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State of Connecticut2020Annual Report of Long-Term Care FacilityCost Year 2020Name of Facility (as licensed)Lord Chamberlain Nursing & Rehabilitation CenterAddress (No. & Street, City, State, Zip Code)7003 Main Street, Stratford, CT 06614Type of Facility Rest Home with Nursing Supervision only(RHNS)Chronic and ConvalescentNursing Home only (CCNH)Report for Year Beginning10/1/2019License Numbers:Medicaid Provider Numbers:For Department Use OnlySequence NumberSigned andAssignedNotarized (Specify)Report for Year ecify)RHNSSequence NumberAssignedMedicare Provider07-5339ICF-IIDSigned and NotarizedDate Received
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-1 Rev.9/2002General InformationName of Facility (as licensed)Lord Chamberlain Nursing & Rehabilitation CenterLicense No.968CReport for Year Ended9/30/2020Page1of37Administrator's/Owner's CertificationMISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THISCOST REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISIONMENT UNDER STATE ORFEDERAL LAW.I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanyingCost Report and supporting schedules prepared for Lord Chamberlain Nursing & Rehabilitation Center[facility name], for the cost report period beginning October 1, 2019 and ending September 30, 2020, andthat to the best of my knowledge and belief, it is a true, correct, and complete statement prepared from thebooks and records of the provider(s) in accordance with applicable instructions.I hereby certify that I have directed the preparation of the attached General Information and Questionnaires,Schedule of Resident Statistics, Statements of Reported Expenditures, Statements of Revenues and the relatedBalance Sheet of this Facility in accordance with the Reporting Requirements of the State of Connecticut for theyear ended as specified above.I have read this Report and hereby certify that the information provided is true and correct to the best ofmy knowledge under the penalty of perjury. I also certify that all salary and non-salary expenses presentedin this Report as a basis for securing reimbursement for Title XIX and/or other State assisted residentswere incurred to provide resident care in this Facility. All supporting records for the expenses recordedhave been retained as required by Connecticut law and will be made available to auditors upon request.Signed (Administrator)DatePrinted Name (Administrator)James BergersSubscribed and Swornto before me:Signed (Owner)DatePrinted Name (Owner)Martin SbriglioState ofDateSigned (Notary Public)Comm. Expires/Address of Notary Public(Notary Seal)/
Table of ContentsGeneral Information - Administrator's/Owner's CertificationGeneral Information and Questionnaire - Data Required for Real Wage AdjustmentGeneral Information and Questionnaire - Type of Facility - Organization StructureGeneral Information and Questionnaire - Partners/MembersGeneral Information and Questionnaire - Corporate OwnersGeneral Information and Questionnaire - Individual ProprietorshipGeneral Information and Questionnaire - Related PartiesGeneral Information and Questionnaire - Basis for Allocation of CostsGeneral Information and Questionnaire - LeasesGeneral Information and Questionnaire - Accounting BasisSchedule of Resident StatisticsSchedule of Resident Statistics (Cont'd)A. Report of Expenditures - Salaries & WagesSchedule A1 - Salary Information for Operators/Owners; Administrators, AssistantAdministrators and Other RelativesSchedule A1 - Salary Information for Operators/Owners; Administrators, AssistantAdministrators and Other Relatives (Cont'd)B. Report of Expenditures - Professional FeesReport of Expenditures - Schedule B-1 - Information Required for Individual(s) Paid on Feefor Service BasisC. Expenditures Other than Salaries - Administrative and GeneralC. Expenditures Other than Salaries (Cont'd) - Administrative and GeneralSchedule C-1 - Management ServicesC. Expenditures Other than Salaries (Cont'd) - DietaryC. Expenditures Other than Salaries (Cont'd) - LaundryC. Expenditures Other than Salaries (Cont'd) - Housekeeping and Resident CareReport of Expenditures - Schedule C-2 - Individuals or Firms