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State of Connecticut
Annual Report^ of^ Long-Term Care^ Facility
Cost Year^2021
Name of Facility (as^ licensed)
Health Center
Address (No.^ &^ Street,^ City, State, Zip Code)
22 Masonic
Walli cr^06492
Type of Facility
Chronic and Convalescent
M Nrrring Home only (CCNH)
Rest Home with^ Nursing
EI Supervision onlY
(RHNS)
M Chronic Disease^ HosPital
Report for^ Year Ending
Report for^ Yeal^ Begirrning
101112020
License Numbers:
CCNH
I l9-C
RHNS
1274-RCH
Chronic Disease HosPital
I l-cD, H
Medicare Provider
07-
Medicaid Provider Numbers^
CCNH
I 198
RHNS
I 587
ICF-IID
For Use
Sequence Number Signed^ and
Notarized
Date
Received
Sequence Nuntber
Assigned
Signed and Notarized^
Date Received
State of Connecticut
Annual Report of Long-Term^ Care^ Facility
CSP-l Rev.9/
General Information
of
Page
I
Report for^ Year
License No.
r l9-c
Name of Facility (as^ licensed)
Masonicare Health Center
Administrator's/Owner's Certifi cation
MISREPRESENTATION OR^ FALSIFICATION^
OF ANY INFORMATION^ CONTAINED^
IN THIS
COST REPORT MAY^ BE PUNISHABLE^
BY FINE AND/OR IMPRISIONMENT^ UNDER^
STATE OR
FEDERAL LAW.
I HEREBY CERTIFY that^ I^ have read the^ above^
statement and that I have^ examilred tlre accompatrying
Cost Report^ and^ supporting^
schedules prepared for^ Masonicare Health Ceuter^ [facility
tranre], for the cost
report period beginning^ October 1, and ending September 30,2021^ , and^ that to the best of my
t no*teage and belief,^ it^ is^ a^ true, eorrect,^
and complete statenlellt prepared^ fronl^ the^ books^
and records of
the provider(s)^ in^ accordance^
with applicable instructions.
I hereby certify that I have directed^ the^ preparation^
o1'the attached General tntbrnratiorr^ and Qucstionnaires,
Schedule of^ Resident^ Statistics,^
Statements of Reportcd Expenditules,^ Statements^
of Revenues and the related
Balance Sheet^ of this^ Facility^ i1 accordance with the Reporting^ Requirements^
of the State o{'Counecticut fbr^ the
year ended as specitied above. (a)
I have^ read^ this^ Report and^
hereby certify that the information^ provided is true and correct to the^ best^ of
my knowledge under^ the penalty
of perjury. I also certifu that^ all^ salary^
and non-salary expenses
presented in this Report^ as^ a basis^
for securing reimbursement for^ Title^ XIX^
and/or other State assisted
residents were incurred to^ provide^ resident care in
this Facility. All^ supporting records
fbr the expenses
recorded have beel retained as^ required by Connecticut
law and will^ be made^ available to auditors
upon
request.
{a}
Subject to Desk Audit Review
Date
Date Signed (Owner) Signed (Administrator)
Printed Name^ (Owner) Printed Name^ (Administrator)
Courtney Wood
Comm. Expires Date Signed^ (Notary Public) Subscribed and Sworn State^ of
before me:
Address of Notary^ Public
(Notary Seal)
State of Connecticut
Annual Report of^ Long-Term^ Care^
Facility
CSP-lA Rev.6/
State of Connecticut
Department of^ Social^ Services
55 Farmington Avenue,^ Hartford, Connecticut 06105
Wages - Compensation computed on
an hourly wage rate'
Salaries -^ Compensation computed on
a weekly or other^ basis^
which does not generally^ vary,^
based on the
number of hours worked.
