2024-11-13T19:07:35-06:00 2023-12-31 161226221 FUSTCHARLES LLP 220 S WARREN STREET SYRACUSE NY 13202 990 2023-01-01 454913668 SAMARITAN SENIOR VILLAGE INC SAMA 3157855702 22691 CAMPUS DRIVE WATERTOWN NY 13601 MAXINE BRIGGS CFO 3157853605 2024-11-12 1 1 PATRICK CAPELLA P01359200 3154463600 2024-11-12 2023 2024-10-15 13:58:12Z MAXINE BRIGGS 830 WASHINGTON STREET WATERTOWN NY 13601 30351185 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 13 444 17 0 0 0 6000000 19428909 24022456 0 205 188922 328524 19617831 30351185 0 0 0 0 13425395 13969299 0 0 0 9510937 10471632 22936332 24440931 -3318501 5910254 49373530 55842090 26678515 27152948 22695015 28689142 TO PROVIDE HIGH QUALITY,COMPREHENSIVE,SAFE AND COMPASSIONATE HEALTH CARE SERVICES AT MULTIPLE LEVELS FOR THE LOCAL ELDERLY POPULATION. 0 0 22827433 24350980 PROFESSIONAL CARE OF RESIDENTS IN A 168 BED SKILLED NURSING FACILITY AND 120 BED ASSISTED LIVING FACILITY. 57,022 RESIDENT SKILLED NURSING DAYS AND 38,724 RESIDENT ASSISTED LIVING DAYS OF CARE WERE RENDERED DURING 2023. 22827433 1 1 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 17 0 1 444 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 1.00 43.50 X X 0 1043591 59072 DENISE YOUNG SMC BOARD CHAIR EX OFFICIO 1.00 1.00 X X 0 0 0 CARL MCLAUGHLIN TRUSTEE 1.00 0.50 X 0 0 0 LINDA O'CONNOR TRUSTEE 1.00 0.50 X 0 0 0 JORDAN JONES VICE CHAIR 1.00 0.50 X X 0 0 0 MARY WARDWELL-DONAHUE CHAIR 1.00 3.50 X X 0 0 0 BARRY ORMSBY TRUSTEE 1.00 0.50 X 0 0 0 MELISSA SCHMITT AUXILLARY REPRESENTATIVE 1.00 0.50 X 0 0 0 FRANCEE CALARCO TRUSTEE 1.00 0.50 X 0 0 0 TRACY VALENTINE SECRETARY 1.00 0.50 X X 0 0 0 MARTIN YENAWINE TRUSTEE 1.00 0.50 X 0 0 0 JOAN TREADWELL-WOODS TRUSTEE 1.00 0.50 X 0 0 0 KI LACLAIR TRUSTEE 1.00 0.50 X 0 0 0 KEVIN KIEFF TRUSTEE 1.00 0.50 X 0 0 0 SAMUEL PURINGTON IMMEDIATE PAST CHAIR 1.00 2.50 X X 0 0 0 ADDISON F VARS III ESQ TRUSTEE 1.00 0.50 X 0 0 0 MAXINE BRIGGS CFO/TREASURER 1.00 42.50 X X 0 559897 48174 PETER WALTON TRUSTEE 1.00 0.50 X 0 0 0 MELANIE PARKER-GEUTSEN SMC BOARD CHAIR EX OFFICIO (2022-2023) 1.00 1.00 X 0 0 0 PATRICK CALLI SSV ADMINISTRATOR 40.00 X 233470 45527 13610 VICKIE SMITHERS NURSE MANAGER 40.00 X 164441 0 31523 SUSAN GREER ASSISTANT DIRECTOR OF NURSING 40.00 0.00 X 209292 0 26097 JEANETTE EMERY DIRECTOR OF NURSING 40.00 X 179908 0 14885 NEVA BOSSARD ASSISTED LIVING ADMINISTRATOR 40.00 X 120118 0 26296 SHAUNA CAMPANARO PHYSICIAN ASSISTANT 40.00 X 127828 0 15576 STEPHANY JO WORTHINGTON STAFF RN 40.00 X 123284 0 25313 1158341 1649015 260546 14 0 1 0 RENZI BROS INC 901 RAIL ST WATERTOWN NY 13601 FOOD SERVICE 609953 MEDEFIS INC PO BOX 5608 NEW YORK NY 100875068 AGENCY STAFF 392191 MOHAWK HEALTHCARE PO BOX 27 UTICA NY 13503 PURCHASED SERVICE 223738 POINT CLICK CARE TECHNOLIGIES 5570 EXPLOYER DRIVE MISSISSAUGA CA SOFTWARE 189417 US FOODS 901 RAIL ST WATERTOWN NY 13601 FOOD SERVICE 141326 5 