Providing Services by ContractC. Expenditures Other than Salaries (Cont'd) - Maintenance and PropertyDepreciation ScheduleAmortization ScheduleC. Expenditures Other than Salaries (Cont'd) - Property QuestionnaireC. Expenditures Other than Salaries (Cont'd) - InterestC. Expenditures Other than Salaries (Cont'd) - Interest and InsuranceD. Adjustments to Statement of ExpendituresD. Adjustments to Statement of Expenditures (Cont'd)F.Statement of RevenueG. Balance SheetG. Balance Sheet (Cont'd)G. Balance Sheet (Cont'd)G. Balance Sheet (Cont'd)G. Balance Sheet (Cont'd) - Reserves and Net WorthH. Changes in Total Net WorthI.Preparer's/Reviewer's 2122232425262728293031323334353637
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-1A Rev. 6/95State of ConnecticutDepartment of Social Services55 Farmington Avenue, Hartford, Connecticut 06105Data Required for Real Wage AdjustmentName of FacilityLord Chamberlain Nursing & Rehabilitation CenterAddress of Facility7003 Main Street, Stratford, CT 06614Report Prepared ByRyders Health ManagementPeriod Covered:Phone Number203-381-1327ItemTotal1.Dietary wages paid 2.Laundry wages paid 3.Housekeeping wages paid 4.Nursing wages paid 5.All other wages paid 6.Total Wages Paid 7.Total salaries paid 8.Total Wages and Salaries Paid (As per page 10 of Report) CCNHPageof1A37FromTo10/1/2019 9/30/2020Date12/17/2020RHNSWages - Compensation computed on an hourly wage rate.Salaries - Compensation computed on a weekly or other basis which does not generally vary, based on thenumber of hours worked.DO NOT include Fringe Benefit Costs.(Specify)
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-2 Rev. 10/2005General Information and QuestionnaireType of Facility - Organization StructurePhone No. of Facility Report for Year EndedPageof9/30/2020203-381-1327237Address (No. & Street, City, State, Zip )7003 Main Street, Stratford, CT 06614RHNS(Specify)Medicare Provider No.07-5339Name of Facility (as shown on license)Lord Chamberlain Nursing & Rehabilitation CenterCCNHLicense Numbers:968CType of Facility (Check appropriate box(es)) Chronic and ConvalescentNursing Home only (CCNH) Rest Home with NursingSupervision only (RHNS) (Specify)Type of Ownership (Check appropriate box) Proprietorship LLC Partnership Profit Corp. Non-Profit Corp.Date Opened Government TrustDate ClosedIf this facility opened or closed during report year provide:Has there been any change in ownershipor operation during this report year?AdministratorName of AdministratorJames Bergers Yes NoIf "Yes," explain fully.Nursing HomeAdministrator'sLicense No.:Other Operators/Owners who are assistant administrators (full or part time) of this facility.NameLicense No.:N/A578
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-3 Rev. 10/2005General Information and QuestionnairePartners/MembersName of FacilityLord Chamberlain Nursing & Rehabilitation CenterLicense No.968CLegal Name of Partnership/LLCReport for Year EndedPageof9/30/2020337State(s) and/or Town(s) inBusiness AddressWhich RegisteredN/AName of Partners/MembersN/ABusiness AddressTitle% Owned
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-3A Rev. 10/2005General Information and QuestionnaireCorporate OwnersName of FacilityLicense No.Report for Year EndedPageof968C9/30/20203A37Lord Chamberlain Nursing & Rehabilitation CIf this facility is owned or operated as a corporation, provide the following information:Legal Name of CorporationBusiness AddressState(s) in Which Incorporated7003 Main Street, Stratford, CTLord Chamberlain, Inc.CT06614Name of Directors, OfficersBusiness AddressTitleNo. SharesHeld by EachRobert Sbriglio, MD, MPH, NHA7003 Main Street, Stratford, CT06614Secretary25Martin Sbriglio, RN, NHA7003 Main Street, Stratford, CT06614Treasurer25The Dr. Robert Sbriglio 2009 Trust7003 Main Street, Stratford, CT0661425The Martin Sbriglio 2009 Trust7003 Main Street, Stratford, CT0661425Names of Stockholders Owning at Least 10%of SharesRobert Sbriglio, MD, MPH, NHA7003 Main Street, Stratford, CT06614Secretary25Martin Sbriglio, RN, NHA7003 Main Street, Stratford, CT06614Treasurer25The Dr. Robert Sbriglio 2009 Trust7003 Main Street, Stratford, CT0661425The Martin Sbriglio 2009 Trust7003 Main Street, Stratford, CT0661425
