2013-11-15T14:12:28-06:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 300 CROWN COLONY DRIVE SUITE 310 QUINCY MA 02169 990 2012-01-01 042200583 CHELSEA JEWISH NURSING HOME INC CHEL 6178870001 165 CAPTAINS ROW CHELSEA MA 02150 BARRY BERMAN 6178870001 2013-11-15 1 ROBERT DILLAN P01688008 6179848100 2013-11-14 2012 2016-02-25 16:41:14Z BARRY BERMAN 165 CAPTAINS ROW CHELSEA MA 02150 11892165 0 X WWW.CJNH.ORG X 1975 MA OPERATING A 123-BED SKILLED NURSING FACILITY PROVIDING NURSING CARE, REHABILITATION THERAPIES AND OTHER SKILLED SERVICES TO FRAIL ELDERLY AND DISABLED. 8 6 247 6 0 0 176906 170000 12785895 11716155 32958 6010 0 0 12995759 11892165 0 0 0 0 7117590 6620088 0 0 0 5228811 5509085 12346401 12129173 649358 -237008 8442750 7939580 5589298 5323136 2853452 2616444 TO PROVIDE SKILLED NURSING CARE TO THE FRAIL, ELDERLY, AND DISABLED. 0 0 10913024 11716155 NURSING HOME: OPERATION OF A 123 BED SKILLED NURSING FACILITY PROVIDING NURSING CARE, REHABILITATION THERAPIES AND OTHER SKILLED SERVICES TO FRAIL ELDERLY AND DISABLED. 10913024 1 1 0 0 0 0 0 0 0 1 1 0 0 1 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 20 0 247 1 0 0 0 0 0 0 0 0 0 0 X 8 6 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 0 0 0 MA X ELLEN SHONER 6178870001 165 CAPTAINS ROW CHELSEA MA 02150 LEONA R GRELL 1.00 0.00 X X 0 0 0 BARRY BERMAN 1.00 43.00 X X 0 567670 8498 NORMAN ALPERT 1.00 0.00 X 0 0 0 CHARLOTTE FLORENCE 1.00 0.00 X 0 0 0 DORIS T FRIEDMAN 1.00 0.00 X 0 0 0 SHELLY KATZ 1.00 0.00 X 0 0 0 ADAM BERMAN 1.00 43.00 X X 0 250782 6248 ANN SLOSBERG 1.00 0.00 X 0 0 0 MILDRED KRAKOW 0.00 40.00 X 0 152370 466 RONILO ANGLO 0.00 40.00 X 0 150369 9385 DEREK PIRES 0.00 40.00 X 0 108061 9770 EMILY STIER 0.00 40.00 X 0 107421 3645 ROSA ROSARIO 40.00 0.00 X 101102 0 15014 101102 1336673 53026 1 0 1 0 ASAR ELDER SERVICES INC 165 CAPTAINS ROW CHELSEA MA 02150 MANAGEMENT SERVICES 695577 1 170000 170000 PATIENT SERVICE REVENUE 623000 11716155 11716155 11716155 6010 6010 11892165 11716155 0 6010 5482139 5176222 305917 88027 83115 4912 636799 601264 35535 413123 390070 23053 695577 695577 32272 32272 57275 57275 528677 467069 61608 3429 3429 103921 103921 764363 764363 18686 18686 536 536 874 874 288253 288253 PATIENT ANCILLARY SERVI 1000108 1000108 USER FEE ASSESSMENT 631813 631813 SUPPLIES & EXPENSE 495640 495640 BAD DEBT EXPENSE 438625 438625 449036 449036 12129173 10913024 1216149 0 500689 312664 1867998 1898777 86583 131162 9541914 7043644 2437267 2498270 3550213 3098707 8442750 7939580 1652763 1186154 3420 0 3340098 3145766 593017 991216 5589298 5323136 X 1203452 966444 1650000 1650000 2853452 2616444 8442750 7939580 -237008 0 X 0 1 X 0 1 1 X 109291 99501 86021 176906 170000 641719 10706746 10809428 11493505 12785895 11716155 57511729 10816037 10908929 11579526 12962801 11886155 58153448 109291 99501 86021 176906 170000 641719 0 109291 99501 86021 176906 170000 641719 57511729 6090 31580 30735 32958 6010 107373 6090 31580 30735 32958 6010 107373 10822127 10940509 11610261 12995759 11892165 58260821 0.98710 0.98780 0.00180 0.00190 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1650000 1650000 1650000 1650000 1.00000 0 0 13575 13575 7230822 4990614 2240208 2297517 2053030 244487 2498270 UNAMORTIZED MORTGAGE ACQUISITION COST 54792 CONSTRUCTION IN PROGRESS 507875 ESCROWS 883765 