I. IDPH License ID Number: 0042192 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

FOR BHF USE LL1 IMPORTANT NOTICE THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY 2008 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 2008) I. IDPH License ID Number: 0042192 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER Facility Name: Alden Orland Park Rehab & Health Care Center I have examined the contents of the accompanying report to the Address: 16450 South 97th Avenue Orland Park 60462 State of Illinois, for the period from 1/1/08 to 12/31/08 Number City Zip Code and certify to the best of my knowledge and belief that the said contents are true, accurate and complete statements in accordance with County: Cook applicable instructions. Declaration of preparer (other than provider) is based on all information of which preparer has any knowledge. Telephone Number: (708) 403-6500 Fax # (708) 873-9774 Intentional misrepresentation or falsification of any information HFS ID Number: 36-3901683 in this cost report may be punishable by fine and/or imprisonment. Date of Initial License for Current Owners: 01/08/98 (Signed) Officer or Type of Ownership: Administrator (Type or Print Name) Joan Carl of Provider VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title) Vice-President Charitable Corp. Individual State Trust Partnership County (Signed) IRS Exemption Code X Corporation Other (Date) "Sub-S" Corp. Paid (Print Name Limited Liability Co. Preparer and Title) Trust Other (Firm Name & Address) (Telephone) ( ) Fax # ( ) 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:Steven M. Kroll Telephone Number: (773) 286-3883 201 S. Grand Avenue East Email Address: Springfield, IL 62763-0001 Phone # (217) 782-1630 (Date)

STATE OF ILLINOIS Page 2 III. STATISTICAL DATA D. How many bed-hold days during this year were paid by the Department? 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 E. List all services provided by your facility for non-patients. 1 2 3 4 (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 1 200 Skilled (SNF) 200 73,200 1 investments not directly related to patient care? 2 Skilled Pediatric (SNF/PED) 0 2 YES NO x 3 Intermediate (ICF) 0 3 4 Intermediate/DD 0 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets? 5 Sheltered Care (SC) 0 5 YES NO x 6 ICF/DD 16 or Less 0 6 I. On what date did you start providing long term care at this location? 7 200 TOTALS 200 73,200 7 Date started 01/19/98 J. Was the facility purchased or leased after January 1, 1978? B. Census-For the entire report period. YES Date NO X 1 2 3 4 5 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? Medicaid YES X NO If YES, enter number Recipient Private Pay Other Total of beds certified 200 and days of care provided 23,996 8 SNF 910 3,944 25,953 30,807 8 9 SNF/PED 9 Medicare Intermediary National Government Services 10 ICF 11,172 12,556 23,728 10 11 ICF/DD 11 IV. ACCOUNTING BASIS 12 SC 12 MODIFIED 13 DD 16 OR LESS 13 ACCRUAL x CASH* CASH* 14 TOTALS 12,082 16,500 25,953 54,535 14 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: 12/31/08 Fiscal Year: 12/31/08 bed days on line 7, column 4.) 74.50% * All facilities other than governmental must report on the accrual basis.