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-3B Rev. 10/2005General Information and QuestionnaireIndividual ProprietorshipName of FacilityLicense No.Report for Year EndedPageLord Chamberlain Nursing & Rehabilitation Center968C9/30/20203BIf this facility is owned or operated as an individual proprietorship, provide the following information:Owner(s) of FacilityN/Aof37
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-4 Rev. 10/2005General Information and QuestionnaireRelated Parties*Name of FacilityLord Chamberlain Nursing & Rehabilitation CenterLicense No.968CReport for Year Ended9/30/2020Are any individuals receiving compensation from the facility related throughmarriage, ability to control, ownership, family or business association? YesAre any individuals or companies which provide goods or services,including the rental of property or the loaning of funds to this facility,related through family association, common ownership, control, or businessassociation to any of the owners, operators, or officials of this facility?Name of RelatedIndividual or CompanySee AttachedBusinessAddressAlso ProvidesGoods/Services toNon-Related PartiesYesNo%** * Use additional sheets if necessary.** Provide the percentage amount of revenue received from non-related parties. NoPage4of37If "Yes," provide the Name/Address andcomplete the information on Page 11 of the report. Yes NoIf "Yes," provide the following information:Description of Goods/ServicesProvidedIndicate WhereCosts are Includedin Annual ReportCostPage # / Line # ReportedActual Cost to theRelated Party
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-5 Rev. 9/2002General Information and QuestionnaireBasis for Allocation of CostsName of FacilityLicense No.Report for Year EndedPageofLord Chamberlain Nursing & Rehabilitation Cen9/30/2020537968CIf the facility is licensed as CDH and/or RCH or provides AIDS or TBI services with special Medicaid rates, costsmust be allocated to CCNH and RHNS as follows:ItemMethod of AllocationDietaryNumber of meals served to residentsLaundryNumber of pounds processedHousekeepingNumber of square feet servicedNumber of hours of routine care provided by EACHNursingemployee classification, i.e., Director (or Charge Nurse),Registered Nurses, Licensed Practical Nurses, Aides andAttendantsDirect Resident Care ConsultantsNumber of hours of resident care provided by EACHspecialist (See listing page 13 )Maintenance and operation of plantSquare feetProperty costs (depreciation)Square feetEmployee health and welfareGross salariesManagement servicesAppropriate cost center involvedAll other General Administrative expensesTotal of Direct and Allocated CostsThe preparer of this report must answer the following questions applicable to the cost information provided.1. In the preparation of this Report, were allIf "No," explain fully why such allocation was not Yes Nomade.costs allocated as required?2. Explain the allocation of related company expenses and attach copy of appropriate supporting data.3. Did the Facility appropriately allocate and self-disallow direct and indirect costs to non-nursing home cost centers?(e.g., Assisted Living, Home Health, Outpatient Services, Adult Day Care Services, etc.) Yes NoIf "No," explain fully why such allocation was notmade.
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-6 Rev. 9/2002General Information and QuestionnaireLeases (Excluding Real Property)Operating Leases - Include all long-term leases for motor vehicles and equipment that have not been capitalized. Short-term leases or as needed rentalsshould not be included in these amounts.Name of FacilityLicense No.Report for Year EndedPageofLord Chamberlain Nursing & Rehabilitation Center968C9/30/2020637Related * toOwners,Operators,AnnualOfficersDate ofTerm ofAmountAmountName and Address of LessorYesNoLease**Leaseof LeaseClaimedDescription of Items LeasedWells FargoBBI TechnologiesLEAF Copier Copier Copier Is a Mileage Log Book Maintained for All Leased Vehicles ? Yes* Refer to Page 4 for definition of related. If "Yes," transaction should be reported on Page 4 also.** Attach copies of newly acquired leases.*** Amount should agree to Page 22, Line 6e. No16,63016,63010,93410,9341,2271,227Total ***28,791
