2017-11-06T05:49:29-06:00 2016-12-31 131517563 LOEB & TROPER LLP 655 THIRD AVENUE 12TH FLOOR NEW YORK NY 10017 990 2016-01-01 133834710 AMSTERDAM NURSING HOME CORP (1992) AMST 2125753322 1060 AMSTERDAM AVENUE NEW YORK NY 10025 MARK PANCIRER SENIOR VP/CFO 2125753322 2017-11-03 1 AARON SHAPIRO P01333816 2128674000 38.98.118.70 2017-11-03 15:57:26 ED P D7076C0EC39B17C3336BFEA465ABF20A32036F2A 73A2BDB4DEE3E1301F7FB9DCBA9193E2BC5F7900 2016 2017-02-10 21:41:12Z AMSTERDAM NURSING HOME MARK PANCIRER 1060 AMSTERDAM AVENUE NEW YORK NY 10025 64600956 0 X AMSTERDAMCARES.ORG X 1995 NY AMSTERDAM NURSING HOME CORP. (1992) (AMSTERDAM) WAS FOUNDED IN 1872 TO PROVIDE A HOME FOR "OLD MEN AND AGED COUPLES; AMSTERDAM IS A 409 BED SKILLED NURSING FACILITY (SNF) AND A 40 REGISTRANT ADULT DAY HEALTH CARE (ADHC) PROVIDING LONG AND SHORT TERM RESIDENTIAL CARE, AS WELL AS DAY CARE, TO PERSONS LIVING IN THE COMMUNITY. AMSTERDAM'S MISSION IS TO PROVIDE THE HIGHEST STANDARD OF HEALTH CARE TO ITS RESIDENTS, PATIENTS AND DAY HEALTH CARE REGISTRANTS. AMSTERDAM IS PROUD TO OFFER INDIVIDUALIZED CARE IN A SETTING THAT SUPPORTS THE QUALITY OF LIFE, DIGNITY, AND AUTONOMY OF EACH PERSON THAT IT SERVES. 12 12 575 97 0 0 1365071 2823914 60380596 61061024 31142 51472 783244 664546 62560053 64600956 0 0 0 0 33525416 37652777 0 0 0 26953752 25988772 60479168 63641549 2080885 959407 62275214 60869468 46763049 44397896 15512165 16471572 X TO OPERATE A NOT FOR PROFIT NURSING HOME WITH 409 NURSING FACILITY BEDS AND AN ADULT DAY HEALTH CARE PROGRAM FOR 40 REGISTRANTS. 0 0 53321177 61061024 AMSTERDAM PROVIDES ROOM AND BOARD AND MEDICAL CARE FOR THE ELDERLY. AMSTERDAM HAS A CAPACITY OF 409 NURSING FACILITY BEDS ALONG WITH AN ADULT DAY HEALTH CARE PROGRAM WITH A CAPACITY OF 40 REGISTRANTS. IN 2016, AMSTERDAM HAD 955 ADMISSIONS AND PROVIDED 11,478 ADULT DAY HEALTH CARE VISITS. AMSTERDAM HAD AN OCCUPANCY RATE OF 97.58 PERCENT IN THE NURSING FACILITY. 53321177 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1 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 1 101 0 575 1 0 0 0 0 0 0 0 0 0 0 X 12 12 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X MARK PANCIRER 2125753322 1060 AMSTERDAM AVENUE NEW YORK NY 10025 LAWRENCE B THOMPSON CHAIRMAN 2.00 3.00 X X 0 0 0 GEORGE L VAN AMSON VICE CHAIRMAN 0.50 0.80 X X 0 0 0 JOSEPH C HOOPES JR TREASURER 1.00 1.50 X X 0 0 0 JOSE V TORRES SECRETARY 0.30 0.30 X X 0 0 0 REVEREND JAMES G CALLAWAY JR BOARD MEMBER 0.30 0.50 X 0 0 0 DR KAREN M HOPKINS BOARD MEMBER 0.30 0.50 X 0 0 0 JAY H MCDOWELL BOARD MEMBER 0.30 0.60 X 0 0 0 REV DEACON FRANK L PETERSON JR BOARD MEMBER 0.30 0.50 X 0 0 0 R SCOTT EDMONDS BOARD MEMBER 0.30 0.50 X 0 0 0 FRANCES R OLIVIERI BOARD MEMBER 0.30 0.50 X 0 0 0 JAMES J CAMPBELL BOARD MEMBER 0.30 0.50 X 0 0 0 ISABEL M CARDEN BOARD MEMBER 0.50 0.50 X 0 0 0 JAMES DAVIS PRESIDENT/CEO 35.00 15.00 X 4035317 52999 45111 MARK