I. IDPH Facility ID Number: II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

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1 FOR OHF USE IMPORTANT NOTICE LL1 THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY 2004 PURPOSE AS OUTLINED IN 210 ILCS 45/ DISCLOSURE STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDE DEPARTMENT OF PUBLIC AID ANY INFORMATION ON OR BEFORE THE DUE DATE WILL FINANCIAL AND STATISTICAL REPORT FOR RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER. (FISCAL YEAR 2004) I. IDPH Facility ID Number: II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER Facility Name: Brentwood N Nsg. & Rehab Ctr. Address: 3705 Deerfield Road Riverwoods I have examined the contents of the accompanying report to the State of Illinois, for the period from 01/01/04 to 12/31/04 Number City Zip Code and certify to the best of my knowledge and belief that the said contents County: Lake are true, accurate and complete statements in accordance with applicable instructions. Declaration of preparer (other than provider) Telephone Number: (847) Fax # (847) is based on all information of which preparer has any knowledge. IDPA ID Number: Intentional misrepresentation or falsification of any information in this cost report may be punishable by fine and/or imprisonment. Date of Initial License for Current Owners: 07/21/01 (Signed) Officer or (Date) Type of Ownership: Administrator (Type or Print Name) of Provider VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title) Charitable Corp. Individual State Trust Partnership County (Signed) IRS Exemption Code Corporation Other (Date) "Sub-S" Corp. Paid (Print Name Marvin Fox, C.P.A. X Limited Liability Co. Preparer and Title) Trust Other (Firm Name Frost, Ruttenberg & Rothblatt, P.C. & Address) 111 Pfingsten Road, Suite 300 Deerfield, IL (Telephone) (847) Fax #(847) MAIL TO: OFFICE OF HEALTH FINANCE In the event there are further questions about this report, please contact: ILLINOIS DEPARTMENT OF PUBLIC AID Name:: Steve Lavenda Telephone Number: (847) S. Grand Avenue East Springfield, IL Phone # (217) DPA 3745 (N-4-99) IL

2 Page 2 III. STATISTICAL DATA D. How many bed-hold days during this year were paid by Public Aid? A. Licensure/certification level(s) of care; enter number of beds/bed days, None (Do not include bed-hold 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 (E.g., day care, "meals on wheels", outpatient therapy) None Beds at Licensed Beginning of Licensure Beds at End of Bed Days During F. Does the facility maintain a daily midnight census? Yes Report Period Level of Care Report Period Report Period G. Do pages 3 & 4 include expenses for services or Skilled (SNF) ,768 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 you start providing long term care at this location? TOTALS ,768 7 Date started 07/21/01 J. Was the facility purchased or leased after January 1, 1978? B. Census-For the entire report period. YES X Date 07/21/01 NO Level of Care Patient Days by Level of Care and Primary Source of Payment K. Was the facility certified for Medicare during the reporting year? Public Aid YES X NO If YES, enter number Recipient Private Pay Other Total of beds certified 248 and days of care provided 12,823 8 SNF 5,106 19,689 14,911 39, SNF/PED 9 Medicare Intermediary Mutual of Omaha 10 ICF 3,298 3, , ICF/DD 11 IV. ACCOUNTING BASIS 12 SC 12 MODIFIED 13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH* 14 TOTALS 8,404 23,069 15,270 46, Is your fiscal year identical to your tax year? YES X NO C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: 12/31/04 Fiscal Year: 12/31/04 bed days on line 7, column 4.) 51.50% * All facilities other than governmental must report on the accrual basis.