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-7 Rev. 6/95General Information and QuestionnaireAccounting BasisName of FacilityLicense No.Report for Year EndedLord Chamberlain Nursing & Rehab968C9/30/2020The records of this facility for the period covered by this report were maintained on the following basis: Accrual Cashof37 Modified CashIs the accounting basis for thisperiod the same as for the Yesprevious period? NoIndependent Accounting FirmName of Accounting Firm1 Marcum, LLP234Services Provided by This Firm (describe fully )1Page7If "No," explain.Address (No. & Street, City, State, Zip Code)555 Long Wharf Drive, New Haven, CT 06511Preparation of financial statements & tax returns 2 3 4 43,918Charge for Services Provided 43,918Are These Charges Reflected in the Expenditure Portion of This Report? If Yes, Specify Expense Classification and Line No.Page 15, Line 1d Yes NoLegal Services InformationName of Legal Firm or Independent Attorney1 See Attached2345Address (No. & Street, City, State, Zip Code )12345Services Provided by This Firm (describe fully )Telephone Number1 2 3 4 5 Charge for Services Provided Are These Charges Reflected in the Expenditure Portion of This Report? If Yes, Specify Expense Classification and Line No. Yes NoPage 15, Line 1e
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-8 Rev. 9/2002Schedule of Resident StatisticsName of FacilityLord Chamberlain Nursing & Rehabilitation CenterLicense No.968CReport for Year Ended9/30/2020Page8Period 10/1 Thru 6/30Total AllLevels1. Certified Bed CapacityA. On last day of PREVIOUS report tal190190190B. On last day of THIS report period2. Number of ResidentsA. As of midnight of PREVIOUS report period190190178178B. As of midnight of THIS report period3. Total Number of Days Care Provided During HNS(Specify)Period 7/1 Thru ,3233,3231,2041,204G. Total Care Days During Period (3A thru F)Total Number of Days Not Included in Figures in4. 3G for Which Revenue Was Received for ReservedBedsA. Medicaid Bed Reserve DaysB. Other Bed Reserve 72202202129129666663635. Total Resident Days (3G 4A 4B)60,00560,00546,17946,17913,82613,826A. MedicareB.Medicaid (Conn.)C.Medicaid (other states)D. Private PayE.State SSI for RCHF.Other (Specify)178of37178RHNS(Specify)
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-9 Rev. 9/2002Schedule of Resident Statistics (Cont'd)Name of FacilityLicense No.Lord Chamberlain Nursing & Rehabilitation C968CReport for Year Ended9/30/2020 Yes4. Were there any changes in the certified bed capacity during the report year?If "YES", provide the following information:Place of Change(Specify)Date ofCCNH RHNSChange(1)(2)(3)Change in BedsLost(1)(2)Page9of37 NoCapacity After ChangeGained(3)(1)(2)(3)CCNHRHNS(Specify)Reason for Change5. If there was any change in certified bed capacity during the report year (as reported in item 4 above) provide the number ofRESIDENT DAYS for 90 days following the change.Change in Resident Days1st change2nd change3rd change4th change6. Number of Residents and Rates on September 30 of Cost YearMedicareMedicaidItemNo. of ResidentsPer Diem Ratea. One bed rm.b. Two bed rms.c. Three or morebed ayCCNHRHNSOther State 7.00239.567. Total Number of Physical Therapy TreatmentsA. Medicare - Part BB. Medicaid (Exclusive of Part B)1. Maintenance Treatments2. Restorative TreatmentsC. OtherD. Total Physical Therapy Treatments8. Total Number of Speech Therapy TreatmentsA. Medicare - Part BB. Medicaid (Exclusive of Part B)1. Maintenance Treatments2. Restorative TreatmentsC. OtherD. Total Speech Therapy Treatments9. Total Number of Occupational Therapy TreatmentsA. Medicare - Part BB. Medicaid (Exclusive of Part B)1. Maintenance Treatments2. Restorative TreatmentsC. OtherD. Total Occupational Therapy 4,35716,455