PANCIRER SENIOR VP/CFO 42.50 7.50 X 287181 30000 48084 JUDITH FENSTER SENIOR VP/COO 35.00 X 240189 0 44828 GERTRUDES DE GUZMAN DIR. OF NURSING 35.00 X 155062 0 43264 LORNA POON DIRECTOR OF FINANCE 35.00 X 176856 0 24893 MICHAEL WHITE DIRECTOR OF FINANCIAL PLAN 17.00 X 120707 0 13372 GEETHA MURLI DIRECTOR OF ACCTS. AND REC. 35.00 X 124691 0 6210 RICHARD HARLEY DIRECTOR OF BUILDING SERVICE 35.00 X 120368 0 29836 5260371 82999 255598 19 0 1 0 THERADYNAMICS PHY REHAB PC 225 CROSSWAYS PARK DRIVE WOODBURY NY 11797 PHYSICAL THERAPY 4058179 UNITED HOME CARE 77-04 BROADWAY ELMHURST NY 11373 NURSING AGENCY 3228304 G-NET CONSTRUCTION CORP 360 TARGEE STREET STATEN ISLAND NY 10304 CONSTRUCTION 2217414 TIMBIL MECHANICAL LLC 68 FANNY ROAD BOONTON NJ 07005 HVAC SYSTEMS 2161134 INPATIENT HOSPITALISTS SERV PO BOX 92284 LOS ANGELES CA 90009 PHYSICIAN SERVICES 1083942 18 2714337 109577 2823914 PATIENT SERVICE REVENUE 623000 59953563 59953563 UNIVERSAL SETTLEMENT 623000 1107461 1107461 61061024 51472 51472 DISCOUNTS ON PURCHASES 623990 165425 165425 EXP. REC. EMPLOYEE BENEFITS 623990 132936 132936 EXPENSE RECOVERY 623990 105934 105934 260251 260251 664546 64600956 61061024 0 716018 X 4700710 4700710 21704122 20548719 1155403 2109140 1898226 210914 7360879 6624791 736088 1777926 1615463 162463 192732 192732 61630 61630 5332 5332 11248394 9778390 1470004 2199 1045 1154 6244632 5456185 788447 1174864 894162 280702 23850 5198 18652 1028383 904977 123406 2079999 1830399 249600 793548 698322 95226 NYS ASSESSMENT 2784560 2784560 OTHER 348649 280740 67909 63641549 53321177 10320372 0 X 2014635 2242604 18520000 16392554 11740025 9897846 124831 120642 1700270 1950821 86933453 58100103 25753820 28833350 2421633 1431651 62275214 60869468 7748092 7832290 479006 434260 36579876 34115099 1956075 2016247 46763049 44397896 X 15404903 16371106 107262 100466 15512165 16471572 62275214 60869468 959407 0 X X 0 1 X 1 1 1 X 6682692 322216 5009 1365071 2823914 11198902 54781112 56860160 58975995 60380596 61061024 292058887 61463804 57182376 58981004 61745667 63884938 303257789 0 0 0 303257789 27462 22513 23622 31142 51472 156211 27462 22513 23622 31142 51472 156211 603200 724854 693292 783244 664546 3469136 62094466 57929743 59697918 62560053 64600956 306883136 0.98820 0.98790 0.00050 0.00050 X SCHEDULE A PART III, LINE 12, EXPLANATION FOR OTHER INCOME RECOVERY OF EXPENSES PHONE & VENDING MACHINE DISCOUNT OF PURCHASES DIRECT TV FEES MISCELLANEOUS RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5332 5332 0 PART II-B, LINE 1: DUES AND OR FEES PAID TO THE FOLLOWING ORGANIZATIONS THAT HAD LOBBYING EXPENSES: 1199/SEIU HEP - $523, CCLC - $1,199, AND LEADING AGE - $3,610. 