F
O
R BHF
US
E
IMPORTANT NOTIC
E
LL1
THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION
THAT IS NECESSARY TO ACCOMPLISH THE STATUTOR
Y
2022
PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE
STATE OF ILLINOIS
OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE
DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
ANY INFORMATION ON OR BEFORE THE DUE DATE WILL
FINANCIAL AND STATISTICAL REPORT
(
COST REPORT
)
RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM
FOR LONG-TERM CARE FACILITIES
HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.
(
FISCAL YEAR 2022
)
I. IDPH License ID Number: 0057133 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER
Facility Name: Accolade Healthcare Peoria
I have examined the contents of the accom
p
an
y
in
g
re
p
ort to the
Add
ress:
5600
N
Gl
en
El
m
D
r
P
eor
i
a
61614
State of Illinois, for the
p
eriod from
02/01/2022
t
o
12/31/2022
Numbe
r
Cit
y
Zi
p
Code
and certif
y
to the best of m
y
knowled
g
e and belief that the said contents
are true, accurate and com
p
lete statements in accordance with
C
ounty:
P
eor
i
a
a
pp
licable instructions. Declaration of
p
re
p
arer
(
other than
p
rovider
)
is based on all information of which
p
re
p
arer has an
y
knowled
g
e.
T
e
l
ep
h
one
N
um
b
er:
309
-
693
-
8777
F
ax
#
(
)
Intentional misre
p
resentation or falsification of an
y
information
HFS
ID
N
um
b
er:
in this cost re
p
ort ma
y
be
p
unishable b
y
fine and/or im
p
risonment.
Date of Initial License for Current Owners: 02/01/2022 (Signed)
Officer or (Date)
Type of Ownership: Administrato
r
(Type or Print Name) Shmuel Freedman
of Provider
VOLUNTARY,NON-PROFIT x PROPRIETARY GOVERNMENTAL (Title) Chief Financial Officer
Charitable Corp. Individual State
Trust x Partnership County (Signed)
IRS Exemption Code Corporation Other (Date)
"Sub-S" Corp. Paid
(Print Name
Deandra Fallon
Limited Liability Co. Preparer
and Title)
Senior Manager
Trust
Other
(
Firm Nam
e
Baker Tilly US, LLP
& Address)
46 Public Square, Suite 400, Wilkes-Barre, PA 18701
(
Tele
p
hone
)
(570)
820
0301
F
ax
#
(
)
MAIL TO: BUREAU OF HEALTH FINANCE
In the event there are further questions about this report, please contact:
ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICES
Name
:
Shmuel Freedman Tele
p
hone Number:
(
973
)
557-3339 201 S. Grand Avenue East
Email Address: S
p
rin
g
field
,
IL 62763-0001 Phone #
(
217
)
782-1630
SEE
ACCOUNTANTS'
PREPARATION
REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 2
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
III. STATISTICAL DATA D. How many bed reserve days during this year were paid by the Department?
A. Licensure/certification level(s) of care; enter number of beds/bed days, 0 (Do not include bed reserve days in Section B.)
(must agree with license). Date of change in licensed beds N/A
E. List all services provided by your facility for non-patients.
1 2 3 4 (E.g., day care, "meals on wheels", outpatient therapy)
Licensed None
Beds at Beds at Bed Days
Beginning of Licensure End of During F. Does the facility maintain a daily midnight census? Yes
Report Period Level of Care Report Report
Period Period G. Do pages 3 & 4 include expenses for services or
1 144 Skilled (SNF) 144 48,096 1 investments not directly related to patient care?
2 Skilled Pediatric (SNF/PED) 2 YES NO x
3 Intermediate (ICF) 3
4 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?
5 Sheltered Care (SC) 5 YES NO x
6 ICF/DD 16 or Less 6
I. On what date did
y
ou start providin
g
lon
g
term care at this location?
7 144 TOTALS 144 48,096 7 Date started
02/01/2022
B. Census-For the entire report period. J. Was the facility purchased or leased after January 1, 1978?
1 2345678 9 YESx Date 02/01/2022 NO
Patient Days by Level of Care and Primary Source of Payment
Level of Care Medicaid Medicaid MMAI Medicare K. Was the facility certified for Medicare during the reporting year?
Fee for MLTSS Medicaid Medicare Private Part A YES x NO If YES, enter certified beds.
Service Primary Primary Pay Only Other Total number of certified beds 144
8 SNF 6,838 15,098 4,690 2,757 2,673 4,734 36,790 8
9 SNF/PED 9 Medicare Intermediary Novitas Solutions
10 ICF 10
11 ICF/DD 11 IV. ACCOUNTING BASIS
12 SC 12 MODIFIED
13 DD 16 OR LESS 13 ACCRUAL x CASH* CASH*
14 TOTALS 6,838 15,098 4,690 2,757 2,673 4,734 36,790 14 Is
y
our fiscal
y
ear identical to
y
our tax
y
ear? YES x NO
C. Percent Occupanc
y
. (Column 9, line 14 divided b
y
total licensed Tax Year: 12/31/21 Fiscal Year: 12/31/21
bed da
y
s on column 4, line 7.) 76.49% * All facilities other than
g
overnmental must report on the accrual basis.
S
EE
ACCO
UNT
A
NT
S'
PREP
A
R
A
TI
O
N REP
O
RT
HFS 3745 (N-4-99) IL478-2471
STATE
OF
ILLINOIS
P
age
3
F
ac
ili
ty
N
ame
&
ID
N
um
b
e
r
A
cco
l
a
d
e
H
ea
l
t
h
care
P
eor
ia
#
0057133
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
02/01/2022
E
n
di
ng:
12/31/2022
V. COST CENTER EXPENSES
(
throu
g
hout the re
p
ort
,
p
lease round to the nearest dollar
)
Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY
Operating Expenses Salary/Wage Supplies Other Total ification Total ments Total
A. General Services 12345678910
1 Dietar
y
414,552 30,387 40,132 485,071 (256) 484,815 484,815 1
2 Food Purchase 313,298 313,298 - 313,298 (1,843) 311,455 2
3 Housekeeping 211,752 32,667 244,419 69,719 314,138 1,285 315,423 3
4 Laundr
y
97,011 20,351 117,362 (69,909) 47,453 47,453 4
5 Heat and Other Utilities 175,272 175,272 - 175,272 175,272 5
6 Maintenance 135,480 22,764 55,942 214,186 (83) 214,103 214,103 6
7 Other (specify):
*
See Detail 71,674 71,674 - 71,674 71,674 7
8 TOTAL General Services 858,795 419,467 343,020 1,621,282 (529) 1,620,753 (558) 1,620,195 8
B. Health Care and Programs
9 Medical Directo
r
42,000 42,000 - 42,000 42,000 9
10 Nursing and Medical Records 3,727,299 264,880 154,237 4,146,416 959 4,147,375 2,045 4,149,420 10
10a Therap
y
35,875 35,875 - 35,875 35,875 10a
11 Activitie
s
113,666 9,461 4,085 127,212 (70) 127,142 127,142 11
12 Social Services 58,170 1,650 59,820 (36) 59,784 59,784 12
13 CNA Training - 13
14 Program Transportatio
n
31,969 4,019 35,988 (104) 35,884 35,884 14
15 Other (specify):
*
- 15
16 TOTAL Health Care and Programs 3,931,104 274,341 241,866 4,447,311 749 4,448,060 2,045 4,450,105 16
C. General Administratio
n
17 Administrativ
e
104,203 21,734 125,937 (64) 125,873 125,873 17
18 Directors Fee
s
- 18
19 Professional Service
s
793,187 793,187 - 793,187 57,954 851,141 19
20 Dues, Fees, Subscriptions & Promotion
s
60,012 60,012 - 60,012 (28,943) 31,069 20
21 Clerical & General Office Expense
s
387,129 27,014 170,121 584,264 (4,050) 580,214 (94,335) 485,879 21
22 Employee Benefits & Payroll Taxe
s
676,805 676,805 676,805 (11,787) 665,018 22
23 Inservice Training & Educatio
n
6,736 6,736 6,736 6,736 23
24 Travel and Semina
r
(1,275) (1,275) 24
25 Other Admin. Staff Transportatio
n
1,275 1,275 1,275 1,275 25
26 Insurance-Prop.Liab.Malpractic
e
176,804 176,804 176,804 176,804 26
27 Other (specify):
*
27
28 TOTAL General Administration 491,332 27,014 1,906,674 2,425,020 (4,114) 2,420,906 (78,386) 2,342,520 28
TOTAL O
p
eratin
g
Ex
p
ense
29
(
sum of lines 8
,
16 & 28
)
5
,
281
,
231
720
,
822
2
,
491
,
560
8
,
493
,
613
(3
,
894)
8
,
489
,
719
(76
,
899)
8
,
412
,
820
29
*Attach a schedule if more than one t
yp
e of cost is included on this line
,
or if the total exceeds $1000
.