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-10 Rev. 9/2002Report of Expenditures - Salaries & WagesName of FacilityLord Chamberlain Nursing & Rehabilitation CenterLicense No.Report for Year Ended968CPageof1037(Specify)Hours9/30/2020 YesAre time records maintained by all individuals receiving compensation? NoTotal Cost and HoursItemA. Salaries and Wages*1. Operators/Owners (Complete also Sec. Iof Schedule A1)2. Administrator(s) (Complete also Sec. IIIof Schedule A1)3. Assistant Administrator (Complete also Sec. IVof Schedule A1)4. Other Administrative Salaries (telephoneoperator, clerks, receptionists, etc.)5. Dietary Servicea. Head Dietitianb. Food Service Supervisorc. Dietary Workers6. Housekeeping Servicea. Head Housekeeperb. Other Housekeeping Workers7. Repairs & Maintenance Servicesa. Engineer or Chief of Maintenanceb. Other Maintenance Workers8. Laundry Servicea. Supervisorb. Other Laundry Workers9. Barber and Beautician Services10. Protective Services11. Accounting Servicesa. Head Accountantb. Other Accountants12. Professional Care of Residentsa. Directors and Assistant Director of Nursesb. RN1. Direct Care2. Administrative**c. LPN1. Direct Care2. Administrative**d. Aides and Attendantse. Physical Therapistsf. Speech Therapistsg. Occupational Therapistsh. Recreation Workersi. Physicians1. Medical Director2. Utilization Review3. Resident Care***4. Other sSocial Workers/Case ManagementMarketingOther (Specify)See Attached ScheduleA-13. Total Salary 52,40211,266,8792,280406,380RHNSHours* Do not include in this section any expenditures paid to persons who receive a fee for services rendered or who are paid on a contract basis.** Administrative - costs and hours associated with the following positions: MDS Coordinator, Inservice Training Coordinator andInfection Control Nurse. Such costs shall be included in the direct care category for the purposes of rate setting.*** This item is not reimbursable to facility. For Title 19 residents, doctors should bill DSS directly. Also, any costs for Title 18 and/or otherprivate pay residents must be removed on Page 28.
Lord Chamberlain Nursing & Rehabilitation Center9/30/2020Attachment Page 10/13Schedule of Other Salaries and Wages (Page 10)PositionRespiratory Therapy CCNH Hours52,4022,280Total 52,402ServiceTherapy Management ConsultantCardiology ConsultantPhillip Simkovitz MDWound CarePDPM ConsultingInfection Control Consulting CCNH 47670Total 102,9632,280RHNS (Specify)Hours- - Hours--Schedule of Other Fees (Page 13)839 RHNS (Specify)Hours- - Hours--
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-11 Rev. 10/2005Schedule A1 - Salary Information for Operators/Owners; Administrators,Assistant Administrators and Other Related Parties*Name of FacilityLicense No.Lord Chamberlain Nursing & Rehabilitation CenterReport for Year Ended968CPageof1137Name and Address of AllOther ders Health Management,88 Ryders Lane, Stratford,CT 066142,970130,000Ryders Health Management,88 Ryders Lane, Stratford,CT 066141,04026,0009/30/2020Salary PaidNameCCNHRHNS(Specify)Fringe Benefitsand/or OtherPayments(describe fully)Full Description ofServices RenderedTotalHoursWorkedLine WhereClaimed onPage 10Section I - Operators/OwnersMartin Sbriglio, RN, NHASection II - Other related partiesof Operators/Owners employedin and paid by facility (EXCEPTthose who may be theAdministrator or AssistantAdministrators who areidentified on Page 12).Mrs. Margaret Sbriglio, NHA* No allowance for salaries will be considered unless full information is provided. Use additional sheets if required.** Include all employment worked during the cost year.
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-12 Rev. 10/2005Schedule A1 - Salary Information for Operators/Owners; Administrators,Assistant Administrators and Other Related Parties*Name of Facility (as licensed)Lord Chamberlain Nursing & Rehabilitation CenterLicense No.968CReport for Year onReceivedSalary PaidNameCCNHRHNS(Specify)Fringe Benefitsand/or OtherPayments(describe fully)Full Description ofServices RenderedLine WhereTotal Hours Claimed on Name and Address of AllWorkedPage 10Other Employment**Section III - Administrators***James Bergers136,141NonDiscriminatoryAdministrative2,168 A2131,713NonDiscriminatoryAdministrative2,080 A3Section IV - AssistantAdministratorsDr. Robert Sbriglio, MD, MPH,NHA*No allowance for salaries will be considered unless full information is provided. Use additional sheets if required.** Include all other employment worked during the cost year.*** If more than one Administrator is reported, include dates of employment for each.