3 Facility Name & ID Number Brentwood N Nsg. & Rehab Ctr. STATE OF ILLINOIS # Report Period Beginning: 01/01/04 Ending: Page 3 12/31/04 V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar) Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR OHF USE ONLY Operating Expenses Salary/Wage Supplies Other Total ification Total ments Total A. General Services Dietary 418,417 48, , ,200 9, , Food Purchase 256, ,775 (3,953) 252,822 (5,959) 246, Housekeeping 3, , , , , Laundry 1, , , , , Heat and Other Utilities 198, , ,472 4, , Maintenance 94,897 16, , , ,924 (11,466) 212, Other (specify):* 7 8 TOTAL General Services 513, , ,735 1,670,526 (3,953) 1,666,573 (3,968) 1,662,605 8 B. Health Care and Programs 9 Medical Director 46,500 46,500 46,500 46, Nursing and Medical Records 3,127, , ,147 3,355,620 3,355,620 12,575 3,368, a Therapy 4,816 4,816 4,816 4,816 10a 11 Activities 209,612 13, , , , Social Services 167, , , , Nurse Aide Training Program Transportation Other (specify):* 10,491 10, TOTAL Health Care and Programs 3,505, , ,587 3,799,074 3,799,074 23,066 3,822, C. General Administration 17 Administrative 90, , , ,858 (198,808) 580, Directors Fees Professional Services 94,642 94,642 94,642 (1,930) 92, Dues, Fees, Subscriptions & Promotions 101, , ,462 (43,719) 57, Clerical & General Office Expenses 138,377 51, , , ,926 (278,369) 274, Employee Benefits & Payroll Taxes 972, ,080 3, , , Inservice Training & Education Travel and Seminar 2,794 2,794 2,794 2, Other Admin. Staff Transportation Insurance-Prop.Liab.Malpractice 459, , , , Other (specify):* 65,485 65, TOTAL General Administration 228,718 51,413 2,682,486 2,962,617 3,953 2,966,570 (457,341) 2,509, TOTAL Operating Expense 29 (sum of lines 8, 16 & 28) 4,247, ,968 3,675,808 8,432,217 8,432,217 (438,243) 7,993, *Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000. NOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification.

4 Page 4 Facility Name & ID Number Brentwood N Nsg. & Rehab Ctr. # Report Period Beginning: 01/01/04 Ending: 12/31/04 # V. COST CENTER EXPENSES (continued) Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR OHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments Total D. Ownership Depreciation 117, , , , , Amortization of Pre-Op. & Org. 96,612 96, Interest 13,336 13,336 13, , , Real Estate Taxes 161, , , , Rent-Facility & Grounds 977, , ,095 (934,064) 43, Rent-Equipment & Vehicles 17,927 17,927 17,927 5,150 23, Other (specify):* TOTAL Ownership 1,287,533 1,287,533 1,287, ,895 1,524, Ancillary Expense E. Special Cost Centers 38 Medically Necessary Transportation Ancillary Service Centers 763, ,991 1,661,962 1,661,962 (24,383) 1,637, Barber and Beauty Shops Coffee and Gift Shops Provider Participation Fee 136, , , , Other (specify):* 85,964 9,905 26, , ,092 (122,092) TOTAL Special Cost Centers 85, ,876 1,060,366 1,920,206 1,920,206 (146,475) 1,773, GRAND TOTAL COST 45 (sum of lines 29, 37 & 44) 4,333,405 1,282,844 6,023,707 11,639,956 11,639,956 (347,824) 11,292, *Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.