SEE ACCOUNTANTS' PREPARATION REPOR
T
NOTE: Include a se
p
arate schedule detailin
g
the reclassifications made in column 5. Be sure to include a detailed ex
p
lanation of each reclassification
.
HFS 3745 (N-4-99) IL478-2471
Accolade Healthcare Peoria
12/31/2022
Cost Center Detail Support
8770-032-000 - Employee Benefits-Training & Educ (Balance forward As of 01/01/2022) -
PEO B/F -
2/14/2022 2/14/2022 3372 LNHA TESTING FOR EMPLOYEE 801 84735 OBJ 214 214
3/22/2022 3/22/2022 3451 TRAINING MATERIALS FOR TANNA NORRIS, LPN 801 85263 OBJ 60 274
3/31/2022 3/31/2022 3664 Relias - Education 801 85364 OBJ 1,651 1,925
5/1/2022 5/1/2022 4677 QUAIMISHA HUGHES 801 85780 OBJ 1,049 2,974
5/10/2022 5/10/2022 4274 SiUC Nurse Aide Training 801 85896 OBJ 75 3,049
6/3/2022 6/3/2022 5080 INVOICE DATE - 06.03.2022 801 86259 OBJ 800 3,849
7/7/2022 7/7/2022 5544 ANTIBIOTIC STEWARDSHIP 801 86744 OBJ 12 3,861
9/9/2022 9/9/2022 5518 Sous,Andrea Marie Tuision 801 87734 OBJ 825 4,686
11/30/2022 11/30/2022 7291 Relias 801 88955 OBJ 1,651 6,337
12/14/2022 12/14/2022 Charge Card Transaction - SIMMONS (6542): Virtual Reality Headset 801 138 CCJ 381 6,719
12/16/2022 12/16/2022 Charge Card Transaction - SIMMONS (6542): Christmas Lamp 801 129 CCJ 17 6,736
Totals for PEO 6,736 - 6,736
Totals for 8770-032-000 - Employee Benefits-Training & Educ 6,736 - 6,736
Total for L23 C3 6,736
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOI
S
Pa
g
e 4
Facilit
y
Name & ID Number Accolade Healthcare Peoria #0057133 Re
p
ort Period Be
g
innin
g
: 02/01/2022 Endin
g
: 12/31/2022
#
V. COST CENTER EXPENSES (continued
)
Cost Per General Led
g
er Reclass- Reclassified Ad
j
ust- Ad
j
usted FOR BHF USE ONL
Y
Ca
p
ital Ex
p
ense Salar
y
/Wa
g
eSu
pp
lies Other Total ification Total ments Total
D. Ownershi
p
12345678910
30 Depreciation 37,910 37,910 37,910 (785) 37,125 30
31
Amortization of Pre-Op. & Org. 31
32
Interest 61,933 61,933 61,933 (766) 61,167 32
33
Real Estate Taxes 108,776 108,776 108,776 108,776 33
34
Rent-Facility & Grounds 674,223 674,223 674,223 674,223 34
35
Rent-Equipment & Vehicles 7,349 7,349 3,894 11,243 11,243 35
36
Other (specify):* 36
37
TOTAL Ownership 890,191 890,191 3,894 894,085 (1,551) 892,534 37
Ancillary Expense
E. Special Cost Centers
38 Medically Necessary Transportation 37,840 37,840 37,840 37,840 38
39
Ancillary Service Centers 192,141 739,598 931,739 931,739 931,739 39
40
Barber and Beauty Shops 40
41
Coffee and Gift Shops 41
42
Provider Participation Fee 410,794 410,794 410,794 410,794 42
43
Other (specify):* See Detail 200,849 200,849 200,849 (199,111) 1,738 43
44
TOTAL Special Cost Centers 192,141 1,389,081 1,581,222 1,581,222 (199,111) 1,382,111 44
GRAND TOTAL COST
45 (sum of lines 29, 37 & 44) 5,281,231 912,963 4,770,832 10,965,026 10,965,026 (277,561) 10,687,465 45
*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.
SEE ACCOUNTANTS' PREPARATION REPORT
HFS 3745 (N-4-99) IL478-2471
Accolade Healthcare Peoria
12/31/2022
Cost Center Detail Support
Line 7
Salary/Wage Supplies Other Total
1234
Maintenance Exp-Contracted Service-Fire Safety 15,493 15,493 8250-024-150
Maintenance-Sanitation & Incineration 24,300 24,300 8250-040-000
Maintenance-Extermination 2,250 2,250 8250-041-000
Maintenance-Landscaping 29,631 29,631 8250-043-000
- -
- -
Total - - 71,674 71,674
Check 71,674
TRUE
Salary/Wage Supplies Other Total
1234
LABORATORY - - 2,787 2,787 6859-000-135 6859-201-135 551825 551850
Radiology - - 11,240 11,240 6859-000-136 6859-201-136 551950
Misc Expense - - 31 31 8010-000-015
Marketing - - 9,910 9,910 8010-068-000 818400
Meels on Wheels - - - - 604001
Credit Card Fee - - 6,685 6,685 8010-077-000
Tolls - - - - 920001
Bad Debt - - 152,549 152,549 8010-000-097
Penalties - - 30,428 30,428 8010-060-000 8010-060-015
Start Up Expenses - - (19,005) (19,005) 8010-779-000
Contributions - - 5,457 5,457 8010-054-000
Theft and Loss - - 767 767 8010-071-000
- - 200,849 200,849
Check 200,849
TRUE
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOI
S
Pa
g
e 5
Facilit
y
Name & ID Number Accolade Healthcare Peoria # 0057133 Re
p
ort Period Be
g
innin
g
: 02/01/2022 Endin
g
: 12/31/2022
VI. ADJUSTMENT DETAIL A. The ex
p
enses indicated below are non-allowable and should be ad
j
usted out of Schedule V,
p
a
g
es 3 or 4 via column 7.
In column 2 below, reference the line on which the
p
articular cost was included. (See instructions.)
1
2
3
R
e
f
er-
BHF
USE
B
.
If
t
h
ere are ex
p
enses ex
p
er
i
ence
d
by
t
h
e
f
ac
ili
t
y
w
hi
c
h
d
o not a
pp
ear
i
n t
h
e
NON
-
ALLOWABLE
EXPENSES
A
mount ence
ONLY
g
enera
l
l
e
dg
er, t
h
e
y
s
h
ou
ld
b
e entere
d
b
e
l
ow.
(S
ee
i
nstruct
i
ons.
)
1 Day Care $$1 12
2 Other Care for Outpatients 2 Amount Reference
3 Governmental Sponsored Special Programs 331 Non-Paid Workers-Attach Schedule* $31
4 Non-Patient Meals 432 Donated Goods-Attach Schedule* 32
5 Telephone, TV & Radio in Resident Rooms 5 Amortization of Organization &
6 Rented Facility Space 633 Pre-Operating Expense 33
7 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization
8 Laundry for Non-Patients 834 Costs (Schedule VII) 34
9 Non-Straightline Depreciation 935 Other- Attach Schedule 35
10 Interest and Other Investment Income (766) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ 36
11 Discounts, Allowances, Rebates & Refunds - 11 (sum of SUBTOTALS
12 Non-Working Officer's or Owner's Salar
y
- 12 37 TOTAL ADJUSTMENTS (A) and (B)
)
$ (201,580) 37
13 Sales Tax - 13
14 Non-Care Related Interest - 14 *These costs are onl
y
allowable if the
y
are necessar
y
to meet minimum
15 Non-Care Related Owner's Transactions - 15 licensin
g
standards. Attach a schedule detailin
g
the items included
16 Personal Expenses (Including Transportation) (1,275) 24 16 on these lines.
17 Non-Care Related Fees - 17
18 Fines and Penalties (30,428) 43 18 C. Are the followin
g
ex
p
enses included in Sections A to D of
p
a
g
es 3
19 Entertainment - 19 and 4? If so, the
y
should be reclassified into Section E. Please
20 Contributions (5,457) 43 20 reference the line on which the
y
a
pp
ear before reclassification.
