2023-11-14T14:00:17-06:00 2022-12-31 161226221 FUSTCHARLES LLP 220 S WARREN STREET SYRACUSE NY 13202 990 2022-01-01 160969838 SAMARITAN-KEEP NURSING HOME INC SAMA 3157855702 133 PRATT STREET WATERTOWN NY 13601 MAXINE BRIGGS CFO 3157853605 2023-11-13 0 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 20499909 0 X WWW.SAMARITANHEALTH.COM X 1970 NY TO PROVIDE HIGH QUALITY,COMPREHENSIVE, SAFE AND COMPASSIONATE HEALTHCARE SERVICES TO MEET THE NEEDS OF OUR CIVILIAN AND MILITARY COMMUNITY. 15 13 450 16 0 0 2477097 0 19773448 19492464 1344 4416 768739 1003029 23020628 20499909 0 0 0 0 17234129 15227481 0 0 0 7885800 7210915 25119929 22438396 -2099301 -1938487 10674459 10080145 7148205 8111370 3526254 1968775 TO PROVIDE HIGH QUALITY,COMPREHENSIVE, SAFE AND COMPASSIONATE HEALTHCARE SERVICES TO MEET THE NEEDS OF OUR CIVILIAN AND MILITARY COMMUNITY. 0 0 20779006 20454973 PROFESSIONAL CARE OF RESIDENTS IN A 272-BED SKILLED NURSING FACILITY. 81,812 RESIDENT DAYS OF CARE WERE RENDERED DURING 2022. 20779006 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 19 0 1 450 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 880166 57874 DANIEL VILLA TRUSTEE 0.50 X 0 0 0 MAXINE BRIGGS CFO/TREASURER 1.00 42.50 X X 0 453847 46030 JAN TURCOTTE MD SMC CHAIR 1.00 2.50 X 0 0 0 MELANIE PARKER-GEURTSEN SMC BOARD CHAIR EX OFFICIO 1.00 1.00 X 0 0 0 MARY WARDWELL-DONAHUE FORMER VICE CHAIR/CURRENT CHAIR 1.00 3.50 X X 0 0 0 JORDAN JONES FORMER SECRETARY/CURRENT VICE CHAIR 1.00 0.50 X X 0 0 0 SAMUEL PURINGTON CHAIR/IMMEDIATE PAST CHAIR 1.00 2.50 X X 0 0 0 TRACY VALENTINE TRUSTEE/CURRENT SECRETARY 1.00 0.50 X X 0 0 0 MELISSA SCHMITT AUXILIARY REPRESENTATIVE/EX-OFFICIO 1.00 0.50 X 0 0 0 ADDISON VARS III IMMEDIATE PAST CHAIR/TRUSTEE 1.00 2.50 X 0 0 0 JOAN TREADWELL-WOODS TRUSTEE 1.00 0.50 X 0 0 0 FRANCEE CALARCO TRUSTEE 1.00 0.50 X 0 0 0 PETER L WALTON TRUSTEE 1.00 0.50 X 0 0 0 BARRY ORMSBY TRUSTEE 1.00 0.50 X 0 0 0 LINDA O'CONNOR TRUSTEE 1.00 0.50 X 0 0 0 POLLY MATARESE TRUSTEE 1.00 0.50 X 0 0 0 CARL MCLAUGHLIN TRUSTEE 1.00 0.50 X 0 0 0 PATRICK CALLI SKH ADMINISTRATOR 40.00 X 207263 0 140 CHRISTINE ROBINSON NURSE AID EDUCATION COORDINATOR 40.00 X 112886 0 7060 MEGAN LABODA SKH NURSING ADMIN 40.00 X 107285 0 11872 KATHLEEN RIVERS SKH DIRECTOR OF NURSING 40.00 X 105182 0 12162 KARA PHAROAH LTC NURSE MANAGER 40.00 X 100868 0 9370 633484 1334013 144508 5 0 1 0 MEDEFIS PO BOX 5068 NEW YORK NY 100875068 AGENCY STAFF 752703 SERVICE EMPLOYEES BENEFIT FUND PO BOX 1240 SYRACUSE NY 13201 BENEFITS 652722 MOHAWK HEALTHCARE PO BOX 27 UTICA NY 13503 PURCHASED SERVICES 323444 WATERTOWN INTERNISTS PC 53-59 PUBLIC SQUARE WATERTOWN NY 13601 MEDICAL DIRECTOR 175000 4 RESIDENT SERVICE REVENUE 623000 19492464 19492464 19492464 4416 4416 40520 0 40520 40520 40520 OTHER REVENUE 623000 674591 674591 SOLD SERVICES 623000 261277 261277 CAFETERIA 623000 26641 26641 962509 20499909 20454973 0 44936 12529858 12269366 260492 385963 379206 6757 1404704 1375501 29203 906956 888101 18855 2775 2775 21412 21412 17781 13714 4067 3217 294 2923 1180 200 980 900 900 527384 527384 325334 325334 PURCHASED SERVICES 2290818 1626774 664044 SUPPLIES/UTILITIES 2288916 1967268 321648 NYS ASSESSMENT 1193934 1193934 PROVISION FOR BAD DEBT 537264 537264 22438396 20779006 1659390 0 545692 351430 3090415 3093895 2409483 2447839 74949 70363 86499 98660 30526055 28007573 2986652 2518482 1045784 1047341 434985 452135 10674459 10080145 4185231 3749092 2962974 4362278 7148205 8111370 X 3343756 1786277 182498 182498 3526254 1968775 10674459 10080145 X -1938487 381008 X X 0 1 X 1 0 X 182498 182498 182498 182498 182498 182498 182498 182498 182498 182498 1.00000 0 0 110000 110000 19678511 18150486 1528025 181306 181306 0 10375629 9613265 762364 180609 62516 118093 2518482 DUE TO (FROM) AFFILIATES (RELATED PARTIES) 2899123 RETIREMENT PLAN OBLIGATIONS 228059 ASSETS HELD FOR RESIDENTS 198762 ESTIMATED THIRD PARTY 884656 LONG TERM DEBT 125922 MEDICARE ADVANCE 25756 4362278 X 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. 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 PATRICK CALLI SKH ADMINISTRATOR 197302 0 0 0 9961 0 0 0 140 0 207403 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 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF SAMARITAN-KEEP NURSING HOME, 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 THROUGOUT 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 319,685. OTHER COMPONENTS OF NET PERIODIC BENEFIT COST 61,323. FORM 990 PART XII LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. SCHEDULE A LINE 3 SAMARITAN KEEP NURSING HOME, 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 KEEP NURSING HOME, 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 STREET WATERTOWN NY 13601 150533577 HOSPITAL NY 501 (C) (3) SCHED A,PART I,LN3 N/A 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 STREET WATERTOWN NY 13601 237227989 HOSPITAL NY 501 (C) (3) SCHED A,PART I,LN3 SAMARITAN MEDICAL CENTER 0 SAMARITAN SENIOR VILLAGE INC 22691 CAMPUS DRIVE WATERTOWN NY 13601 454913668 SENIOR CITIZEN COMMUNITY NY 501 (C) (3) SCHED A,PART I,LN3 SAMARITAN MEDICAL CENTER 0 SAMARITAN MEDICAL PRACTICE PC 830 WASHINGTON STREET WATERTOWN NY 13601 261528342 PHYSICIAN MEDICAL PRACTICE NY 501 (C) (3) SCHED A,PART I,LN3 SAMARITAN MEDICAL CENTER 0 SAMARITAN HOME HEALTH 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