STATE OF ILLINOIS Page 3 Facility Name & ID Number Alden Orland Park Rehab & Health Care Ce # 0042192 Report Period Beginning: 1/1/08 Ending: 12/31/08 V. COST CENTER EXPENSES (throughout the report, please 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 1 2 3 4 5 6 7 8 9 10 1 Dietary 641,034 39,427 10,800 691,261 2,712 693,973 4,510 698,483 1 2 Food Purchase 493,191 493,191 (27,099) 466,092 (22,826) 443,266 2 3 Housekeeping 293,164 88,508 381,672 3,606 385,278 4,396 389,674 3 4 Laundry 79,279 26,285 645 106,209 93 106,302 106,302 4 5 Heat and Other Utilities 279,382 279,382 279,382 (4,520) 274,862 5 6 Maintenance 58,901 252,658 311,559 688 312,247 48,560 360,807 6 7 Other (specify):* Security & Rel Party 84 84 84 6,584 6,668 7 8 TOTAL General Services 1,072,378 647,411 543,569 2,263,358 (20,000) 2,243,358 36,704 2,280,062 8 B. Health Care and Programs 9 Medical Director 41,600 41,600 41,600 41,600 9 10 Nursing and Medical Records 3,212,166 258,835 5,500 3,476,501 26,792 3,503,293 55,116 3,558,409 10 10a Therapy 83,777 304 84,081 84,081 84,081 10a 11 Activities 121,731 3,075 2,729 127,535 103 127,638 127,638 11 12 Social Services 72,024 72,024 72,024 72,024 12 13 CNA Training 13 14 Program Transportation 14 15 Other (specify):* Related Party Benef 8,451 8,451 15 16 TOTAL Health Care and Programs 3,489,698 262,214 49,829 3,801,741 26,895 3,828,636 63,567 3,892,203 16 C. General Administration 17 Administrative 130,249 130,249 130,249 107,453 237,702 17 18 Directors Fees 18 19 Professional Services 1,352,100 1,352,100 (20,163) 1,331,937 (1,256,036) 75,901 19 20 Dues, Fees, Subscriptions & Promotions 78,899 78,899 78,899 (60,604) 18,295 20 21 Clerical & General Office Expenses 301,944 39,199 71,966 413,109 1,921 415,030 293,269 708,299 21 22 Employee Benefits & Payroll Taxes 779,288 779,288 11,347 790,635 (12,028) 778,607 22 23 Inservice Training & Education 23 24 Travel and Seminar 7,467 7,467 7,467 3,007 10,474 24 25 Other Admin. Staff Transportation 4,620 4,620 4,620 13,205 17,825 25 26 Insurance-Prop.Liab.Malpractice 218,631 218,631 (1,731) 216,900 11,837 228,737 26 27 Other (specify):* Bad Debt & relat party benef 133,460 133,460 133,460 (74,163) 59,297 27 28 TOTAL General Administration 432,193 39,199 2,646,431 3,117,823 (8,626) 3,109,197 (974,060) 2,135,137 28 TOTAL Operating Expense 29 (sum of lines 8, 16 & 28) 4,994,269 948,824 3,239,829 9,182,922 (1,731) 9,181,191 (873,789) 8,307,402 29 *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.

STATE OF ILLINOIS Page 4 Facility Name & ID Number Alden Orland Park Rehab & Health Care Center #0042192 Report Period Beginning: 1/1/08 Ending: 12/31/08 # V. COST CENTER EXPENSES (continued) Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments Total D. Ownership 1 2 3 4 5 6 7 8 9 10 30 Depreciation 83,367 83,367 83,367 417,147 500,514 30 31 Amortization of Pre-Op. & Org. 905 905 (905) 31 32 Interest 218,872 218,872 2,636 221,508 734,186 955,694 32 33 Real Estate Taxes 685,358 685,358 (685,358) 708,376 708,376 33 34 Rent-Facility & Grounds 998,594 998,594 685,358 1,683,952 (1,683,952) 34 35 Rent-Equipment & Vehicles 12,762 12,762 12,762 41,376 54,138 35 36 Other (specify):* 70,595 70,595 36 37 TOTAL Ownership 1,999,858 1,999,858 1,731 2,001,589 287,728 2,289,317 37 Ancillary Expense E. Special Cost Centers 38 Medically Necessary Transportation 38 39 Ancillary Service Centers 1,131,191 1,978,991 3,110,182 3,110,182 (153,092) 2,957,090 39 40 Barber and Beauty Shops 53,071 53,071 53,071 53,071 40 41 Coffee and Gift Shops 41 42 Provider Participation Fee 109,800 109,800 109,800 109,800 42 43 Other (specify):* 43 44 TOTAL Special Cost Centers 53,071 1,131,191 2,088,791 3,273,053 3,273,053 (153,092) 3,119,961 44 GRAND TOTAL COST 45 (sum of lines 29, 37 & 44) 5,047,340 2,080,015 7,328,478 14,455,833 14,455,833 (739,153) 13,716,680 45 *Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.