21 Owner or Key-Man Insurance - 21 (See instructions.) 1 2 3 4
22 Special Legal Fees & Legal Retainers (1,195) 19 22 Yes No Amount Reference
23 Malpractice Insurance for Individuals - 23 38 Medically Necessary Transport. x$ 38
24 Bad Debt (152,549) 43 24 39 39
25 Fund Raising, Advertising and Promotional (9,910) 43 25 40 Gift and Coffee Shops x40
I
ncome
T
axes an
d
Illi
no
i
s
P
ersona
l
41
B
ar
b
er an
d
B
eauty
Sh
ops x
41
26
P
roperty
R
ep
l
acement
T
ax
26
42
L
a
b
oratory an
d
R
a
di
o
l
og
y
x
42
27
CNA
T
ra
i
n
i
ng
f
or
N
on-
E
mp
l
oyee
s
27
43
P
rescr
i
pt
i
on
D
rugs x
43
28
Y
e
ll
ow
P
age
Ad
vert
i
s
i
ng
28
44
44
29
O
t
h
er-
A
ttac
h
S
c
h
e
d
u
l
e
29
45
O
t
h
er-
A
ttac
h
S
c
h
e
d
u
l
e
45
30 SUBTOTAL (A): (Sum of lines 1-29) $ (201,580) $ 30 46 Other-Attach Schedule 46
47 TOTAL (C): (sum of lines 38-46) $ 47
BHF USE ONL
Y
48
49
50
51
52
SEE
ACCOUNTANTS'
PREPARATION
REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 5A
Accolade Healthcare Peoria
ID# 0057133
Report Period Beginning: 02/01/2022
Ending: 12/31/2022
Sch. V Line
NON-ALLOWABLE EXPENSES Amount Reference
1 Political Action Committee Payments $ 020 1
2 Other Expenses Related to Lobbying Activities 20 2
3 Miscellaneous Income (2,065) 21 3
4 Marketing Salaries (91,975) 21 4
5 Marketing Benefits (11,787) 22 5
6 Equipment below $2,500 capitalization threshold: 2,045 10 6
7 Equipment below $2,500 capitalization threshold: 1,285 3 7
8 Depreciation on items below cap threshold (785) 30 8
9 Non-Allowable Dues and Subscriptions (28,943) 20 9
10 Sales tax on food (1,843) 2 10
11 Non-Allowable Bank Charges (295) 21 11
12 Theft and Loss (767) 43 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34 34
35
35
36 36
37 37
38 38
39 39
40 40
41 41
42 42
43 43
44 44
45 45
46 46
47 47
48 48
49
Total (135,130) 49
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Summary A
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I
SUMMARY
Operating Expenses PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALS
A. General Services 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)
1 Dietar
y
0000000000001
2
Food Purchase (1,843) 0000000000(1,843) 2
3
Housekeeping 1,285 00000000001,285 3
4
Laundr
y
0000000000004
5
Heat and Other Utilities 0000000000005
6
Maintenance 0000000000006
7
Other (specify):* 0000000000007
8
TOTAL General Services (558) 0000000000(558) 8
B. Health Care and Programs
9 Medical Director 0000000000009
10
Nursing and Medical Records 2,045 00000000002,045 10
10a
Therapy 000000000000 10a
11
Activities 00000000000011
12
Social Services 00000000000012
13
CNA Training 00000000000013
14
Program Transportation 00000000000014
15
Other (specify):* 00000000000015
16 TOTAL Health Care and Programs 2,045 00000000002,045 16
C. General Administration
17 Administrativ
e
00000000000017
18
Directors Fees 00000000000018
19
Professional Services (1,195) 59,149 00000000057,954 19
20
Fees, Subscriptions & Promotions (28,943) 0000000000(28,943) 20
21
Clerical & General Office Expenses (94,335) 0000000000(94,335) 21
22
Employee Benefits & Payroll Taxes (11,787) 0000000000(11,787) 22
23
Inservice Training & Education 00000000000023
24
Travel and Seminar (1,275) 0000000000(1,275) 24
25
Other Admin. Staff Transportation 00000000000025
26
Insurance-Prop.Liab.Malpractice 00000000000026
27
Other (specify):* 00000000000027
28 TOTAL General Administration (137,535) 59,149 000000000(78,386) 28
TOTAL Operating Expense
29 (sum of lines 8,16 & 28) (136,048) 59,149 000000000(76,899) 29
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Summary B
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I
SUMMARY
Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALS
D. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)
30 Depreciation (785) 0000000000(785) 30
31 Amortization of Pre-Op. & Org. 00000000000031
32 Interest (766) 0000000000(766) 32
33 Real Estate Taxes 00000000000033
34 Rent-Facility & Grounds 00000000000034
35 Rent-Equipment & Vehicles 00000000000035
36 Other (specify):* 00000000000036
37
TOTAL Ownership (1,551) 0000000000(1,551) 37
Ancillary Expense
E. Special Cost Centers
38 Medically Necessary Transportation 00000000000038
39 Ancillary Service Centers 00000000000039
40 Barber and Beauty Shops 00000000000040
41 Coffee and Gift Shops 00000000000041
42 Provider Participation Fee 00000000000042
43 Other (specify):* (199,111) 0000000000(199,111) 43
44
TOTAL Special Cost Centers (199,111) 0000000000(199,111) 44
GRAND TOTAL COST
45 (sum of lines 29, 37 & 44) (336,710) 59,149 000000000(277,561) 45
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 6
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
VII. RELATED PARTIES
A.
Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.
1 2 3
OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES
Name Ownership % Name City Name City Type of Business
Moshe Freedman 90 Accolade Healthcare of Pontiac Pontiac Accolade Healthcare,
L
Chicago Management Comp
a
Shmuel Freedma
n
10 Accolade Healthcare of the Heartland Paxton
Accolade Healthcare of Paxton Senior Living Paxton
Accolade Healthcare of Danville Danville
Accolade Healthcare of East Peoria Peoria
B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,
management fees, purchase of supplies, and so forth. x YES NO
If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance with
the instructions for determining costs as specified for this form.
1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:
Percent Operating Cost Adjustments for
Schedule V Line Item Amoun
t
Name of Related Organization of of Related Related Organization
Ownership Organization Costs (7 minus 4)
1 V 19 Management Fees $ 583,600 Accolade Healthcare, LLC 100.00% $ 642,749 $ 59,149 1
2
V 2
3
V 3
4
V 4
5
V 5
6
V 6
7
V 7
8
V 8
9
V 9
10
V 10
11
V 11
12
V 12
13
V 13
14 Total $ 583,600 $ 642,749 $ * 59,149 14
*
T
ota
l
must agree w
i
t
h
t
h
e amount recor
d
e
d
on
li
ne
34
o
f
S
c
h
e
d
u
l
e
VI
.
SEE
ACCOUNTANTS'
PREPARATION
REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Ownership Listing-1
Accolade Healthcare Peoria
ID# 0057133
Report Period Beginning: 02/01/2022
Ending: 12/31/2022
-Names of individual owners must be listed. (Full legal name (no nicknames) and middle initial)
-Owners of companies must be listed instead of company names.
-Names of trust beneficiaries must be listed. Place of Residence
Ownership
First Name M.I. Last Name City State Percentage
1 Shmuel Freedman St. Louis MO 10.00000 1
2 Moshe Freedman Chicago IL 90.00000 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34 34
35 35
36 36
37 37
38 38
39 39
40 40
41 41
42 42
43 43
44 44
45 45
46 46
47 47
48 48
49
49
50 50
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 7
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
VII. RELATED PARTIES (continued)
C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors.
NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this home
must be listed on this schedule.
1 2 345 6 7 8
Average Hours Per Work
Compensation Week Devoted to this Compensation Included Schedule V.
Received Facility and % of Total in Costs for this Line &
Ownership From Other Work Week Reporting Period** Column
Name Title Function Interest Nursing Homes* Hours Percent Description Amount Reference
1
Shmuel Freedman Owner Finance 10.00 See Attachment 8 21.00 Alloc Salary $ See Attachme
n
L19, C3 1
2
Moshe Freedman Owner Administration 90.00 See Attachment 21.00 Alloc Salary See Attachme
n
L19, C3 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 TOTAL $ 13
* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s)
of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS.
**
This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees).
FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME
,
ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATIO
N
SEE
ACCOUNTANTS'
PREPARATION
REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 8
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 2/31/2022
VIII. ALLOCATION OF INDIRECT COSTS
Name of Related Organization
Accolade Healthcare LLC
A. Are there any costs included in this report which were derived from allocations of central office Street Address 9433 Olive Blvd, Ste 100
or parent organization costs? (See instructions.) YES x NO City / State / Zip Code St. Louis, MO 63132
Phone Number ( 309-885-0005
B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( )
12 3456789
Schedule V Unit of Allocation Number of Total Indirect Amount of Salary
Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility Allocation
Reference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6
1 19 Management Fees Direct Cost 49,445,634 6 $ 3,060,086 $ 2,397,046 10,385,706 $ 642,749 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 TOTALS $ 3,060,086 $ 2,397,046 $ 642,749 25
SEE ACCOUNTANTS' PREPARATION REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 9
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE
A. Interest: (Com
p
lete details must be
p
rovided for each loan - attach a se
p
arate schedule if necessar
y
.)
12 3 45678910
Re
p
ortin
g
Monthl
y
Maturit
y
Interest Period
Name of Lender Related** Pur
p
ose of Loan Pa
y
men
t
Date of Amount of Note Date Rate Interest
YES NO Re
q
uired Note Ori
g
inal Balance (4 Di
g
its) Ex
p
ense
A. Directl
y
Facilit
y
Related
Lon
g
-Term
1 $$ $ 1
2 See Attachmemt 9A 250,000 250,000 2
3 See Attachmemt 9A 39,997 21,216 1,935 3
4 4
5 5
Workin
g
Ca
p
ital
6 See Attachmemt 9A 1,328,035 55,641 6
7 Misc Interest & Loan Ac
q
Ex
p
ense 2,103 7
8 See Attachmemt 9A 56,781 39,508 2,254 8
9 TOTAL Facilit
y
Related $ 1,674,813 $ 310,724 $ 61,933 9
B. Non-Facilit
y
Related*
10 Interest Income (766) 10
11 11
12 12
13 13
14 TOTAL Non-Facilit
y
Related $ $ $ (766) 14
15 TOTALS (line 9+line14) $ 1,674,813 $ 310,724 $ 61,167 15
16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ Line #
*An
y
interest ex
p
ense re
p
orted in this section should be ad
j
usted out on
p
a
g
e 5, line 14 and, conse
q
uentl
y
,
p
a
g
e 4, col. 7.
(S
ee
i
nstruct
i
ons.
)
SEE
ACCOUNTANTS'
PREPARATION
REPORT
** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.
(See instructions.)
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOI
S
Page 10
Facility Name & ID Numbe
r
Accolade Healthcare Peori
a
# 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued)
B. Real Estate Taxes
Im
p
ortant
,
p
lease see the next worksheet
,
"RE
_
Tax". The real estate tax
1. Real Estate Tax accrual used on 2021 report.
statement and bill must accompan
y
the cost report.
$1
2. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 108,776 2
3. Under or (over) accrual (line 2 minus line 1). $ 108,776 3
4. Real Estate Tax accrual used for 2022 report. (Detail and explain your calculation of this accrual on the lines below.) $4
5. Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C.
(Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) $5
6. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costs
classified as a real estate tax cost plus one-half of any remaining refund.
TOTAL REFUND $ For Tax Year.
(Attach a copy of the real estate tax appeal board's decision.) $6
7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6
.
$ 108,776 7
Real Estate Tax History:
Real Estate Tax Bill for Calendar Year:
2017 127,307 8
FOR BHF USE ONLY
2018 128,262 9
2019 128,279 10 13 FROM R. E. TAX STATEMENT FOR 2021 $13
2020 126,329 11
2021 132,093 12 14 PLUS APPEAL COST FROM LINE
5
$14
No accrual in current
y
ear as taxes are
p
aid to landlord on a monthl
y
basis.
Landlord
p
a
y
s real estate taxes and Accolade remits
p
a
y
ments to the Landlord in turn. 15 LESS REFUND FROM LINE 6 $15
PY real estate tax bills from
p
revious owners
16 AMOUNT TO USE FOR RATE CALCULATION $16
NOTES: 1. Please indicate a negative number by use of brackets( ). Deduct any overaccrual o
f
taxes from prior year.
2. If facility is a non-profit which pays real estate taxes, you must attach a denial of an
application for real estate tax exemption unless the building is rented from a for-profit entity
.
Thi
s
d
en
i
a
l
mus
t
b
e no more
th
an
f
our years o
ld
a
t
th
e
ti
me
th
e cos
t
repor
t
i
s
fil
e
d
.
SEE
ACCOUNTANTS'
PREPARATION
REPORT
HFS 3745 (N-4-99) IL478-2471
2021 LONG TERM CARE REAL ESTATE TAX STATEMENT
FACILITY NAME Accolade Healthcare Peoria COUNTY Peoria
FACILITY IDPH LICENSE NUMBER 0057133
CONTACT PERSON REGARDING THIS REPORT Shmuel Freedman
TELEPHONE 973-557-3339 FAX #: ( )
A. Summary of Real Estate Tax Cost
Enter the tax index number and real estate tax assessed for 2021 on the lines provided below. Enter only the portion of the
cost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursing
home property which is vacant, rented to other organizations, or used for purposes other than long term care must not be
entered in Column D. Do not include cost for any period other than calendar year 2021.
(A) (B) (C) (D)
Tax
Applicable to
Tax Index Numbe
r
Property Description Total Tax Nursing Home
1. 14-16-451-008 LTC Facility $ 103,386.94 $ 103,386.94
2. 14-16-451-009 LTC Facility $ 21.88 $ 21.88
3. 14-16-451-011 LTC Facility $ 345.98 $ 345.98
4. 14-16-451-018 LTC Facility $ 307.20 $ 307.20
5. 14-16-451-019 LTC Facility $ 307.20 $ 307.20
6. $ $
7. $ $
8. $ $
9. $ $
10. $ $
TOTALS $ 104,369.20 $ 104,369.20
B. Real Estate Tax Cost Allocations
Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directly
used for nursing home services? YES x NO
If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.
(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)
C. Tax Bills
Attach copies of the original 2021 tax bills which were listed in Section A to this statement. Be sure to use the 2021
tax bill which is normally paid during 2022.
PLEASE NOTE:
P
ayment information from the Internet or otherwise is not considered acceptable tax bill
documentation . Facilities located in Cook County are required to provide copies
of their original second
installment
tax bill.
Page 10A
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOI
S
Pa
g
e 11
Facilit
y
Name & ID Numb
e
Accolade Healthcare Peoria # 0057133 Re
p
ort Period Be
g
innin
g
: 02/01/2022 Endin
g
: 12/31/2022
X. BUILDING AND GENERAL INFORMATION:
A. S
q
uare Feet: 33,022 B. General Construction T
yp
e: Exterior Masonr
y
Frame Steel Number of Stories 1
C. Does the O
p
eratin
g
Entit
y
? (a) Own the Facilit
y
(b) Rent from a Related Or
g
anization. x (c) Rent from Com
p
letel
y
Unrelated
O
r
g
an
i
zat
i
on.
(Facilities checkin
g
(a) or (b) must com
p
lete Schedule XI. Those checkin
g
(c) ma
y
com
p
lete Schedule XI or Schedule XII-A. See instructions.