5 Page 5 VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7. In column 2 below, reference the line on which the particular cost was included. (See instructions.) 1 2 Refer- 3 OHF USE B. If there are expenses experienced by the facility which do not appear in the NON-ALLOWABLE EXPENSES Amount ence ONLY general ledger, they should be entered below.(see instructions.) 1 Day Care $ $ Other Care for Outpatients 2 Amount Reference 3 Governmental Sponsored Special Programs 3 31 Non-Paid Workers-Attach Schedule* $ 31 4 Non-Patient Meals (4,695) Donated Goods-Attach Schedule* 32 5 Telephone, TV & Radio in Resident Rooms (20,603) 21 5 Amortization of Organization & 6 Rented Facility Space 6 33 Pre-Operating Expense 33 7 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization 8 Laundry for Non-Patients 8 34 Costs (Schedule VII) 303, Non-Straightline Depreciation (144,124) Other- Attach Schedule Interest and Other Investment Income (3,906) SUBTOTAL (B): (sum of lines 31-35) $ 303, Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS 12 Non-Working Officer's or Owner's Salary TOTAL ADJUSTMENTS (A) and (B) ) $ (347,824) Sales Tax (1,264) Non-Care Related Interest 14 *These costs are only allowable if they are necessary to meet minimum 15 Non-Care Related Owner's Transactions 15 licensing standards. Attach a schedule detailing the items included 16 Personal Expenses (Including Transportation) 16 on these lines. 17 Non-Care Related Fees Fines and Penalties 18 C. Are the following expenses included in Sections A to D of pages 3 19 Entertainment (2,234) and 4? If so, they should be reclassified into Section E. Please 20 Contributions 20 reference the line on which they appear before reclassification. 21 Owner or Key-Man Insurance 21 (See instructions.) Special Legal Fees & Legal Retainers 22 Yes No Amount Reference 23 Malpractice Insurance for Individuals Medically Necessary Transport. $ Bad Debt (220,000) Fund Raising, Advertising and Promotional (34,531) Gift and Coffee Shops 40 Income Taxes and Illinois Personal 41 Barber and Beauty Shops Property Replacement Tax Laboratory and Radiology Nurse Aide Training for Non-Employees Prescription Drugs Yellow Page Advertising (6,658) Exceptional Care Program Other-Attach Schedule (213,245) Other-Attach Schedule SUBTOTAL (A): (Sum of lines 1-29) $ (651,261) $ Other-Attach Schedule TOTAL (C): (sum of lines 38-46) $ OHF USE ONLY

6 Page 5A Brentwood N Nsg. & Rehab Ctr. ID# Report Period Beginning: 01/01/04 Ending: 12/31/04 Sch. V Line NON-ALLOWABLE EXPENSES Amount Reference 1 Private Duty Wages $ (37,677) Bldg Co - Legal Fees (1,078) Marketing Salaries (85,964) Marketing Consultants (7,265) Marketing Expenses (28,863) Bank Fees (27,198) Taxes - Other (2,385) Misc. Income (5,949) IL Council - COPE Dues (2,530) Capitalized R&M (12,406) Non-Allowable Legal (1,930)

7 Total (213,245) 101

8 Summary A 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 Dietary 9,228 9, Food Purchase (5,959) (5,959) 2 3 Housekeeping 3 4 Laundry 4 5 Heat and Other Utilities 4,229 4, Maintenance (12,406) 940 (11,466) 6 7 Other (specify):* 7 8 TOTAL General Services (18,365) 14,397 (3,968) 8 B. Health Care and Programs 9 Medical Director 9 10 Nursing and Medical Records (37,677) 50,252 12, a Therapy 10a 11 Activities Social Services Nurse Aide Training Program Transportation Other (specify):* 10,491 10, TOTAL Health Care and Programs (37,677) 60,743 23, C. General Administration 17 Administrative (198,808) (198,808) Directors Fees Professional Services (3,008) 1,078 (1,930) Fees, Subscriptions & Promotions (43,719) (43,719) Clerical & General Office Expenses (278,369) (278,369) Employee Benefits & Payroll Taxes Inservice Training & Education Travel and Seminar Other Admin. Staff Transportation Insurance-Prop.Liab.Malpractice Other (specify):* 65,485 65, TOTAL General Administration (325,096) 1,078 (133,323) (457,341) 28 TOTAL Operating Expense 29 (sum of lines 8,16 & 28) (381,138) 1,078 (58,183) (438,243) 29

9 Summary B 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 (144,124) 658,549 23, , Amortization of Pre-Op. & Org. 96,612 96, Interest (3,906) 533,193 2, , Real Estate Taxes Rent-Facility & Grounds (974,508) 40,444 (934,064) Rent-Equipment & Vehicles 5,150 5, Other (specify):* TOTAL Ownership (148,030) 313,846 71, , Ancillary Expense E. Special Cost Centers 38 Medically Necessary Transportation Ancillary Service Centers (24,383) (24,383) Barber and Beauty Shops Coffee and Gift Shops Provider Participation Fee Other (specify):* (122,092) (122,092) TOTAL Special Cost Centers (122,092) (24,383) (146,475) 44 GRAND TOTAL COST 45 (sum of lines 29, 37 & 44) (651,261) 314,924 12,896 (24,383) (347,824) 45