DO NOT include Fringe Benefit
Costs.
of
JI
Page
1A
Data Required for^ Real Wage^ Adjustment
From
To
Period Covered:
Masonicare Health Center
ame of Facility
Address of^ Facility
22 Masonic Avenu^
Wall cr^06492
Date
Phone Number
Report Prepared By
Marcum LLP
Chronic
Disease
Total CCNH^ RHNS
Item
$ id
aid
J
4. Nursi
$
5. Allother
6 Totul^ Paicl
7. Total^ salaries^
and Salaries Puid^
l0 of $
8. Total^
As
State of^ Connecticut
Annual Report^ of^ Long-Term^ Care^
Facility
CSP-2 Rev. 10/
General Information^ and Questionnaire
Type of Facility - Organization Structure
of
Page
Report for Year Ended
Phone No, of Facility
203-678-
Address (No.^ &^ Street,^ City,^
State, Zip
22 Masonic Aven^ w^ cr 06492
of Facility (as^ shown on^ Iicense)
Masonicare Health Center^
Medicare Provider No.
I I.CD H0008 07-
RHNS^ Disease Hospita
1274-RCH
CCNH
I tg-C License Nutnbers:
Chronic and^ Convalescent
Nursing Home^ only (CCNH)
EI Chronic Disease HosPital V
Type of Facility (Check appropriate box(es))
g
Rest Horne with Nursing
Supervision only (RHNS)
O Proprietorship O LI-C^ O^ Partnership O Profit^ Corp.^ O^ Non-l'rofit Corp. O Government^ O^
Trust
Type of^ Ownership (Check appropriate box)
Date Opened^ Date Closed
Ifthis facility opetred^ or^ closed^ during report year^ provide
Has there been any change^ in^ ownership
If
O Yes ONo ''Y
t'gx
lain fu or duri^ this
A
Administrator
Nursing
Administrator's
License No.:
Name of Administrator
Courtney Wood
Other
tune of this facil who are assistant^ admini^
strators full or
Name
N/A
License No.
State of Connecticut
Annual Report of Long-Term Care Facility
CSP-3A Rev. l0/
General Information and^ Questionnaire
Corporate Owners
Name of Facility
Masonicare Health Center
License No.
ll9-c
Report for^ Year^ Ended
9t301202t
Page
3A
of
37
lf this facili^ is^ owned or^
asa vide^ the^
information
Name of^ oration^
Business Address
in Which
Masonicare Health Center
22 Masonic Avenue, Wallingford, CT
CT
Name of Directors, Officers^
Business Address Title^
No. Shares
Held by^ Each
Please see attached
Names of Stockholders Owning^
at Least 10%
of Shares
IA
lJpdated 419l2A2l
Masonicare Board of Trustees
Residential Services Board^ of Directors
Home and Community-Based Services^ Board^ of Directors
Healthcare Services Board of Directors
2020-
Board Member Telephone Numbers^
Snouse/Sisnifi cant Other &Bmail Term Exoires
Robert F Jr Chair
J. Earle, Vice Chair
Newton Buckner, Treasurer
Janet S.
By virtue of position in
Order of Eastern Star
Bruce R. Belhnore
By virtue of position in
the Grand l-odge
Patrick M.
William E. Bohman
By virtue of position in
the Grand Lodge
Francis X. Conlon
Robert J. Furce
David A. Cessert
Susan
By virtue of position
Order of Amaranth
Bonnie S. McWain
Howard W. Or
h J. Porco
By virtue of position in
Grand Lodge
Thaddeus M. Stewart
By virtue of position
Prince Hall
Jon-Paul Venoit, President and CEO
Assistant Secretary
Masouicare
PO Box 70
Wallineford, CT 06492
Arr officer of the Board,
but not a Trustee.
Steven Beaulieu, CFO & Assistant
Treasurer
Masonicare
PO Box 70
Wallineford. CT 06492
An officer ofthe Board,
but not a Trustee.
The Masonic Charity Foundation^ of^ Connecticut
Board of Directors
2020-202r
Board Member Telephone Numbers Spouse/Sig.!rifi cant Other^ &Email
Address
Term Expires
Charles W. Yo^ Chair^
James J. Vice Chair
David O Treasurer
Gordon C. S
T. Carrott
er J. Earle
Laura S. Michnowski
Theodore J. Nelson
Edward
By virtue of position^ in
Grand Lodge
J. Wentworth
Jennifer A. King, Executive Director
Assistant
Senior Adrninistrator, but
not a Director
Jon-Paul Venoit, President and CEO^ &
Masonicare
PO Box (^70)
Wallinsford, CT 06492
An officer ofthe Board,^ but
not a Director.
Steven Beaulieu, CFO &^ Assistant
Treasurer
Masonicare
PO Box^70
Wallineford. CT 06492
An officer ofthe Board, but
not a Director.