0 1 X 1432917 1432917 55492384 40771252 14721132 102698 92888 9810 21301988 17161353 4140635 8603466 74610 8528856 28833350 DUE TO THIRD PARTIES 1900155 ACCRUED INTEREST PAYABLE 116092 2016247 X 64600956 0 64600956 0 64600956 63641549 0 63641549 0 63641549 PART IV, LINE 2B: PATIENT FUNDS ARE HELD FOR THE RESIDENTS IN SEPARATE BANK ACCOUNTS TO BE USED AT THE DISCRETION OF THE PATIENTS AND/OR THEIR FAMILIES. PART X, LINE 2: THE HOME HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. PERIODS ENDING DECEMBER 31, 2013 AND SUBSEQUENT REMAIN SUBJECT TO EXAMINATION BY APPLICABLE TAXING AUTHORITIES. X X X X X X 0 0 0 0 0 0 0 1 0 JAMES DAVIS PRESIDENT/CEO 451504 52999 0 0 3583813 0 19110 0 26001 0 4080428 52999 19110 0 MARK PANCIRER SENIOR VP/CFO 229657 30000 50000 0 7524 0 19110 0 28974 0 335265 30000 19100 0 JUDITH FENSTER SENIOR VP/COO 214460 0 25000 0 729 0 15079 0 29749 0 285017 0 14964 0 GERTRUDES DE GUZMAN DIR. OF NURSING 150989 0 3500 0 573 0 9365 0 33899 0 198326 0 5671 0 LORNA POON DIRECTOR OF FINANCE 166525 0 10000 0 331 0 10862 0 14031 0 201749 0 10484 0 RICHARD HARLEY DIRECTOR OF BUILDING SERVICE 116801 0 2500 0 1067 0 6215 0 23621 0 150204 0 5965 0 PART I, LINE 7 THE PRESIDENT/CEO GATHERS COMPARABLE INFORMATION, EVALUATES AND APPROVES A BONUS FOR THE ORGANIZATION'S OFFICERS, KEY EMPLOYEES AND HIGHLY COMPENSATED EMPLOYEES. THE BOARD OF DIRECTORS ESTABLISHES THE COMPENSATION FOR THE PRESIDENT/CEO BASED ON COMPARABLE MARKET DATA. PART I, LINE 7 AND PART II, LINE 1 (I), COL. (III): THE BOARD OF DIRECTORS OF AMSTERDAM NURSING HOME CORP. (1992) RECOGNIZED THE NEARLY THREE DECADES OF DISTINGUISHED SERVICE BY ITS PRESIDENT AND CHIEF EXECUTIVE OFFICER BY AUTHORIZING A SUPPLEMENTAL RETIREMENT BENEFIT. THE ORGANIZATION ENTERED INTO A WRITTEN AGREEMENT PROVIDING FOR A LUMP SUM SUPPLEMENTAL RETIREMENT PAYMENT OF $3,575,000 TO MAKE THE PRESIDENT AND CHIEF EXECUTIVE OFFICER'S OVERALL COMPENSATION PACKAGE COMPETITIVE WITH PEER ORGANIZATIONS AND TO ENCOURAGE THE PRESIDENT AND CHIEF EXECUTIVE OFFICER TO CONTINUE HIS EMPLOYMENT, TAKING INTO ACCOUNT THE ADVICE OF AN INDEPENDENT COMPENSATION CONSULTANT RETAINED TO ASSESS REASONABLE COMPENSATION BASED ON COMPARABLE MARKET DATA. FORM 990, PART VI, SECTION A, LINE 2 TWO MEMBERS OF THE BOARD OF DIRECTORS ARE PARTNERS IN THE SAME BUSINESS FIRM. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 IS PROVIDED TO THE AUDIT COMMITTEE. THE CFO MAKES THE 990 AVAILABLE TO ALL BOARD MEMBERS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C A INTERESTED DIRECTOR MEANS ANY AMSTERDAM DIRECTOR WHO HAS AN INTEREST AS A PRINCIPAL, PARTNER, DIRECTOR, OFFICER, EMPLOYEE, AGENT, OR STOCKHOLDER (OTHER THAN A STOCKHOLDER OF A PUBLICLY TRADED CORPORATION WHO STOCK IS WIDELY HELD) OF ANY ENTITY WITH WHICH AMSTERDAM HAS OR CONTEMPLATES TRANSACTING BUSINESS. AN INTERESTED DIRECTOR MUST DISCLOSE THE RELATIONSHIP OR INTEREST IN THE TRANSACTION TO THE BOARD OF DIRECTORS OF THE APPLICABLE AMSTERDAM ENTITY. DISCLOSURE SHALL BE MADE TO THE CHAIRMAN OF THE BOARD AS SOON AS THE INTERESTED DIRECTOR BECOMES AWARE OF THE POTENTIAL