10 Page 6 VII. RELATED PARTIES A. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Attach an additional schedule if necessary OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES Name Ownership % Name City Name City Type of Business Boulevard Healthcare, LLC See Attached See Attached 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 1 V 34 Rental Income $ 974,508 Brentwood Realty, LLC $ $ (974,508) 1 2 V 19 Legal Fees Brentwood Realty, LLC 1,078 1, V 30 Depreciation Brentwood Realty, LLC 658, , V 31 Amortization Brentwood Realty, LLC 96,612 96, V 32 Interest Expense Brentwood Realty, LLC 533, , V 6 7 V 7 8 V 8 9 V 9 10 V V V V Total $ 974,508 $ 1,289,432 $ * 314, * Total must agree with the amount recorded on line 34 of Schedule VI.

11 Page 6A VII. RELATED PARTIES (continued) 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 17 Management Fees $ 688,517 Boulevard Healthcare Management, LLC % $ $ (688,517) V 5 Utilities Boulevard Healthcare Management, LLC % 4,229 4, V 10 Nursing & Rehabilitation Boulevard Healthcare Management, LLC % 50,252 50, V 15 Payroll Taxes, Fringes, Staff Dev. Boulevard Healthcare Management, LLC % 10,491 10, V 1 Dietary Expenses Boulevard Healthcare Management, LLC % 9,228 9, V 17 Administrative & General Boulevard Healthcare Management, LLC % 489, , V 6 Maint. & Minor Equipment Boulevard Healthcare Management, LLC % V 27 Payroll Taxes, Fringes, Staff Dev. Boulevard Healthcare Management, LLC % 65,485 65, V 30 Depreciation Boulevard Healthcare Management, LLC % 23,406 23, V 34 Lease & Rent - Building Boulevard Healthcare Management, LLC % 40,444 40, V 35 Lease & Rent - Equipment Boulevard Healthcare Management, LLC % 5,150 5, V 32 Interest Expense Boulevard Healthcare Management, LLC % 2,079 2, V V V V V V V V V V V V Total $ 688,517 $ 701,413 $ * 12, * Total must agree with the amount recorded on line 34 of Schedule VI.

12 Page 6B VII. RELATED PARTIES (continued) 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 10A REHAB CONSULTING $ ADVANCED THERAPY & REHAB, LLC % $ $ V 39 ANCILLARY REHAB 893,154 ADVANCED THERAPY & REHAB, LLC % 868,771 (24,383) V V V V V V V V V V V V V V V V V V V V V V Total $ 893,154 $ 868,771 $ * (24,383) 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

13 Page 6C VII. RELATED PARTIES (continued) 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. 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V $ $ $ V V V V V V V V V V V V V V V V V V V V V V V Total $ $ $ * 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

14 Page 6D VII. RELATED PARTIES (continued) 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. 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V $ $ $ V V V V V V V V V V V V V V V V V V V V V V V Total $ $ $ * 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

15 Page 6E VII. RELATED PARTIES (continued) 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. 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V $ $ $ V V V V V V V V V V V V V V V V V V V V V V V Total $ $ $ * 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

16 Page 6F VII. RELATED PARTIES (continued) 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. 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V $ $ $ V V V V V V V V V V V V V V V V V V V V V V V Total $ $ $ * 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

17 Page 6G VII. RELATED PARTIES (continued) 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. 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V $ $ $ V V V V V V V V V V V V V V V V V V V V V V V Total $ $ $ * 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

18 Page 6H VII. RELATED PARTIES (continued) 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. 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V $ $ $ V V V V V V V V V V V V V V V V V V V V V V V Total $ $ $ * 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

19 Page 6I VII. RELATED PARTIES (continued) 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. 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 Cost Per General Ledger 4 5 Cost to Related Organization Difference: Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V $ $ $ V V V V V V V V V V V V V V V V V V V V V V V Total $ $ $ * 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

20 Page 7 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 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 Marilyn Cloch Relative Clerical 0 None % Salary $ 9, Jeff Elowe Owner Administrative 2.10% See Attached % Alloc. Salary 19, Fred Benjamin Owner Administrative 0.70% See Attached % Alloc. Salary 24, TOTAL $ 53, * 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 COMPENSATION