The Masonic Charity Foundation^ of^ Connecticut
Emeritus Members^ of^ the Board^ of^ Directors
Emeritus Member Telenhone Numbers Snouse/Sisnificant^ Other^ and Email
Carleton V.^ Erickson
Gail N. Smith
State of Connecticttt
Annual Report^ of^ Long-Term^ Care Facility
CSP-38 Rev.^1012005
General Information^
and Questionnaire
Individual ProPrietorshiP
of
JI
Page
3B
Reporl for^ Year^ Ended
913012021
License No.
1 19-C
Nanre of Facility
Masonicare Health Center
information:
is owned or as^ an^ individual
If this
the
Owner(s) of^ Facility
IA
State
of
Connecticut
Annual
Report of Long-Term Care
Facilify
CSP-
Rev. l0/
General
Information
and
Questionnaire
Related
Parties*
l
2,722.r
Actual
Cost to the
Related Party
Cost
Reoorted
of 37
Page
4
Pase
I Line l4c
Pe.
Ml
Indicate
Where
Costs are
Included
in
Annual
Report
Paee
I
Line#
Malpractice
lnsurance
Please see
attached
Please see
attached
Please see
attached
Description of
Goods/Services
Provided
Please see
attached
Report for Year
Ended
9t30/202r
Yo**
o o o o o o o^ o o
No
o o o^ o o o o^ o Yes
o
Also
Provides
Goods/Services
to
Non-Related
Parties
No.
Plains Road,
Wallingford,
cT
Cheshire Road,
Wallingford,
CT
No.
Plains Road,
Wallingford,
cT
St-
Paul Street, Suite 500.
Burlington.
VT
PO
Box
Wallingford, CT
BusinessAddress
Masonicare
at
Ashlar Village
Masonicare
Home.
Health
&
Hospice
(MHHH)
LTD
Masonicare Masonicare^ Keystone
Chariry
Foundation
Name
of
Related
Individual
or Company
Are
any
individuals receiving
compensation
from
the
facility
related
through
ONo
O
Yes
I
ofthe
report.
the
information
on
If
"Yes," provide
the
Name/Address
and
or business association?
ability
to control,
ownership,
Are
any
individuals or
companies
which provide
goods
or
services,
including
the
rental
of
property or the
loaning of
funds to
this
facility,
the
following
information
If
"Y
OYes
ONo
through
family
association,
corlmon
ownership,
control,
or business
or
ofiicials
of this
facility?
association
to
any
ofthe
owners,
No.^ l
r9-c
Name
of
Facility
Health
Center
Use
additional
sheets
if
necessary.
**
Provide the
percentage
amount
ofrevenue
received
from
non-related parties.
To
/ From MHC
001
oo
MCF
MHHH
(55,135)
(95,608)
(6,02e)
illasonicare
Health
Center
Related Party
Elimination Transactions
-tt-1TA
FYE
9t30t
110
/OO
't MCV
47
J36,MO
47
,1 ,
KEYSfONE
CHCP
47j36j
47j36,
Tdrl
Cost Report
Amdnt
-'t.o70h
Ls
Non
Reimb.
G/L
Account
Total MHC lntercompany
Revenue
Cosls TOTAL MHC REVENUE^ Per€ntage
of affiliate
€venue
to total MHC
€venue
Non-Related
Revenue
MHC
AON
47j
AV
MC
MAH
47j36,
{AC22507340CE48DC488G57210185383A}
xls
MHC
State of Connecticut
Annual Report of Long-Term^
Care Facility
CSP-5 Rev.9/
General Information^ and Questionnaire
Basis for Allocation of^ Costs
Page
of
37
Report for Year^ Ended
License No.