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-13 Rev. 9/2002B. Report of Expenditures - Professional FeesName of FacilityLicense No.968CLord Chamberlain Nursing & Rehabilitation CenterItem*B. Direct care consultants paid on a feefor service basis in lieu of salary(For all such services complete Schedule B1)1. Dietitian2. Dentist3. Pharmacist4. Podiatrist5. Physical Therapya. Resident Careb. Other6. Social Worker7. Recreation Worker8. Physiciansa. Medical Director (entire facility)b. Utilization Review(Title 18 and 19 only) monthly meetingc. Resident Care**d. Administrative Services facilityCCNHReport for Year Ended9/30/2020Total Cost and oursPage13of37(Specify)Hours1. Infection Control Committee(Quarterly meetings)2. Pharmaceutical Committee(Quarterly meetings)3. Staff Development Committee(Once annually)e. Other (Specify)Medical Staff9. Speech Therapista. Resident Careb. Other10. Occupational Therapista. Resident Careb. Other11. Nurses and aides and attendantsa. RN1. Direct Care2. Administrative***b. LPN1. Direct Care2. Administrative***c. Aidesd. Other12. Other (Specify)See Attached ScheduleB-13 Total Fees Paid in Lieu of Salaries* Do not include in this section management consultants or services which must be reported on Page 16 item M-12 and supported by required information, Page 17.** This item is not reimbursable to facility. For Title 19 residents, doctors should bill DSS directly. Also, any costs for Title 18 and/or other private pay residents mustbe removed on Page 28.*** Administrative - costs and hours associated with the following positions: MDS Coordinator, Inservice Training Coordinator and Infection Control Nurse. Suchcosts shall be included in the direct care category for the purposes of rate setting.
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-14 Rev. 6/95Report of ExpendituresSchedule B1 - Information Required for Individual(s) Paid on Fee for Service Basis*Name of FacilityLord Chamberlain Nursing & Rehabilitation CenterName & Address of IndividualLicense No.968CFull Explanation of ServiceDr. Scifo, Trumbull, CTMedical DirectorGeorge Goldfarb, MDMedical DirectorDr. D Das, Fairfield, CTMedical StaffDr. Douglas Duchen, Bridgeport, CTMedical StaffDr. J.B. Bharucha, Trumbull, CTMedical StaffDr. Leonard Karkanista, Milford, CTMedical StaffDr. Charles Kochan, Stratford, CTMedical StaffDr. Anthony Arslan, Stratford, CTMedical StaffDr. Mogelof, Stratford, CTMedical StaffDr. Robert Prewitt, Stratford, CTMedical StaffDr. Carlos Schweitzer, Derby, CTMedical StaffDr. Phillip Simkovitz, Trumbull, CTMedical StaffWould Care ConsultantsDr. Brijesh Chandwani, Fairfield, CTValueRxRanno Goldfard & AssocWound Care ServiesDental ServicesPharmacy ConsultantMedical DirectorJP American Staffing & Health ServicesNurse PoolExecutive CareNurse PoolDedicated Nursing AssocNurse Pool* Use additional sheets if necessary.** Refer to Page 4 for definition of related.Report for Year EndedPageof9/30/20201437Related** to Owners,Operators, OfficersExplanation of RelationshipYesNo Common Ownership
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-15 Rev. 9/2018C. Expenditures Other Than Salaries - Administrative and GeneralName of FacilityLicense No.968CLord Chamberlain Nursing & Rehabilitation CentItem1. Administrative and Generala. Employee Health & Welfare Benefits1. Workmen's Compensation2. Disability Insurance3. Unemployment Insurance4. Social Security (F.I.C.A.)5. Health Insurance6. Life Insurance (employees only)(not-owners and not-operators)7. Pensions (Non-Discriminatory)(not-owners and not-operators)8. Uniform Allowance9. Other (Specify )See Attached Scheduleb. Personal Retirement Plans, Pensions, andProfit Sharing Plans for Owners andOperators (Discriminatory)*c.d.e.f.Report for Year Ended9/30/2020TotalCCNH 524,024524,024956,1411,320,153956,1411,320,153 33,65733,65725,96425,964 