FOR A CONFLICT IN CONNECTION WITH THE TRANSACTION, WHO SHALL INFORM THE APPLICABLE BOARD.IF THE CHAIRMAN IS INVOLVED IN THE TRANSACTION, THE CHAIRMAN SHALL ADVISE THE SECRETARY OF THE APPLICABLE AMSTERDAM ENTITY WHO SHALL ARRANGE FOR BOARD DISCLOSURE. NO INTERESTED DIRECTOR SHALL PARTICIPATE IN THE DISCUSSION,DELIBERATIONS AND VOTING REGARDING A TRANSACTION. THE AFFIRMATIVE VOTE OF THE MAJORITY OF ALL THE DIRECTORS OF THE APPLICABLE AMSTERDAM ENTITY SHALL BE REQUIRED BEFORE ENTERING INTO THE TRANSACTION,(EXCLUDED IN SUCH COUNTS IS THE INTERESTED DIRECTOR.) NO TRANSACTION SHALL BE INVALIDATED OR AFFECTED IN ANY WAY IF THIS POLICY IS FOLLOWED. ALL OFFICERS AND KEY EMPLOYEES ARE REQUIRED TO DISCLOSE ANY POTENTIAL CONFLICTS OF INTEREST. SAID CONFLICTS ARE ADDRESSED BY MANAGEMENT. FORM 990, PART VI, SECTION B, LINE 15 AMSTERDAM HAS A PROCESS TO DETERMINE COMPENSATION FOR THE OFFICERS WHICH INCLUDES A REVIEW BY A COMPENSATION AND BENEFITS CONSULTANT, THE USE OF COMPARABILITY DATA AND CONTEMPORANEOUS SUBSTANTIATION IN THE DELIBERATION AND THE FINAL DECISION. THIS PROCESS WAS UNDERTAKEN IN 2015 FOR THE YEAR 2016. THIS PROCESS INCLUDES A REVIEW OF TOTAL COMPENSATION INCLUDING BONUS CONSIDERATION. COMPENSATION OF KEY EMPLOYEES IS BASED ON AN INFORMAL REVIEW BY THE PRESIDENT/CEO OF COMPARABLE DATA. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G NURSING HOME CONSULTING SERVICES: PROGRAM SERVICE EXPENSES 9,778,390. MANAGEMENT AND GENERAL EXPENSES 1,470,004. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 11,248,394. FORM 990, PART X, LINE 15 OTHER RECEIVABLES $0 OTHER ASSETS $224,863 DUE FORM THIRD PARTY PAYOR $1,206,785 SUBVENTION CERTIFICATE FROM $3 TOTAL-OTHER ASSETS $1,431,651 FORM 990, PART XII, LINE 2C: AMSTERDAM HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENT AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE PROCESS HAS NOT CHANGED FROM PRIOR YEARS. AMSTERDAM CONSULTING LLC 1060 AMSTERDAM AVENUE NEW YORK NY 10025 134034061 PROVIDING ADMINISTRATIVE AND CONSULTING SERVICES NY 438480 2742957 N/A AMSTERDAM SERVICES CORP 1060 AMSTERDAM AVENUE NEW YORK NY 10025 133902473 PROVIDING ADMINISTRATIVE AND CONSULTING SERVICES TO HEALTHCARE FACILITIES NY 501(C)(3) LINE 10 AMSTERDAM CONTINUING CARE HEALTH SYSTEM 0 AMSTERDAM CONTINUING CARE HEALTH SYSTEMS 1060 AMSTERDAM AVENUE NEW YORK NY 10025 134034061 PROVIDING ADVICE, INFORMATION & MONETARY CONTRIBUTIONS TO ELDERLY & DISABLED NY 501(C)(3) LINE 7 N/A 0 AMSTERDAM HOUSE CONTINUING CARE RETIREMENT COMMUNITY INC 1060 AMSTERDAM AVENUE NEW YORK NY 10025 113711764 INDEPENDENT LIVING, ENRICHED HOUSING AND SKILLED NURSING CARE NY 501(C)(3) LINE 12A, I AMSTERDAM CONTINUING CARE HEALTH SYSTEM 0 AMSTERDAM SERVICES CORP 2001 1060 AMSTERDAM AVENUE NEW YORK NY 10025 134184082 PROVIDING NURSING HOME CONSULTING AND ADMIN. OVERSITE. NY N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0