)
D. Does the O
p
eratin
g
Entit
y
? x (a) Own the E
q
ui
p
men
t
(b) Rent e
q
ui
p
ment from a Related Or
g
anization. (c) Rent e
q
ui
p
ment from Com
p
letel
y
U
nre
l
ate
d
O
r
g
an
i
zat
i
on.
(Facilities checkin
g
(a) or (b) must com
p
lete Schedule XI-C. Those checkin
g
(c) ma
y
com
p
lete Schedule XI-C or Schedule XII-B. See instructions.
)
E. List all other business entities owned b
y
this o
p
eratin
g
entit
y
or related to the o
p
eratin
g
entit
y
that are located on or ad
j
acent to this nursin
g
home's
g
rounds
(such as, but not limited to, a
p
artments, assisted livin
g
facilities, da
y
trainin
g
facilities, da
y
care, inde
p
endent livin
g
facilities, CNA trainin
g
facilities, etc.)
List entit
y
name, t
yp
e of business, s
q
uare foota
g
e, and number of beds/units available (where a
pp
licable).
None
F. List the bed capacity for the building if it differs from the licensed total.
G. Have you properly capitalized all major repairs and equipment purchases? Yes
H. Are you presently operating under a sale and leaseback arrangement? No
If YES, give effective date of lease.
I. Are you presently operating under a sublease agreement? No
J. Was this home previously operated by a related party (as is defined in the instructions for Schedule VII)
?
YES
N
O No If YES, please indicate name of the facility,
IDPH license number of this related party and the date the present owners took over.
K. Does this cost re
p
ort reflect an
y
or
g
anization or
p
re-o
p
eratin
g
costs which are bein
g
amortized? YES x NO
If so,
p
lease com
p
lete the followin
g
:
1. Total Amount Incurred: 2. Number of Years Over Which it is Bein
g
Amortized:
3. Current Period Amortization: 4. Dates Incurred:
Nature of Costs:
(Attach a com
p
lete schedule detailin
g
the total amount of or
g
anization and
p
re-o
p
eratin
g
costs.)
XI. OWNERSHIP COSTS:
1 2 3 4
A. Land. Use S
q
uare Feet Year Ac
q
uired Cost
1 $1
2 2
3 TOTALS $ 3
SEE
ACCOUNTANTS'
PREPARATION
REPORT
HFS 3745 (N-4-99) IL478-2471
STATE
OF
ILLINOIS
P
age
12
F
ac
ili
ty
N
ame
&
ID
N
um
b
er
A
cco
l
a
d
e
H
ea
l
t
h
care
P
eor
i
a
#
0057133
R
eport
P
er
i
o
d
B
eg
i
nn
i
ng:
02/01/2022
E
n
di
ng:
12/31/2022
XI
.
OWNERSHIP
COSTS
(
cont
i
nue
d)
B
.
B
u
ildi
ng an
d
I
mprovement
C
osts-
I
nc
l
u
di
ng
Fi
xe
d
E
qu
i
pment.
(S
ee
i
nstruct
i
ons.
)
R
oun
d
a
ll
num
b
ers to nearest
d
o
ll
ar.
1
2
3
4
5
6
7
8
9
FOR
BHF
USE
ONLY
Y
ear
Y
ear
C
urrent
B
oo
k
Lif
e
S
tra
i
g
h
t
Li
ne
A
ccumu
l
ate
d
B
e
d
s
*
A
cqu
i
re
d
C
onstructe
d
C
ost
D
eprec
i
at
i
on
i
n
Y
ears
D
eprec
i
at
i
on
Adj
ustments
D
eprec
i
at
i
on
4 $$ $$$ 4
5 5
6 6
7 7
8 8
I
mprovement
T
ype
**
9 Laundry Room A/C Repair
2021
11
,
100
1
,
388
8
1
,
388
1
,
850
9
10 Smoke & heat detector servic
e
2021
5
,
093
637
8
637
849
10
11 CUBICLE CURTAINS FOR RESIDENT ROOMS
2021
6
,
772
846
8
846
1
,
058
11
12 LED Lighting Upgrade
2021
4
,
780
598
8
598
747
12
13 Dishwasher Servicing and Plumbing Proj
2021
10
,
098
1
,
262
8
1
,
262
1
,
367
13
14 Painting / Flooring in resident rooms 300 Hall & Conference Room
2021
7
,
923
990
8
990
1
,
073
14
15 Mixing Valve Proj
2022
13
,
580
1
,
793
8
1
,
793
1
,
793
15
16 Water Heater Projec
t
2022
49
,
178
3
,
325
8
3
,
325
3
,
325
16
17 Outdoor Signage Installation
2022
6
,
750
375
8
375
375
17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
31 31
32 32
33 33
34 34
35 35
36 36
*Total beds on this schedule must agree with page 2.
See Pa
g
e 12A
,
Line 70 for total
**Improvement type must be detailed in order for the cost report to be considered complete
.
SEE ACCOUNTANTS' PREPARATION REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Pa
g
e 13
Facilit
y
Name & ID Number Accolade Healthcare Peori
a
# 0057133 Report Period Be
g
innin
g
: 02/01/2022 Endin
g
: 12/31/2022
XI. OWNERSHIP COSTS (continued)
C. Equipment Costs-Excludin
g
Transportation. (See instructions.)
Cate
g
or
y
of 1 Current Book Strai
g
ht Line 4 Component Accumulated
Equipment Cost Depreciation 2 Depreciation 3 Ad
j
ustments Life 5 Depreciation 6
71 Purchased in Prior Years $ 112,374 $ 22,475 $ 22,475 $ 5 $ 30,339 71
72 Current Year Purchases 37,006 3,436 3,436 5 3,436 72
73 Fully Depreciated Assets 73
74 74
75 TOTALS $ 149,380 $ 25,911 $ 25,911 $ $ 33,775 75
D. Vehicle Costs. (See instructions.)*
1 Model, Make Year 4 Current Book Strai
g
ht Line 7 Life in Accumulated
Use and Year 2 Acquired 3 Cost Depreciation 5 Depreciation 6 Ad
j
ustments Years 8 Depreciation 9
76 $ $$$ $ 76
77 77
78 78
79 79
80 TOTALS $ $ $ $ $ 80
E. Summar
y
of Care-Related Assets 1 2
Reference Amount
81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 264,654 81
82 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 37,125 82
83 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 37,125 83 **
84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ 84
85 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 46,212 85
F. Depreciable Non-Care Assets Included in General Led
g
er. (See instructions.) G. Construction-in-Pro
g
ress
1 2 Current Book Accumulated
Description & Year Acquired Cost Depreciation 3 Depreciation 4 Description Cost
86 $ $ $ 86 92 $ 92
87 87 93 93
88 88 94 94
89 89 95 $ 95
90 90
91 TOTALS $ $ $ 91
*
V
ehicles used to transport residents to & from
d
ay
t
ra
i
n
i
ng mus
t
b
e recor
d
e
d
i
n
XI
-
F
, no
t
XI
-
D
.
SEE ACCOUNTANTS' PREPARATION REPORT ** This must a
g
ree with Schedule V line 30, column 8.
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 14
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
XII. RENTAL COSTS
A. Building and Fixed Equipment (See instructions.)
1. Name of Party Holding Lease: Paradox Peoria Property
2. Does the facility also pay real estate taxes in addition to rental amount shown below on line 7, column 4?
If NO, see instructions. x YES NO 22
25
123 4 56
Year Numbe
r
Original Rental Total Years Total Years
Constructed of Beds Lease Date Amoun
t
of Lease Renewal Option*
Original 10. Effective dates of current rental agreement:
3 Building: 1963 144 02/01/2022 $ 674,223 3 3 3 Beginning 02/01/2022
4 Additions 4 Ending 04/30/2025
5 5
6 6 11. Rent to be paid in future years under the current
7 TOTAL 144 $ 674,223 7 rental agreement:
**
8. List separately any amortization of lease expense included on page 4, line 34. 45,231 Fiscal Year Ending Annual Rent
This amount was calculated by dividing the total amount to be amortized 2,179,500
by the length of the lease 57 mos . 12. 12/31/23 $ 669,000
13. 12/31/24 $ 717,000
9. Option to Buy: x YES NO Terms:
*
14. 12/31/25 $ 675,000
B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.)
