 0 0 0 THOMAS CARMAN PRESIDENT/CEO 0 699733 0 174933 0 5500 0 11200 0 46674 0 938040 0 0 MAXINE BRIGGS CFO/TREASURER 0 433347 0 0 0 20500 0 17300 0 28730 0 499877 0 0 VICKI SMITHERS LTC NURSE MANAGER 142725 0 1750 0 0 0 6561 0 21189 0 172225 0 0 0 PART I, LINE 1A PART 1, LINE 4B: THE FOLLOWING INDIVIDUALS RECEIVED CONTRIBUTIONS TO AN IRC 457 (B) PLAN DURING 2022: MAXINE BRIGGS- $20,500 A JEFFERSON COUNTY CIVIC FACILITY DEVELOPMENT 2012-10-01 28145000 CONSTRUCTION OF SKILLED NURSING FACILITY 0 0 0 A 28145000 250905 27510001 384094 2013 0 0 0 1 A 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 A 0 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF SAMARITAN SENIOR VILLAGE, INC. IS THE SAMARITAN MEDICAL CENTER. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S FORM 990 AND ACCOMPANYING SCHEDULES WERE REVIEWED BY THE EXECUTIVE COMMITTEE OF THE BOARD, PRIOR TO FILING. FORM 990 WAS PROVIDED TO EACH BOARD MEMBER PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL DISCLOSURE STATEMENTS ARE REQUIRED BY ALL BOARD MEMBERS AND KEY PERSONS. WE HAVE MET 100% COMPLIANCE WITH THIS REQUIREMENT EACH YEAR. RESPONSES ARE REVIEWED INITIALLY BY THE CHIEF EXECUTIVE OFFICER AND CHIEF COMPLIANCE OFFICER FOR ACCURACY AND COMPLETENESS. THIS INFORMATION IS DISCLOSED IN A FULL REPORT TO THE BOARD OF TRUSTEES FOR REVIEW AND CONSIDERATION FOR FUTURE DECISION MAKING. BOARD MEMBERS AND KEY PERSONS AFFIRM THEIR UNDERSTANDING OF THEIR DUTY TO REPORT ANY ADDITIONAL OR NEW POTENTIAL CONFLICTS THROUGHOUT THE YEAR. BOARD MEMBERS WITH A CONFLICT ARE PROHIBITED FROM PARTICIPATION IN VOTING AND DECISION MAKING IN RELATED TRANSACTIONS. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION USES AN EXTERNAL CONSULTANT TO ANALYZE AND ESTABLISH COMPENSATION AND BENEFITS FOR ALL EXECUTIVE POSITIONS. AN EVALUATION IS PERFORMED ANNUALLY. THE ANALYSIS INCLUDES A REVIEW OF MARKET DATA BASED ON REGION, FACILITY SIZE, AND RESPECTIVE RESPONSIBILITIES. THIS INFORMATION IS PRESENTED TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR REVIEW AND SUBSEQUENTLY PRESENTED TO THE FULL BOARD OF TRUSTEES FOR APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC. THE FINANCIAL STATEMENTS ARE FILED AS PART OF THE ANNUAL NYS DEPARTMENT OF HEALTH INSTITUTIONAL COST REPORT, AND ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: PENSION LIABILITY ADJUSTMENTS -219,612. FORM 990 PART XII LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. SCHEDULE A LINE 3 SAMARITAN SENIOR VILLAGE, INC. IS A NURSING HOME WHICH HAS AS ITS MAIN PURPOSE THE PROVISION OF HEALTHCARE SERVICES, IT APPROPRIATELY NOTED ON FORM 1023 THAT IT IS A HOSPITAL. THE STATE OF NEW YORK DOES NOT REQUIRE NURSING HOMES TO BE LICENSED AS A HOSPITAL. AS A NURSING HOME, SAMARITAN SENIOR VILLAGE, INC. HAS AS ITS PRINCIPAL PURPOSE THE PROVISION OF HEALTH CARE. ACCORDINGLY, IT WAS (I) PROPERLY IDENTIFIED AS A "HOSPITAL" ON FORM 1023; (II) PROPERLY IDENTIFIED AS A "HOSPITAL" ON FORM 990 SCHEDULE A; AND (III) SHOULD NOT BE DESIGNATED AS A "HOSPITAL/HOSPITAL FACILITY" ON FORM 990 SCHEDULE H. SAMARITAN MEDICAL CENTER 830 WASHINGTON ST WATERTOWN NY 13601 150533577 HOSPITAL NY 501 (C) (3) SCHED A,PART I,LN3 N/A 0 SAMARITAN KEEP NURSING HOME INC 133 PRATT ST WATERTOWN NY 13601 160969838 SKILLED NURSING FACILITY NY 501 (C) (3) SCHED A,PART I,LN3 SAMARITAN MEDICAL CENTER 0 THE SAMARITAN MEDICAL CENTER FDN OF NORTHERN NEW YORK INC 830 WASHINGTON STREET WATERTOWN NY 13601 161490523 PROVIDES FUND FOR SAMARITAN MEDICAL CENTER AND AFFLIATES NY 501 (C) (3) SCHED A,PART I,LN7 SAMARITAN MEDICAL CENTER 0 EDWARD J NOBLE HOSPITAL- SAMARITAN 104 PADDOCK ST WATERTOWN NY 13601 237227989 HOSPITAL NY 501 (C) (3) SCHED A,PART I,LN3 SAMARITAN MEDICAL CENTER 0 SAMARITAN MEDICAL PRACTICE PC 830 WASHINGTON ST WATERTOWN NY 13601 261528342 PHYSICIAN MEDICAL PRACTICE NY 501 (C) (3) SCHED A,PART I,LN3 SAMARITAN MEDICAL CENTER 0 SAMARITAN HOME HEALTH INC 165 COLEMAN AVENUE WATERTOWN NY 13601 461043637 CERTIFIED HOME HEALTH AGENCY NY 501 (C) (3) SCHED A,PART I,BOX 1 SAMARITAN MEDICAL CENTER 0 CLIFTON-FINE HEALTH CARE CORPORATION 1014 OSWEGATCHIE TRAIL STAR LAKE NY 13690 900909506 HOSPITAL NY 501 (C) (3) SAMARITAN MEDICAL CENTER 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0