Alden Orland Park Rehab & Health Care Center IDPH Facility ID Number: #0042192 Reclassifications on Pgs 3 & 4 - Column 5 Report Period Beginning: 1/1/2008 Report Period Ending: 12/31/2008 From Line To Line Amount Description 2 (27,099.00) Employee Meals 22 27,099.00 26 (1,731.00) Insurance Expense 32 1,731.00 22 (15,752.00) Uniform 1 2,712.00 3 3,606.00 4 93.00 6 688.00 10 7,129.00 11 103.00 21 1,421.00 19 (19,663.00) Pathway Service 10 19,663.00 31 (905.00) Amortization of Pre-Op. & Org. 32 905.00 33 (685,358.00) Rent - Real Estate Tax on associated landowner (Pg 6) 34 685,358.00 Rent - Real Estate Tax on associated landowner (Pg 6) 19 (500.00) Prepay misc court expense (AMS Legal) 21 500.00 Prepay misc court expense (AMS Legal) Net -

STATE OF ILLINOIS 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 3 Refer- BHF 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 $ $ 1 1 2 2 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 32 Donated Goods-Attach Schedule* 32 5 Telephone, TV & Radio in Resident Rooms 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) (409,327) Various 34 9 Non-Straightline Depreciation 2,145 30 9 35 Other- Attach Schedule (130,557) Pg 5A 35 10 Interest and Other Investment Income (1,336) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ (539,884) 36 11 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS 12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ (739,153) 37 13 Sales Tax (3,474) 2 13 14 Non-Care Related Interest (7,566) 32 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 (1,768) 21 17 18 Fines and Penalties 18 C. Are the following expenses included in Sections A to D of pages 3 19 Entertainment (2,715) 20 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions (6,795) 20 20 reference the line on which they appear before reclassification. 21 Owner or Key-Man Insurance 21 (See instructions.) 1 2 3 4 22 Special Legal Fees & Legal Retainers (24,221) 19 22 Yes No Amount Reference 23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. x $ 38 24 Bad Debt (133,460) 27 24 39 x 39 25 Fund Raising, Advertising and Promotional (19,588) 20 25 40 Gift and Coffee Shops x 40 Income Taxes and Illinois Personal 41 Barber and Beauty Shops x 41 26 Property Replacement Tax 26 42 Laboratory and Radiology x 42 27 CNA Training for Non-Employees 27 43 Prescription Drugs x 43 28 Yellow Page Advertising (491) 20 28 44 x 44 29 Other-Attach Schedule 29 45 Other-Attach Schedule x 45 30 SUBTOTAL (A): (Sum of lines 1-29) $ (199,269) $ 30 46 Other-Attach Schedule x 46 47 TOTAL (C): (sum of lines 38-46) $ 47 48 BHF USE ONLY 49 50 51 52