15. Is Movable equipment rental included in building rental? x YES NO
16. Rental Amount for movable equipment: $ 8,694 Description: Copier (3,894); Dish machine (4,800)
(Attach a schedule detailing the breakdown of movable equipment)
C. Vehicle Rental (See instructions.)
12 3 4
Model Year Monthly Lease Rental Expense
Use and Make Payment for this Period * If there is an option to buy the building,
17 $ $ 17 please provide complete details on attached
18 18 schedule.
19 19
20 20 ** This amount plus any amortization of lease
21 TOTAL $ $ 21 expense must agree with page 4, line 34.
S
EE
ACCO
UNT
A
NT
S'
PREP
A
R
A
TI
O
N REP
O
RT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 15
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.)
A. TYPE OF TRAINING PROGRAM (If CNAs are trained in another facility program, attach a schedule listing the facility name, address and cost per CNA trained in that facility.)
1. HAVE YOU TRAINED CNAs YES 2. CLASSROOM PORTION: 3. CLINICAL PORTION:
DURING THIS REPORT
PERIOD? x NO IN-HOUSE PROGRAM IN-HOUSE PROGRAM
IN OTHER FACILITY IN OTHER FACILITY
If "yes", please complete the remainder
of this schedule. If "no", provide an COMMUNITY COLLEGE HOURS PER CNA
explanation as to why this training was
not necessary. HOURS PER CNA
B. EXPENSES C. CONTRACTUAL INCOME
ALLOCATION OF COSTS (d)
In the box below record the amount of income your
1 2 3 4 facility received training CNAs from other facilities.
Facility
Drop-outs Completed Contract Total $
1 Community College Tuition $$$$
2 Books and Supplies D. NUMBER OF CNAs TRAINED
3 Classroom Wages (a)
4 Clinical Wages (b) COMPLETED
5 In-House Trainer Wages (c) 1. From this facility
6 Transportation 2. From other facilities (f)
7 Contractual Payments DROP-OUTS
8 CNA Competency Tests 1. From this facility
9 TOTALS $$$$ 2. From other facilities (f)
10 SUM OF line 9, col. 1 and 2 (e) $ TOTAL TRAINED
(a) Include wages paid during the classroom portion of training. Do not include fringe benefits. (e) The total amount of Drop-out and Completed Costs for
(b) Include wages paid during the clinical portion of training. Do not include fringe benefits. your own CNAs must agree with Sch. V, line 13, col. 8.
(c) For in-house training programs only. Do not include fringe benefits. (f) Attach a schedule of the facility names and addresses
(d) Allocate based on if the CNA is from your facility or is being contracted to be trained in of those facilities for which you trained CNAs.
your facility. Drop-out costs can only be for costs incurred by your own CNAs. SEE ACCOUNTANTS' PREPARATION REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 16
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
XIV. SPECIAL SERVICES (Direct Cost) (See instructions.)
1 2 3 4 5 6 7 8
Schedule V Staff Outside Practitioner Supplies
Service Line & Column Units of Cost (other than consultant) (Actual or) Total Units Total Cost
Reference Service Units Cost Allocated) (Column 2 + 4) (Col. 3 + 5 + 6)
1 Licensed Occupational Therapist L39, C3 hrs $ 3,951 $ 326,955 $ 3,951 $ 326,955 1
Licensed Speech and Language
2 Development Therapist L39, C3 hrs 509 45,434 509 45,434 2
3 Licensed Recreational Therapist hrs 3
4 Licensed Physical Therapist L39, C3 hrs 4,238 345,190 4,238 345,190 4
5 Physician Care visits 5
6 Dental Care visits 6
7 Work Related Program hrs 7
8 Habilitation hrs 8
# of
9 Pharmacy prescrpts 192,141 192,141 9
Psychological Services
(Evaluation and Diagnosis/
10 Behavior Modification) hrs 10
11 Academic Education hrs 11
12 Other (specify): 12
13 Other (specify): 13
14 TOTAL $ 8,698 $ 717,579 $ 192,141 8,698 $ 909,720 14
NOTE: This schedule should include fees (other than consultant fees) paid to licensed practitioners. Consultant fees should be detailed on
Schedule XVIII-B. Salaries of unlicensed practitioners, such as CNAs, who help with the above activities should not be listed
on this schedule.
SEE ACCOUNTANTS' PREPARATION REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 17
Facility Name & ID Numbe
r
Accolade Healthcare Peori
a
# 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
XV. BALANCE SHEET - Unrestricted Operating Fund. As of 12/31/2022 (last day of reporting year)
This report must be completed even if financial statements are attached
.
1 2 After 1 2 After
Operating Consolidation* Operating Consolidation*
A. Current Assets C. Current Liabilities
1 Cash on Hand and in Banks $ 10,352 $ 10,352 126 Accounts Payable $ 747,958 $ 747,958 26
2 Cash-Patient Deposits 227 Officer's Accounts Payabl
e
27
Accounts & Short-Term Notes Receivable
-
28 Accounts Payable-Patient Deposit
s
28
3 Patients (less allowance 150,000 ) 1,563,355 1,563,355 329 Short-Term Notes Payabl
e
23,718 23,718 29
4 Supply Inventory (priced a
t
) 430 Accrued Salaries Payabl
e
279,075 279,075 30
5 Short-Term Investment
s
5 Accrued Taxes Payable
6 Prepaid Insurance 32,549 32,549 631 (excluding real estate taxes
)
53,076 53,076 31
7 Other Prepaid Expenses 1,260 1,260 732 Accrued Real Estate Taxes(Sch.IX-B
)
32
8 Accounts Receivable (owners or related parties
)
46,462 46,462 8 33 Accrued Interest Payabl
e
33
9 Other(specify): See Detail 4,350,571 4,350,571 934 Deferred Compensatio
n
34
TOTAL Current Assets 35 Federal and State Income Taxe
s
35
10 (sum of lines 1 thru 9) $ 6,004,549 $ 6,004,549 10 Other Current Liabilities(specify):
B. Long-Term Assets 36 See Detail 1,106,002 1,106,002 36
11 Long-Term Notes Receivabl
e
11 37 37
12 Long-Term Investment
s
12 TOTAL Current Liabilities
13 Lan
d
13 38 (sum of lines 26 thru 37) $ 2,209,829 $ 2,209,829 38
14 Buildings, at Historical Cos
t
14 D. Long-Term Liabilities
15 Leasehold Improvements, at Historical Cos
t
116,485 116,485 15 39 Long-Term Notes Payabl
e
287,006 287,006 39
16 Equipment, at Historical Cos
t
132,551 132,551 16 40 Mortgage Payabl
e
40
17 Accumulated Depreciation (book methods
)
(25,047) (25,047) 17 41 Bonds Payable 41
18 Deferred Charges 18 42 Deferred Compensatio
n
42
19 Organization & Pre-Operating Cost
s
19 Other Long-Term Liabilities(specify):
Accumulated Amortization
-
43 Operating Lease Liabilit
y
3,233,564 3,233,564 43
20 Organization & Pre-Operating Cost
s
20 44 44
21 Restricted Fund
s
21 TOTAL Long-Term Liabilities
22 Other Long-Term Assets (specify)
:
22 45 (sum of lines 39 thru 44) $ 3,520,570 $ 3,520,570 45
23 Other(specify): See Detail 800,579 800,579 23 TOTAL LIABILITIES
TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ 5,730,399 $ 5,730,399 46
24 (sum of lines 11 thru 23) $ 1,024,568 $ 1,024,568 24
47 TOTAL EQUITY(page 18, line 24) $ 1,298,718 $ 1,298,718 47
TOTAL ASSETS TOTAL LIABILITIES AND EQUITY
25 (sum of lines 10 and 24) $ 7,029,117 $ 7,029,117 25 48 (sum of lines 46 and 47) $ 7,029,117 $ 7,029,117 48
SEE ACCOUNTANTS' PREPARATION REPORT *(See instructions.)