SOFTWARE, NET 2275 BENEFICIAL INTEREST IN TESTAMENTARY TRUST 1650000 3098707 DUE TO RELATED PARTIES 991216 991216 X 11892165 0 11892165 0 11892165 12129173 0 12129173 0 12129173 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE ORGANIZATION IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE ORGANIZATION FILES AS A TAX-EXEMPT ENTITY. SHOULD THAT STATUS BE CHALLENGED IN THE FUTURE, THE ORGANIZATION'S 2009 THROUGH 2012 TAX YEARS ARE OPEN FOR EXAMINATION BY FEDERAL AND STATE TAXING AUTHORITIES. 0 0 0 0 0 0 0 0 0 BARRY BERMAN 0 567670 0 0 0 0 0 0 0 8498 0 576168 0 0 ADAM BERMAN 0 250782 0 0 0 0 0 0 0 6248 0 257030 0 0 MILDRED KRAKOW 0 152370 0 0 0 0 0 0 0 466 0 152836 0 0 RONILO ANGLO 0 150369 0 0 0 0 0 0 0 9385 0 159754 0 0 FORM 990, PART VI, SECTION A, LINE 2 BARRY BERMAN AND ADAM BERMAN HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 8B THERE ARE NO COMMITTEES AUTHORIZED TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 MANAGEMENT WILL CONDUCT A REVIEW OF THE FORM 990 AFTER IT HAS BEEN FINALIZED, INCLUDING READING AND REVIEWING THE KEY INFORMATION. THEY WILL REPORT TO THE BOARD IF THERE ARE ANY MAJOR DEVIATIONS FROM THE PROVIDED DATA. ALL MEMBERS RECEIVE A COPY OF THE FEDERAL 990 TO REVIEW. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, ALL BOARD MEMBERS ARE INSTRUCTED TO INFORM THE REST OF THE BOARD IF ANY CONFLICT OF INTEREST EXISTS PERTAINING TO THEIR MEMBERSHIP ON THE BOARD. ANY POTENTIAL CONFLICT OF INTEREST IS THEN DISCUSSED AND ASSESSED BY THE REMAINING BOARD MEMBERS. IF A CONFLICT EXISTS IT MUST BE DISCLOSED AND HELD TO HIGHER LEVEL OF SCRUTINY IN ORDER TO VERIFY THAT ALL TRANSACTIONS ARE ARMS LENGTH. ANY BOARD MEMBER DEEMED TO HAVE A CONFLICT OF INTEREST WILL ABSTAIN FROM PARTICIPATING IN THE BOARD'S DELIBERATIONS AND DECISIONS IN THE TRANSACTION. THE CEO IS NOT PAID FROM THE FILING ORGANIZATION. PRIOR TO MAJOR SALARY ADJUSTMENTS FOR THE CEO, A RELATED ORGANIZATION'S BOARD OF DIRECTORS ARRANGES FOR A SALARY STUDY TO BE PERFORMED. THE STUDY INCLUDES THE EXECUTIVE SALARIES OF COMPARABLY-SIZED COMPANIES IN THE INDUSTRY. THE BOARD OF DIRECTORS THEN CONSIDERS THE FINDINGS OF THE STUDY IN SETTING THE CEO'S COMPENSATION. 2011 WAS THE MOST RECENT YEAR IN WHICH THE PROCESS INCLUDED REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION. OFFICERS AND KEY EMPLOYEES ARE NOT PAID FROM THE FILING ORGANIZATION. COMPENSATION FOR KEY EMPLOYEES IS DETERMINED THROUGH THE USE OF SALARY STUDIES OR OTHER DATA AND ADJUSTED BASED ON THE EMPLOYEE'S YEARS OF EXPERIENCE AND RESPONSIBILITIES BY A RELATED ORGANIZATION'S BOARD OF DIRECTORS. 2011 WAS THE MOST RECENT YEAR IN WHICH THE PROCESS INCLUDED REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY & FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION'S MANAGEMENT PERFORMS MANAGEMENT DUTIES WHICH INCLUDE, BUT ARE NOT LIMITED TO, HIRING, FIRING, AND SUPERVISING PERSONNEL, PLANNING OR EXECUTING BUDGETS OR FINANCIAL OPERATIONS, OR SUPERVISING EXEMPT OPERATIONS OR UNRELATED TRADES OR BUSINESSES OF THE ORGANIZATION FOR SEVERAL RELATED ENTITIES. MANAGEMENT CONTROL IS NOT CONSIDERED DELEGATED AND MANAGEMENT PERSONNEL ARE PAID FROM A CENTRALIZED MANAGEMENT ORGANIZATION, ASAR ELDER SERVICES, INC. PLEASE SEE FORM 990, PART VII FOR COMPENSATION DETAIL. 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