21 Page 8 VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO X City / State / Zip Code Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( ) 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 $ $ $ TOTALS $ $ $ 25

22 Page 8A VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization Boulevard Healthcare Management, LLc A. Are there any costs included in this report which were derived from allocations of central office Street Address 8950 Gross Point Road, Suite 600 or parent organization costs? (See instructions.) YES X NO City / State / Zip Code Skokie, IL Phone Number ( 847) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( 847) 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 $ $ $ Utilities Patient Days/Direct 289, ,313 46,743 4, Nursing & Rehabilitation Patient Days/Direct 289, , ,816 46,743 50, Payroll Taxes, Fringes, Staff Dev. Patient Days/Direct 289, ,368 46,743 10, Dietary Expenses Patient Days/Direct 289, ,197 53,197 46,743 9, Administrative & General Patient Days/Direct 289, ,972,648 1,908,144 46, , Maint. & Minor Equipment Patient Days/Direct 289, ,628 46, Payroll Taxes, Fringes, Staff Dev. Patient Days/Direct 289, ,384 46,743 65, Depreciation Patient Days/Direct 289, ,111 46,743 23, Lease & Rent - Building Patient Days/Direct 289, ,312 46,743 40, Lease & Rent - Equipment Patient Days/Direct 289, ,234 46,743 5, Interest Expense Patient Days/Direct 289, ,783 46,743 2, TOTALS $ 4,188,794 $ 2,262,157 $ 701,413 25

23 Page 8B VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization ADVANCED THERAPY AND REHAB, LLC A. Are there any costs included in this report which were derived from allocations of central office Street Address 8950 GROSS POINT RD. #E or parent organization costs? (See instructions.) YES X NO City / State / Zip Code SKOKIE, IL Phone Number ( 847) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( 847) 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 A REHAB CONSULTING DIRECT ALLOCATION ANCILLARY REHAB DIRECT ALLOCATION 868, TOTALS $ $ $ 868,771 25

24 Page 8C VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( ) 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 $ $ $ TOTALS $ $ $ 25

25 Page 8D VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( ) 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 $ $ $ TOTALS $ $ $ 25

26 Page 8E VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( ) 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 $ $ $ TOTALS $ $ $ 25

27 Page 8F VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( ) 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 $ $ $ TOTALS $ $ $ 25

28 Page 8G VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( ) 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 $ $ $ TOTALS $ $ $ 25

29 Page 8H VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( ) 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 $ $ $ TOTALS $ $ $ 25

30 Page 8I VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO City / State / Zip Code Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( ) 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 $ $ $ TOTALS $ $ $ 25

31 STATE OF ILLINOIS Page 9 IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.) Reporting Monthly Maturity Interest Period Name of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest YES NO Required Note Original Balance (4 Digits) Expense A. Directly Facility Related Long-Term 1 LaSalle Bank X Mortgage Building $ $ 10,856,000 $ 533, See Supplemental Schedule 5 Working Capital 6 LaSalle Bank X Line of Credit 2,000, ,388 Prime+1% 13, Intercompany Note X 300, See Supplemental Schedule 2, TOTAL Facility Related $ 2,000,000 $ 11,722,388 $ 548,608 9 B. Non-Facility Related* 10 Interest Income X (3,906) See Supplemental Schedule TOTAL Non-Facility Related $ $ $ (3,906) TOTALS (line 9+line14) $ 2,000,000 $ 11,722,388 $ 544, ) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ None Line # N/A *Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7. (See instructions.) ** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2. (See instructions.)

32 STATE OF ILLINOIS Page 9 - SUPPLEMENTAL IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE - SUPPLEMENTAL SCHEDULE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.) Reporting Monthly Maturity Interest Period Name of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest YES NO Required Note Original Balance (4 Digits) Expense A. Directly Facility Related Long-Term 1 $ $ $ TOTAL Long-Term 7 Working Capital 8 Alloc From Boulevard HC X $ $ $ 2, TOTAL Working Capital 2, B. Non-Facility Related* 15 $ $ $ TOTAL Non-Facility Related 20 *Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7. (See instructions.) ** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2. (See instructions.)