HFS 3745 (N-4-99) IL478-2471
Accolade of Danville
FY2022
Balance Sheet Detail
Line 9 - Other Assets
Acct Desc Salary Benefits Other Total After Consolidation
RB30 ROU Asset - Operating 3,805,581 3,805,581 -
2025-590-000 Other Accrued-Revenue 544,990 544,990 -
Total - - 4,350,571 4,350,571 -
Line 23 - Other Assets
Acct Desc Salary Benefits Other Total After Consolidation
1080-672-092 Other Assets-Escrow Deposits-Capital Reserve 35,729 35,729 -
1080-674-000 Other Assets-Option Deposit 750,000 750,000 -
1080-775-000 Other Assets-MCO Contract 19,500 19,500 -
1081-775-000 Accum Amortization-MCO Contract (4,650) (4,650) -
Total - - 800,579 800,579 -
Line 36 - Other Liabilities
Acct Desc Salary Benefits Other Total After Consolidation
RB40 Operating Lease Liability - Current 625,240 625,240 -
2020-745-000 Accrued Wages & Related-Garnishments W/H 1,177 1,177 -
2025-028-000 Other Accrued-Management Fees 133,216 133,216 -
2025-118-000 Other Accrued-Provider Tax 128,987 128,987
2040-306-000 Due To/(From)-Old Owner 7,719 7,719
RB2040-000-802 Due To/(From)-EPEO 129,668 129,668 -
RB2040-000-803 Due To/(From)-SAX 5,595 5,595
RB2040-000-804 Due To/(From)-PELLS 74,400 74,400
Total - - 1,106,002 1,106,002 -
Line 43 - Other LTL
Acct Desc Salary Benefits Other Total After Consolidation
RB41 Operating Lease Liability - Long-Term 3,233,564 3,233,564 -
- - -
Total - - 3,233,564 3,233,564 -
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 18
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
XVI. STATEMENT OF CHANGES IN EQUIT
Y
1
Total
1 Balance at Beginning of Year, as Previously Reported $ 1
2 Restatements (describe): 2
3 Equity at change of ownership 173,586 3
4 4
5 5
6 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ 173,586 6
A. Additions (deductions):
7 NET Income (Loss) (from page 19, line 43) 1,125,132 7
8 Aquisitions of Pooled Companies 8
9 Proceeds from Sale of Stoc
k
9
10 Stock Options Exercised 10
11 Contributions and Grants 11
12 Expenditures for Specific Purposes 12
13 Dividends Paid or Other Distributions to Owners ()13
14 Donated Property, Plant, and Equipment 14
15 Other (describe) 15
16 Other (describe) 16
17 TOTAL Additions (deductions) (sum of lines 7-16) $ 1,125,132 17
B. Transfers (Itemize):
18 18
19 19
20 20
21 21
22 22
23 TOTAL Transfers (sum of lines 18-22) $ 23
24 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ 1,298,718 24 *
* This must agree with page 17, line 47.
SEE ACCOUNTANTS' PREPARATION REPOR
T
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 19
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
XVII. INCOME STATEMENT (attach any explanatory footnotes necessary to reconcile this schedule to Schedules V and VI.) All required
classifications of revenue and expense must be provided on this form, even if financial statements are attached.
Note: This schedule should show gross revenue and expenses. Do not net revenue against expense
1
2
I. Revenue Amount II. Expenses Amount
A. Inpatient Care A. Operating Expenses
1 Gross Revenue -- All Levels of Care
$ 13,428,518 131 General Services 1,620,753 31
2 Discounts and Allowances for all Levels (2,067,704) 232 Health Care 4,448,060 32
3 SUBTOTAL Inpatient Care (line 1 minus line 2)
$ 11,360,814 3 33 General Administration 2,420,906 33
B. Ancillary Revenue B. Capital Expense
4 Day Care 434 Ownership 894,085 34
5 Other Care for Outpatients 18,287 5 C. Ancillary Expense
6 Therapy 358,037 635 Special Cost Centers 1,170,428 35
7 Oxyge
n
736 Provider Participation Fee 410,794 36
8 SUBTOTAL Ancillary Revenue (lines 4 thru 7)
$ 376,324 8 D. Other Expenses (specify):
C. Other Operating Revenue 37 37
9 Payments for Education 938 38
10 Other Government Grants 10 39 39
11 CNA Training Reimbursements 11
12
Gif
t an
d
C
o
ff
ee
Sh
op
12
40
T
O
T
A
L EXPEN
S
E
S
(
sum o
f
l
i
nes
31
thru
39)*
$
10
,
96
5,
026
40
13 Barber and Beauty Care 13
14 Non-Patient Meals 14 41 Income before Income Taxes (line 30 minus line 40)** 1,125,132 41
15 Telephone, Television and Radio 15
16 Rental of Facility Space 16 42 Income Taxes 42
17 Sale of Drugs 17
18
S
a
l
e o
f
S
upp
li
es to Non-Pat
i
ents
18
43
NET IN
CO
ME
O
R L
OSS
F
O
R THE YE
A
R
(
l
i
ne
41
m
i
nus l
i
ne
42)
$
1
,
12
5,
132
43
19 Laboratory 19
20 Radiology and X-Ra
y
20 III. Net Inpatient Revenue detailed by Payer Source for each line
21 Other Medical Services 21 44 Medicaid Fee for Service
$ 1,670,869.00 44
22 Laundry 22 45 Medicaid Managed Long Term Services and Supports (MLTSS) 3,689,205.00 45
23 SUBTOTAL Other Operating Revenue (lines 9 thru 22)
$ 23 46 MMAI-Medicaid is the Primary Paye
r
1,146,004.00 46
D. Non-Operating Revenue 47 MMAI-Medicare is the Primary Paye
r
47
24 Contributions 24 48 Private Pa
y
849,616.00 48
25 Interest and Other Investment Income*** 766 25 49 Mediciare Part A 1,975,607.00 49
26 SUBTOTAL Non-Operating Revenue (lines 24 and 25)
$ 766 26 50 Other-(specify) 50
E. Other Revenue (specify):**** 51 Other-(specify) Hospice 555,700.00 51
27
S
e
ttl
emen
t
I
ncome
(I
nsurance,
L
ega
l
,
Et
c.
)
27 52 Other-(specify) MCR HMO 1,457,833.00 52
28 See Detail 352,254 28 53 Other-(specify) Commercial 15,980.00 53
28a 28a 54 Other-(specify) 54
29 SUBTOTAL Other Revenue (lines 27, 28 and 28a)
$ 352,254 29 55 Other-(specify) 55
30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29)
$ 12,090,158 30 56
TOTAL In
p
atient Care Revenue
(
This total must a
g
ree to Line 3
)
