0001209191-17-001194.txt : 20170104 0001209191-17-001194.hdr.sgml : 20170104 20170104171824 ACCESSION NUMBER: 0001209191-17-001194 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20161231 FILED AS OF DATE: 20170104 DATE AS OF CHANGE: 20170104 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Diversicare Healthcare Services, Inc. CENTRAL INDEX KEY: 0000919956 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-SKILLED NURSING CARE FACILITIES [8051] IRS NUMBER: 621559667 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1621 GALLERIA BLVD. CITY: BRENTWOOD STATE: TN ZIP: 37027 BUSINESS PHONE: 6157717575 MAIL ADDRESS: STREET 1: 1621 GALLERIA BLVD. CITY: BRENTWOOD STATE: TN ZIP: 37027 FORMER COMPANY: FORMER CONFORMED NAME: ADVOCAT INC DATE OF NAME CHANGE: 19940309 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Gill Kelly J. CENTRAL INDEX KEY: 0001460581 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-12996 FILM NUMBER: 17506982 MAIL ADDRESS: STREET 1: 27442 PORTOLA PARKWAY, SUITE 200 CITY: FOOTHILL RANCH STATE: CA ZIP: 92610 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2016-12-31 0 0000919956 Diversicare Healthcare Services, Inc. DVCR 0001460581 Gill Kelly J. 1621 GALLERIA BOULEVARD BRENTWOOD TN 37027 1 1 0 0 CEO & President Common Stock 199686 D Dividend Equivalent Rights on 2014 Restricted Shares 2016-12-31 4 A 0 47.08 0.00 A Common Stock 47.08 615.05 D Dividend Equivalent Rights on 2015 Restricted Shares 2016-12-31 4 A 0 91.64 0.00 A Common Stock 91.64 753.8 D Dividend Equivalent Rights on 2016 Restricted Shares 2016-12-31 4 A 0 134.69 0.00 A Common Stock 134.69 602.49 D 2015 Restricted Stock Units 2016-12-31 4 A 0 82.79 0.00 A Common Stock 82.79 15717.74 D 2016 Restricted Stock Units 2016-12-31 4 A 0 33.22 0.00 A Common Stock 33.22 6315.72 D Stock Options (right to buy) 5.60 2011-11-10 2021-11-10 Common Stock 50000 50000 D Stock Settled Stock Appreciation Right 6.21 2010-04-05 2020-04-05 Common Stock 35000 35000 D Stock Settled Stock Appreciation Right 5.45 2010-06-18 2020-06-18 Common Stock 15000 15000 D These dividend equivalent rights accrued on shares of restricted stock granted on March 12, 2014 and will vest as the underlying shares vest. These dividend equivalent rights accrued on shares of restricted stock granted on March 10, 2015 and will vest as the underlying shares vest. These dividend equivalent rights accrued on shares of restricted stock granted on March 11, 2016 and will vest as the underlying shares vest. Each Restricted Stock Unit is equal to one share. The 2015 Restricted Stock Units shall vest and be exercisable in full on the 2nd anniversary of their original Grant Date (03/10/2015). The 2016 Restricted Stock Units shall vest and be exercisable in full on the 2nd anniversary of their original Grant Date (03/11/2016). Vests 1/3 on the first anniversary of the date of grant, 1/3 on the second anniversary of the date of grant, and 1/3 on the third anniversary of the date of grant. /s/ Jonathan D. Stanley, Attorney-in-Fact for Kelly J. Gill 2017-01-04 EX-24.4_692348 2 poa.txt POA DOCUMENT POWER OF ATTORNEY Know all by these presents, that the undersigned hereby constitutes and appoints each of Jonathan D. Stanley, Sam Daniel, Kelly J. Gill and Susan V. Sidwell signing singly, the undersigned's true and lawful attorney-in-fact to: (1) execute for and on behalf of the undersigned, in the undersigned's capacity as an officer and/or director of Advocat Inc. (the "Company"), Forms 3, 4, and 5 in accordance with Section 16(a) of the Securities Exchange Act of 1934 and the rules thereunder; (2) do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Form 3, 4, or 5, complete and execute any amendment or amendments thereto, and timely file such form with the United States Securities and Exchange Commission and any stock exchange or similar authority; (3) execute for and on behalf of the undersigned a Form ID and any subsequent filings, submissions or correspondence relating thereto; and (4) take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact's discretion. The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934. This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4, and 5 with respect to the undersigned's holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact. This Power of Attorney replaces and revokes any and all prior powers of attorney granted by the undersigned, in the undersigned's capacity as an officer and/or director of the Company, relating to Section 16 of the Securities Exchange Act of 1934. IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 31st day of January, 2012. /s/ Kelly Gill Signature Kelly Gill Print Name