of37RHNS(Specify) Bad Debts*Accounting and AuditingLegal (Services should be fully described on Page 7)Insurance on Lives of Owners andOperators (Specify )*g. Office Suppliesh. Telephone and Cellular Phones1. Telephone & Pagers2. Cellular Phonesi. Appraisal (Specify purpose andattach copy )* 242,32543,91823,419242,32543,91823,419 16,54516,545 18,9315,17917618,9315,179176j. Corporation Business Taxes (franchise tax )k. Other Taxes (Not related to property - See Page 22)1. Income*2. Other (Specify )See Attached Schedule3. Resident Day User FeeSubtotal 1,058,0854,268,5191,058,0854,268,519* Facility should self-disallow the expense on Page 28 of the Cost Report.Page15 (Carry Subtotals forward to next page)
*** DO NOT Include Holiday Parties / Awards / Gifts to StaffLord Chamberlain Nursing & Rehabilitation Center9/30/2020Attachment Page 15Schedule of Other Employee BenefitsDescriptionTotalCCNH (Specify)RHNS- - -Schedule of Other TaxesDescriptionTotalCCNH (Specify)RHNS- - -
State of ConnecticutAnnual Report of Long-Term Care FacilityCSP-16 Rev. 9/2002C. Expenditures Other Than Salaries (cont'd) - Administrative and GeneralName of FacilityLord Chamberlain Nursing & Rehabilitation CenterLicense No.968CItemTotalSubtotals Brought Forward:l.Report for Year Ended9/30/20204,268,519CCNH4,268,519Travel and Entertainment1. Resident Travel and Entertainment 2,4922,4922. Holiday Parties for Staff 9,2619,2613. Gifts to Staff and Residents 4. Employee Travel 2,2332,2335. Education Expenses Related to Seminars and Conventions 3,9743,9746. Automobile Expense (not purchase or depreciation ) 6,5556,5557. Other (Specify ) 5,2595,259See Attached Schedulem. Other Administrative and General Expenses1. Advertising Help Wanted (all such expenses ) 6,3896,3892. Advertising Telephone Directory a( ll such expenses )*** 3. Advertising Other (Specify )*** 25,78225,782See Attached Schedule4. Fund-Raising*** 5. Medical Records 27,36027,3606. Barber and Beauty Supplies (if this service is supplied directly and not by contract or fee for service)***7. Postage 5,8375,837* 8. Dues and Membership Fees to Professional 15,49915,499Associations (Specify )See Attached Schedule8a. Dues to Chamber of Commerce & Other Non-Allowable Org.*** 3783789. Subscriptions 10. Contributions*** See Attached Schedule11. Services Provided by Contract (Specify and Complete 167,354167,354Schedule C-2, Page 21 for each firm or individual)12. Administrative Management Services** 676,763676,76313. Other (Specify ) 55,79155,791See Attached ScheduleC-14 Total Administrative & General Expenditures 5,279,445 5,279,445* Do not include Subscriptions, which should go in item 9.** Schedule C-1, Page 17 must be fully completed or this expenditure will not be allowed.*** Facility should self-disallow the expense on Page 28 of the Cost Report.Page16of37RHNS(Specify)
Lord Chamberlain Nursing & Rehabilitation Center9/30/2020Attachment Page 16Schedule of Other Travel and EntertainmentDescriptionMeals & Entertainment CCNH5,259Total Other Travel and Entertainment 5,259DescriptionAdv & Pub Relations CCNH25,782Total Other Advertising 25,782DescriptionICNCCAHCFAmerican ExpressCSMSAHCABridgeport Regional Business Council CCNH37811,6731061,1041,691547Total Dues 15,499(Specify)RHNS - -Schedule of Other Advertising(Specify)RHNS - -Schedule of Dues(Specify)RHNS - -Schedule of ContributionsDescriptionTotal ContributionsCCNH (Specify)RHNS- - -Schedule of Other Administrative and GeneralDescriptionPhysician Care - EmployeesBank Charges
Lord Chamberlain Nursing & Rehabilitation Center 10/1/20199/30/2020 Address of Facility 7003 Main Street, Stratford, CT 06614 Report Prepared By Phone Number Date Ryders Health Management 203-381-1327 Item Total CCNH RHNS 1. Dietary wages paid 2. Laundry wages paid 3. Housekeeping wages paid 4. Nursing wages paid 5. All other wages paid .