l l9-c
Masonicare Health^ Center
of Facility
TBI services^ with^
special Medicaid rates,^ costs
If the facility^ is licensed^ as^ CDH^
and/or RCH or provides^ AIDS^ or
must be allocated to^ CCNH^
and RHNS as follows
Method of Allocation
Item
um ber of meals served^ to^ residents
umber of
Number of^ uare^ feet serviced Ho
Number of^ hours^ of^
routine care provided by^ EA
ernployee classification,^
i'e., Director (or^ Charge^ Nurse),
Registered Nurses, Licensed Practical Nurses, Aides^ and
ttendants
CH
Nursing
of hours of resident care^
provided by EACH
ist list 13
Direct Resident Care^ Consultants
feet Maintenance and^ of
uare feet costs
Gross salaries health and welfare
A^ cost^ center^ involved
servlces
otalof Direct^ and^
Allocated Costs
Allother General Adrninistrative
icable to the cost information
of this must answer^ the
uestions The
1. In the preparation of^ this Report, were^
OYes ONo^
If "No," explain fullY^ whY such allocation was not
all
rnade.
costs allocated as
Supervision only^
(RHNS) refers to the Residential^ care^
Home (RCH)
purposes, Rest Home with Nursing
that for cost rePofting
Please see^ attached^ allocation schedule.
Also,^ please note
the allocation of related^
and attach
data.
of 2
Please see page 4.
homecostcenters?
direct andindirect costs^ tonon-nurslng
allocateand^ SCf-disal^ low
3 Di dtheFacllity^ appropriately
CareS etc.
S Adu^ It
Day ervlces,^ ) Ho lneH^ ervlces, e Ass isted
o Llvlng, ealth, Outpatient
'at't
allocation wasnot f EX fu^ llvwhysuch
"No,
plain
o Y CS o No
made.
TOTAI
(123.s05)
t6.865) (16.215l(90,333) (s78.378)
IA
L
\
TOTAL
ALLOCATED
AMOUNTS
Other
-^
Not
lmpo4cd
(s.s69)
( (5.340)(6.s
(578.
1697\
CDH
(24,377],
16.O
(
RCH
it ll
L
ALLoCATION
I I
Nursing
BASIS
Home
li
Payroll
I
I
(86,ss7)
Other
I
Other
li
Pavroll
I i
OtherOther
ll
SQFi
I
e,462\
Meals
PT
Treat
il
Nursing
home
I
I
NursinE
home
I
I
CDH
ti
RCH
Salarv - nursins
no
RCH
|
|
Other
l ll
Salaru-
nursing
I
i
Volunteer
]lll
patientdays
i i
Nursins
home
I
(ao,aZs)
Pavroll
il
Spiritual
1l
Davs
w
lL
Other
I
SQFT
l
Nursins
home
I
I tl I
I
(31.823,6s
AIIOCATION
SCHEDUTE
INPUT
Total AMOUNT
Meals -
SNF
Onlv
(123,s0s)
Meals - salaries
and Waees
Meals - Non Reimbursable
(2,364,405ll
Room Rental Non ReimbursableTelephone
-^
Number of Computers
{6,86s)
lnterest income
Other
Cther
Meals Per Dav
Other -
PTTreatments
Other -
SNF
Onlv
Other -
ICF
Other -
CDH
Other
CCH, RHNS,
AHU, GMP
other
Non Reimbursable
1578,378\
Other
-^
Transportation
Services
Other
other
Volunteer
Time Spent
other
Other
Eouivalent
Patient
Davs
Other -
Patient
Davs-
SNF
ICF
Only
Other - Non Salary Expenses Other
Services
Other
Davs
w/
lndependent
Living
Other
Revenue - Non Reimb
Other
Revenue
other
Revenue -
SNF
Onlv
fotal
Revenue
(5r,o74,
MASONICARE
OF
WALLINGFORD
ACCOUNT NAME^ Other
-^
RCH-
ACCOUNTNUMBER
30
|^
rv1.
30
I^ rv1.1s
301rv1.223011v2.22 301
tv3.
301rvs.22 30I
tv8.o2tv8.
301rv8.07 30
|^ rv8.
301
rv8. lrv8.
301tv8.13 30
I^ tv8.
30
|^ rv8.
301rv8,
rv8.
301
rv8.
30
|^ rv8.
30lrv8_38 30
|^
tv8.
301tv8.41 301rv8.42 301tv8.43^301
301
30
I^
18.L
Page 2
of
TOTAL
I
695,163 191,400^ 218.
2,046,35t^ 1,337,
826,247^ 645,680^ 262,642269,
_-
l,qgg1os^ 2,746,O91-
69.2764a,
s,444,578L.r76.
TOTAL
ALLOCATED
AMOUNTS
Other
-^
Not
lmpgllell
57.429^ 74,
149,455302,163272,O
39.424 86,494^ 13.