$
11
,
360
,
814
56
SEE ACCOUNTANTS' PREPARATION REPORT
HFS 3745 (N-4-99) IL478-2471
Accolade of Peoria
FY2022
Misc Income Detail
Acct Desc Amt
5900-000-390 Other Rev-Quality Incentive 48,081
5900-000-392 Other Rev-CNA Incentive 73,171
5900-025-000 Other Rev-Miscellaneous 2,065
5900-232-000 Other Rev-Stimulus Rev 228,937
Total 352,254
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 20
Facility Name & ID Number Accolade Healthcare Peori
a
# 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
XVIII. A. STAFFING AND SALARY COSTS (Please report each line separately.)
(This schedule must cover the entire reporting period.) B. CONSULTANT SERVICES
12**34 123
# of Hrs. # of Hrs. Reporting Period Average Numbe
r
Total Consultant Schedule V
Actually Paid and Total Salaries, Hourly of Hrs. Cost for Line &
Worked Accrued Wages Wage Paid & Reporting Column
1 Director of Nursing 1,969 2,088
$ 113,749 $ 54.48 1 Accrued Period Reference
2 Assistant Director of Nursing 3,630 3,896 161,288 41.40 2 35 Dietary Consultant 796
$ 40,132 L1, C3 35
3 Registered Nurses 22,465 23,536 960,443 40.81 3 36 Medical Director N/A 42,000 L9, C3 36
4 Licensed Practical Nurses 24,388 26,016 850,976 32.71 4 37 Medical Records Consultant 37
5 CNAs & Orderlies 72,405 76,443 1,602,325 20.96 5 38 Nurse Consultant 38
6 CNA Trainees - - - 6 39 Pharmacist Consultant N/A 21,781 L10, C3 39
7 Licensed Therapist - - - 7 40 Physical Therapy Consultant 40
8 Rehab/Therapy Aides - - - 8 41 Occupational Therapy Consultant 41
9 Activity Director 1,866 2,062 48,720 23.63 9 42 Respiratory Therapy Consultant 42
10 Activity Assistants 4,933 5,122 64,876 12.67 10 43 Speech Therapy Consultant 43
11 Social Service Workers 1,849 1,921 58,134 30.26 11 44 Activity Consultant 30 2,005 L11, C3 44
12 Dietician - - - 12 45 Social Service Consultant 25 1,650 L12, C3 45
13 Food Service Supervisor 3,974 4,522 106,848 23.63 13 46 Other(specify) 46
14 Head Cook 10,667 11,468 182,737 15.93 14 47 47
15 Cook Helpers/Assistants 8,104 8,681 124,711 14.37 15 48 48
16 Dishwashers - - - 16
17 Maintenance Workers 5,453 5,762 135,397 23.50 17 49 TOTAL (lines 35 - 48) 851
$ 107,568 49
18 Housekeepers 16,778 17,785 281,471 15.83 18
19 Laundry 2,007 2,010 27,102 13.48 19
20 Administrato
r
2,014 2,101 104,139 49.57 20
21 Assistant Administrator - - - 21 C. CONTRACT NURSES
22 Other Administrative 13,205 14,144 386,889 27.35 22 1 2 3
23 Office Manager - - - 23 Numbe
r
Schedule V
24 Clerical - - - 24 of Hrs. Total Line &
25 Vocational Instruction - - - 25 Paid & Contrac
t
Column
26 Academic Instruction - - - 26 Accrued Wages Reference
27 Medical Director - - - 27 50 Registered Nurses 96
$ 6,695 L10,C3 50
28 Qualified MR Prof. (QMRP) - - - 28 51 Licensed Practical Nurses 248 13,159 L10,C3 51
29 Resident Services Coordinator - - - 29 52 Certified Nurse Assistants/Aides 1,355 63,425 L10,C3 52
30 Habilitation Aides (DD Homes) - - - 30
31 Medical Records 1,934 2,138 39,477 18.46 31 53 TOTAL (lines 50 - 52) 1,699
$ 83,279 53
32 Other Health Care(specify) - - - 32
33 Other(specify) Transport 2,037 2,159 31,949 14.80 33
34 TOTAL (lines 1 - 33) 199,678 211,854
$ 5,281,231
*
$ 24.93 34 SEE ACCOUNTANTS' PREPARATION REPORT
* This total must agree with page 4, column 1, line 45. ** See instructions.
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Page 21
Facility Name & ID Number Accolade Healthcare Peoria # 0057133 Report Period Beginning: 02/01/2022 Ending: 12/31/2022
XIX. SUPPORT SCHEDULES
A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions
Name Function % Amoun
t
Description Amoun
t
Description Amoun
t
Tasha Williams Administrator 0 $ 104,203 Workers' Compensation Insurance $ 41,883 IDPH License Fee $
Unemployment Compensation Insurance Advertising: Employee Recruitment 31,069
FICA Taxes 437,187 Health Care Worker Background Check
Employee Health Insurance 187,049 (Indicate # of checks performed )
Employee Meals 7,690 Patient Background Checks
Illinois Municipal Retirement Fund (IMRF)*
Association Dues (total from pg 22, #4)
401K 2,996
TOTAL (agree to Schedule V, line 17, col. 1)
(List each licensed administrator separately.) $ 104,203 Marketing Benefits (11,787)
B. Administrative - Other
Less: Public Relations Expense ( )
Description Amount PAC and Lobbying payments ( )
Admin Consulting $ 21,734 All non-allowable advertising ( )
TOTAL (agree to Schedule V, $ 665,018 TOTAL (agree to Sch. V, $ 31,069
line 22, col.8) line 20, col. 8)
TOTAL (agree to Schedule V, line 17, col. 3) $ 21,734 E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar**
(Attach a copy of any management service agreement) to Owners or Employees
C. Professional Services Description Amount
Vendor/Payee Type Amount Description Line # Amount
Global Tech Solutions IT $ 11,794 $ Out-of-State Travel $
Creative Tech Solutions IT 12,556
Various, See Detail Legal 27,302
RubinBrown Accounting 9,055 In-State Travel
Amort Insurance Contracts AR 4,650
Platinum Billing AR 110,700
ProPayHR Payroll Processing 30,321
TouchSupport Bookkeeping 2,988 Seminar Expense
STL Bookkeeping Bookkeeping 221
Accolade Health Management Fees 583,600
Entertainment Expense ( )
TOTAL (agree to Schedule V, line 19, column 3) TOTAL $ (agree to Sch. V,
(For legal fee disclosure, see page 39 of instructions) $ 793,187 TOTAL line 24, col. 8) $
* Attach copy of IMRF notifications **See instructions.
SEE ACCOUNTANTS' PREPARATION REPORT
HFS 3745 (N-4-99) IL478-2471
STATE OF ILLINOIS Pa
g
e 22
Facilit
y
Name & ID Number Accolade Healthcare Peori
a
# 0057133 Report Period Be
g
innin
g
: 02/01/2022 Endin
g
: 12/31/2022
XX. GENERAL INFORMATION:
(1) Are nursing employees (RN,LPN,NA) represented by a union
?
No (9) Have costs for all supplies and services which are of the type that can be billed t
o
the Department, in addition to the daily rate, been properly classifie
d
(2) Please list the ALLOWABLE PAYMENTS OR dues paid to provider associations on the lines below
.
in the Ancillary Section of Schedule V
?
Yes
Use the drop down list to identify the association
.
Association Name Amount (10) Is a portion of the building used for any function other than long term care services for
the patient census listed on page 2, Section B? No For example,
is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attach
a schedule which explains how all related costs were allocated to these functions.
Total
(11) Indicate the cost of employee meals that has been reclassified to employee benefits
(3) List the amount of NON-ALLOWABLE payments OR DUES made to PROVIDER ASSOCIATION
S
on Schedule V. $ N/A Has any meal income been offset agains
t
OR political action organizations. related costs? No Indicate the amount. $ N/A
The total amount for Question #3 will be adjusted out of the cost report on Page 5A, Line 1.
(12) Travel and Transportation
a. Are there costs included for out-of-state travel? No
If YES, attach a complete explanation.
b. Do you have a separate contract with the Department to provide medical transportation for
Total residents? No If YES, please indicate the amount of income earned from such
a
program during this reporting period. $
(4) EXHIBIT: Total payments OR DUES TO EACH ORGANIZATION LISTED ABOV
E
c. What percent of all travel expense relates to transportation of nurses and patients
?
100%
(2 and 3 combined
)
d. Have vehicle usage logs been maintained
?
N/A
e. Are all vehicles stored at the nursing home during the night and all othe
r
times when not in use
?
No
f. Has the cost for commuting or other personal use of autos been adjuste
d
out of the cost report?
Total
g.
D
oes
th
e
f
ac
ilit
y
t
ranspor
t
res
id
en
t
s
t
o an
d
f
rom
d
ay
t
ra
i
n
i
ng
?
No
Indicate the amount of income earned from providing such
(5) Indicate the total amount of both disposable and non-disposable incontinent expens
e
transportation during this reporting period. $
and the location of this expense on Sch. V. $ 80,119 Line 10
(13) Has an audit been performed by an independent certified public accounting firm
?
No
(6) Have all costs reported on this form been determined using accounting procedure
s
Firm Name:
consistent with prior reports? Yes If NO, attach a complete explanation.
(14) Have all costs which do not relate to the provision of long term care been adjusted ou
t
(7) Indicate the amount of the Provider Participation Fees paid and accrued to the Departmen
t
out of Schedule V? Yes
during this cost report period. $ 410,794
This amount is to be recorded on line 42 of Schedule V. (15) Has a schedule for the legal fees reported on the cost report been provided by the facility
?
See page 39 of the instructions for details. Yes
(8) Are there any salary costs which have been allocated to more than one line on Schedule
V
Attach invoices and a summary of services for all architect and appraisal fees
.
for an individual employee
?
No If YES, attach an explanation of the allocation.
HFS 3745 (N-4-99) IL478-2471