6000000 6000000 NET RESIDENT REVENUE 623000 24022456 24022456 24022456 205 205 TELEVISION 623000 42938 42938 CAFETERIA 623000 29074 29074 256512 256512 328524 30351185 24350980 0 205 443044 434136 8908 10851509 10633335 218174 288216 282743 5473 1565175 1533706 31469 821355 804841 16514 50557 50557 27860 27860 1640000 1495909 144091 57357 11235 46122 141102 141102 578278 578278 5357 4369 988 5091 5091 609138 536587 72551 1226044 793717 432327 1740519 1740519 297833 297833 BAD DEBT 1249265 1249265 DIETARY SUPPLIES 952701 946407 6294 NYS ASSESSMENT 873419 873419 MEDICAL SUPPLIES 617170 607325 9845 399941 296551 103390 24440931 22827433 1613498 0 1500 1275 642002 2159202 6000000 2157973 2451041 48100 41240 117689 116785 64442707 19684739 46285300 44757968 120966 314579 49373530 55842090 2089589 2856789 21120173 20334222 3468753 3961937 26678515 27152948 X 22507854 23741501 187161 4947641 22695015 28689142 49373530 55842090 X 5910254 83873 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 187161 6000000 1239520 4947641 187161 187161 187161 187161 187161 187161 187161 187161 1.00000 0 0 297775 297775 58804540 15504015 43300525 5319632 4180724 1138908 20760 20760 44757968 DUE TO AFFILATES 2928180 DUE TO THIRD PARTY PAYORS 312326 OTHER LIABILITIES 250744 PENSION PLANS 211152 RESIDENTS FUND 259535 3961937 X PART V, LINE 4: THE INTENDED PURPOSE OF THE ENDOWMENT FUNDS IS TO PROVIDE LONG-TERM SUPPORT FOR CHARITABLE PROGRAM. PART X, LINE 2: SAMARITAN SENIOR VILLAGE QUALIFIES AS A TAX-EXEMPT, NOT-FOR-PROFIT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF DECEMBER 31, 2023 AND 2022, SAMARITAN DID NOT HAVE ANY UNRECOGNIZED TAX BENEFITS. THE TAX YEARS OPEN TO EXAMINATION BY FEDERAL AND NEW YORK STATE TAXING AUTHORITIES ARE 2020 THROUGH 2023. X X X X X 0 1 0 0 0 0 0 0 0 THOMAS CARMAN PRESIDENT/CEO 0 735218 0 306133 0 2240 0 11200 0 47872 0 1102663 0 0 MAXINE BRIGGS CFO/TREASURER 0 494062 0 43335 0 22500 0 17800 0 30374 0 608071 0 0 PATRICK CALLI SSV ADMINISTRATOR 200751 43364 22701 0 10018 2163 12187 1213 169 41 245826 46781 0 0 SUSAN GREER ASSISTANT DIRECTOR OF NURSING 209092 0 200 0 0 0 4906 0 21191 0 235389 0 0 0 VICKIE SMITHERS NURSE MANAGER 161841 0 2600 0 0 0 9051 0 22472 0 195964 0 0 0 JEANETTE EMERY DIRECTOR OF NURSING 179158 0 750 0 0 0 6369 0 8516 0 194793 0 0 0 PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED CONTRIBUTIONS TO AN IRC 457 (B) PLAN DURING 2023: MAXINE BRIGGS- $22,500 PATRICK CALLI- $12,182 THE FOLLOWING INDIVIDUALS RECEIVED COMPENSATION FROM SAMARITAN MEDICAL CENTER DURING 2023: THOMAS CARMAN: $1,102,663 MAXINE BRIGGS: $608,071 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 AND OTHER POSTRETIREMENT LIABILITY ADJUSTMENTS 118,005. OTHER COMPONENTS OF NET PERIODIC BENEFIT COST -34,132. 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 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0