33 STATE OF ILLINOIS Page 10 IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued) B. Real Estate Taxes Important, please see the next worksheet, "RE_Tax". The real estate tax statement and 1. Real Estate Tax accrual used on 2003 report. bill must accompany the cost report. $ 154, 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.) $ 153, Under or (over) accrual (line 2 minus line 1). $ (1,097) 3 4. Real Estate Tax accrual used for 2004 report. (Detail and explain your calculation of this accrual on the lines below.) $ 163, 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. $ 161,903 7 Real Estate Tax History: Real Estate Tax Bill for Calendar Year: FOR OHF USE ONLY , , FROM R. E. TAX STATEMENT FOR 2003 $ , , PLUS APPEAL COST FROM LINE 5 $ 14 Beginning Accrual Adjusted To Correct Amount 2004 Accrual - $153,325 X 1.06 = $163, LESS REFUND FROM LINE 6 $ AMOUNT TO USE FOR RATE CALCULATION $ 16 NOTES: 1. Please indicate a negative number by use of brackets( ). Deduct any overaccrual of 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. This denial must be no more than four years old at the time the cost report is filed.

34 IMPORTANT NOTICE TO: Long Term Care Facilities with Real Estate Tax Rates RE: 2003 REAL ESTATE TAX COST DOCUMENTATION In order to set the real estate tax portion of the capital rate, it is necessary that we obtain additional information regarding your calendar 2003 real estate tax costs, as well as copies of your original real estate tax bills for calendar Please complete the Real Estate Tax Statement below and forward with a copy of your 2003 real estate tax bill to the Department of Public Aid, Office of Health Finance, 201 South Grand Avenue East, Springfield, Illinois Please send these items in with your completed 2004 cost report. The cost report will not be considered complete and timely filed until this statement and the corresponding real estate tax bills are filed. If you have any questions, please call the Office of Health Finance at (217) LONG TERM CARE REAL ESTATE TAX STATEMENT FACILITY NAME Brentwood N Nsg. & Rehab Ctr. COUNTY Lake FACILITY IDPH LICENSE NUMBER CONTACT PERSON REGARDING THIS REPORT Steve Lavenda TELEPHONE (847) FAX #: (847) A. Summary of Real Estate Tax Cost Enter the tax index number and real estate tax assessed for 2003 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 (A) (B) (C) (D) Tax Applicable to Tax Index Number Property Description Total Tax Nursing Home Long Term Care Property $ 147, $ 147, Long Term Care Property $ 3, $ 3, Long Term Care Property $ 1, $ 1, $ $ 5. $ $ 6. $ $ 7. $ $ 8. $ $ 9. $ $ 10. $ $ B. Real Estate Tax Cost Allocations TOTALS $ 153, $ 153, 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 & 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 a copy of the original 2003 tax bills which were listed in Section A to this statement. Be sure to use the 2003 tax bill which is normally paid during Page 10A

35 IMPORTANT NOTICE TO: Long Term Care Facilities with Real Estate Tax Rates RE: 2000 REAL ESTATE TAX COST DOCUMENTATION In order to set the real estate tax portion of the capital rate, it is necessary that we obtain additional information regarding your calendar 2000 real estate tax costs, as well as copies of your real estate tax bills for calendar Please complete the Real Estate Tax Statement below and forward with a copy of your 2000 real estate tax bill to the Department of Public Aid, Office of Health Finance, 201 South Grand Avenue East, Springfield, Illinois Please send these items in with your completed 2001 cost report. The cost report will not be considered complete and timely filed until this statement and the corresponding real estate tax bills are filed. If you have any questions, please call the Office of Health Finance at (217) LONG TERM CARE REAL ESTATE TAX STATEMENT FACILITY NAME Brentwood N Nsg. & Rehab Ctr. COUNTY Lake FACILITY IDPH LICENSE NUMBER CONTACT PERSON REGARDING THIS REPORT Steve Lavenda TELEPHONE (847) FAX #: (847) A. Summary of Real Estate Tax Cost Enter the tax index number and real estate tax assessed for 2000 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 (A) (B) (C) (D) Tax Applicable to Tax Index Number Property Description Total Tax Nursing Home 1. $ $ 2. $ $ 3. $ $ 4. $ $ 5. $ $ 6. $ $ 7. $ $ 8. $ $ 9. $ $ 10. $ $ B. Real Estate Tax Cost Allocations TOTALS $ $ 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 NO If YES, attach an explanation & 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 a copy of the 2000 tax bills which were listed in Section A to this statement. Be sure to use the 2000 tax bill which is normally paid during Page 10B