CDH
AA
41\
39.748^ 52,955 12.535 52,
6_s
Lr16,
RCH
a, 42,644 16,694 69. 365,
NursinP
Home
177 469.2tt 129,188 199,
I I
I
i
s44-889 120.869^ 787.L
)1 \M
I
1.811.1s
|
1
s.444.s
I
s3.
ALTOCATION
BASIS Days
w
lL
Administrator Patient
Days
Patient
Davs
Patient
Davs -
Less HFA
Patient
Days
Accum Costs
Mea
ls
Housekeeping
SQFTCDH
Nursins
Home
Laundry
Other SQFT
Pavroll-
less
admin
Salary - nursing
no
RCH
Nursine
Home
CDH
Salary -
nursins
Salary
nursing
no
RCH
Nursinq Home
CDH RCH
Salarv - nursins
no
RCH
Nursins
Home
Salary - nursing
CDH^ RCH
Salarv - nursing
no
RCH
PT
Treat CDH ST
Treat
ALLOCATION
SCHEDULE
INPUT^ Total
ACCOUNT NAME
AMOUNT
Owner - Equivalent
Days
w/
lndependent
Living
administrator
Salarv -
Eouivalent
Davs
w/
lndependent
Livins
other
Admin
5alaru
%
Other Admin
reimb
Other Admin
Volunteer
Other Administrative
Salaries -
Number of Communlcation Driver
other Administrative
Salaries -
Admissions
2ra,
other Admin
Patient
davs
Other
Admin
Patient
daYs
Head
Dietitian
Food seruice SuperuisorDietary
reimb
Dietarv Workers
Meals
2,c/,63sr
Head
Housekeeper
other
Housekeeoine
Workers
Soft
Other
Housekeeoins
Workers
hours
1,337,68s
Eneineer
or
Chief
of Maintenance
other Maintenance Workers
Campus
Other Maintenance Workers
CDH
Only
Other
Maintenance Workers
SNF
OnlY
Laundrv Superuisor other
Laundrv
Workers
Barber and Beautician
Seruices
Barber
and
Beautician
Services Non-Reimbursable
Prdtective
Seruices
Protective Services Securiw
Coverase
Head
Accountant
Other
Accountants
of
Director
RNs
Direct
Care - Nursine Salarv-
CCH, RHNS,
AHU, GMP
RNs
SNF
Only
RNs
-^
Direct
Care -
CDH
Only
RNs
-^
Administrative
5alary
RNs
-^
Administrative
GMP
LPNS
SNF
Onlv
2,746,O
LPNS
Direct
Care
Only
LPN
RCH
Only
LPNs
- Direct Care - Nursing Salary-CCH,RHNS,AHU,GMP
Aides and
Attendants
SNF
Onlv
Aides and
Attendants
Aides and
Aftendants
CDH
!,r76,
Aides and
Attendants
RCH
Onlv
Aides and
Attendants
- Nursing Salary-CCH,RHNS,AHU,GMP
Physical TherapistsPhvsical Theraoists
PT
Treatments
Phvsical Theraoists
Speech
Therapists
ST
-^
ST
Treatments
occuoational Theraoists
MASONICARE
OF
WATLINGFORD
ACCOUNT NUMBER
L0-
I^
10-A
I^
1o-A
|^
70-A14.2210-A14.
10-A
|^
10-A
10-A14.
5A
10-A
I^
sB
-19i41!c
10-Al5C.
6A
r.0-A
I^
10-Al68. 1O.A
I^
10-A
I
7B.
10-A178.12 10-A
I^
7B.
10-A
I^
8A
10-Al88.s
10-Al
10-Al 10 10-a170. 10-A
I^
11A
10-Al 118 10-Al 12A. 10-A
I^
10-Al 1281.10^ 10-A
I^
ro-A||1282.26 10-Al 1282.r.4 1o-A
I^
12C1.
10-al 12c1.12 10-AI 12C1.13 10-A
I^
12C1.
10-Al 12D.101GA112D.
rzD.
10-Al 12D.
IzE
LO-Alt2E.
72E.t
1G.Al12F 1C.A112F. 10-Al
12G
10-A
10-A 10-A
10-A
10-A
Page
of