36 Page 11 X. BUILDING AND GENERAL INFORMATION: A. Square Feet: 90,758 B. General Construction Type: Exterior Brick/Masonry Frame Metal Frame Number of Stories 1 C. Does the Operating Entity? (a) Own the Facility X (b) Rent from a Related Organization. (c) Rent from Completely Unrelated Organization. (Facilities checking (a) or (b) must complete Schedule XI. Those checking (c) may complete Schedule XI or Schedule XII-A. See instructions.) D. Does the Operating Entity? X (a) Own the Equipment X (b) Rent equipment from a Related Organization. X (c) Rent equipment from Completely Unrelated Organization. (Facilities checking (a) or (b) must complete Schedule XI-C. Those checking (c) may complete Schedule XI-C or Schedule XII-B. See instructions.) E. List all other business entities owned by this operating entity or related to the operating entity that are located on or adjacent to this nursing home's grounds (such as, but not limited to, apartments, assisted living facilities, day training facilities, day care, independent living facilities, nurse aide training facilities, etc.) List entity name, type of business, square footage, and number of beds/units available (where applicable). None F. Does this cost report reflect any organization or pre-operating costs which are being amortized? X YES NO If so, please complete the following: 1. Total Amount Incurred: 238, Number of Years Over Which it is Being Amortized: 5 Years; 2 Years 3. Current Period Amortization: 96, Dates Incurred: 2001 Nature of Costs: Closing Costs (Attach a complete schedule detailing the total amount of organization and pre-operating costs.) XI. OWNERSHIP COSTS: A. Land. Use Square Feet Year Acquired Cost 1 Facility 2001 $ 2,200, Gazebo Property , TOTALS $ 2,434,006 3

37 Page 12 XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar FOR OHF USE ONLY Year Year Current Book Life Straight Line Accumulated Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation 1 4 $ $ $ $ $ Improvement Type** *Total beds on this schedule must agree with page 2. See Page 12A, Line 70 for total **Improvement type must be detailed in order for the cost report to be considered complete.

38 Page 12A XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar Year Current Book Life Straight Line Accumulated Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation $ $ $ $ $ Related Building Company (Pages 12-BLDG & 12A-BLDG) 8,989, , ,432 8, Related Party Allocations (Pages 12-REP & 12A-REP) 2, , Financial Statement Depreciation 117,272 (117,272) TOTAL (lines 4 thru 69) $ 8,992,816 $ 568,638 $ 460,008 $ (108,630) $ 1, **Improvement type must be detailed in order for the cost report to be considered complete.

39 Page 12B XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar Year Current Book Life Straight Line Accumulated Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation 1 Totals from Page 12A, Carried Forward $ 8,992,816 $ 568,638 $ 460,008 $ (108,630) $ 1, Water Heater Repair Light Ballasts Plumbing Simplex Lock Soffit Repair , Network Cabling , ,041 1,041 3, Newwork Install , , Plumbing A/C Heat Exchanger Nurse Call System , Security Keypads , Nurse Call System , Repair Boiler , Network Cabling , Air Conditioning Unit , Gutter Cables , Electrical Wiring , Fire Alarm Components , Fire Alarm Covers Thermocouples - Boiler , Replace Boiler # , , Condensor Coil Install Burners A/C Repair Drain , Drain Door Ice Removal Roof , Toilet Repair Electrical , Garbage Disposal , Door Release TOTAL (lines 1 thru 33) $ 9,082,284 $ 568,638 $ 465,431 $ (103,207) $ 16, **Improvement type must be detailed in order for the cost report to be considered complete.