STATE OF ILLINOIS Page 5A Alden Orland Park Rehab & Health Care Center ID# 0042192 Report Period Beginning: 1/1/08 Ending: 12/31/08 Sch. V Line NON-ALLOWABLE EXPENSES Amount Reference 1 Late fees on utilities $ (7,827) 5 1 2 Late fees on telephone (67) 21 2 3 Other nursing income (flu, w/chair, etc) (12) 21 3 4 Intercompany interest (59,150) 32 4 5 Intercompany interest 5 6 Misc Income (Payroll) (59) 21 6 7 Misc Income (Medical Records) (20) 10 7 8 Misc Income (Jury Duty) (34) 21 8 9 Misc Income (Vending Receipts) (561) 2 9 10 Misc Income (Food Rebates) (956) 2 10 11 Marketing Manager Salaries (GL 6701-100-009) (77,904) 21 11 12 Add back credit posted for prior yr legal fees 345 19 12 13 Deduct Mkts Manager Employee Benefits (12,028) 22 13 14 Back out PAC of 32.30% of IHCA fees (3,269) 20 14 15 Leadership (Deming) training cost [4,001 x.21] (840) 24 15 16 Correct YTD Depreciation (1,577) 30 16 17 Expense Pg12 assets<$2,500 3,816 6 17 18 Elimin Pg 12 Depreciation adj for assets < $2,500 (4,337) 30 18 19 Expense Pg13 assets<$2,500 28,357 6 19 20 Elimin Pg 13 Depreciation adj for assets < $2,500 (9,133) 30 20 21 Expense related party items < $2,500 774 6 21 22 Elim Refund for '05 Tax Year 17,674 33 22 23 23 24 Adj for ABC related party profit-pg 12 (4) 30 24 25 Adj for ABC related party profit-pg 12 (1) 30 25 26 26 27 Eliminate "Americans for Job Security" costs (1,744) 20 27 28 Eliminate "Alliance for Quality Nursing" costs (2,000) 20 28 29 29 30 Correct YTD Depreciation 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 (130,557) 49

STATE OF ILLINOIS 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 0 0 6,262 (1,752) 0 0 0 0 0 0 0 4,510 1 2 Food Purchase (4,991) 0 0 (17,835) 0 0 0 0 0 0 0 (22,826) 2 3 Housekeeping 0 0 4,396 0 0 0 0 0 0 0 0 4,396 3 4 Laundry 0 0 0 0 0 0 0 0 0 0 0 0 4 5 Heat and Other Utilities (7,827) 0 3,307 0 0 0 0 0 0 0 0 (4,520) 5 6 Maintenance 32,947 0 15,753 0 0 0 (140) 0 0 0 0 48,560 6 7 Other (specify):* 0 0 5,932 652 0 0 0 0 0 0 0 6,584 7 8 TOTAL General Services 20,129 0 35,650 (18,935) 0 0 (140) 0 0 0 0 36,704 8 B. Health Care and Programs 9 Medical Director 0 0 0 0 0 0 0 0 0 0 0 0 9 10 Nursing and Medical Records (20) 0 50,146 3,251 1,739 0 0 0 0 0 0 55,116 10 10a Therapy 0 0 0 0 0 0 0 0 0 0 0 0 10a 11 Activities 0 0 0 0 0 0 0 0 0 0 0 0 11 12 Social Services 0 0 0 0 0 0 0 0 0 0 0 0 12 13 CNA Training 0 0 0 0 0 0 0 0 0 0 0 0 13 14 Program Transportation 0 0 0 0 0 0 0 0 0 0 0 0 14 15 Other (specify):* 0 0 8,451 0 0 0 0 0 0 0 0 8,451 15 16 TOTAL Health Care and Programs (20) 0 58,597 3,251 1,739 0 0 0 0 0 0 63,567 16 C. General Administration 17 Administrative 0 0 107,453 0 0 0 0 0 0 0 0 107,453 17 18 Directors Fees 0 0 0 0 0 0 0 0 0 0 0 0 18 19 Professional Services (23,876) 11,350 (1,243,510) 0 0 0 0 0 0 0 0 (1,256,036) 19 20 Fees, Subscriptions & Promotions (36,602) 0 (24,002) 0 0 0 0 0 0 0 0 (60,604) 20 21 Clerical & General Office Expenses (79,844) 9,975 262,162 17,602 83,374 0 0 0 0 0 0 293,269 21 22 Employee Benefits & Payroll Taxes (12,028) 0 0 0 0 0 0 0 0 0 0 (12,028) 22 23 Inservice Training & Education 0 0 0 0 0 0 0 0 0 0 0 0 23 24 Travel and Seminar (840) 0 3,847 0 0 0 0 0 0 0 0 3,007 24 25 Other Admin. Staff Transportation 0 0 13,205 0 0 0 0 0 0 0 0 13,205 25 26 Insurance-Prop.Liab.Malpractice 0 11,621 216 0 0 0 0 0 0 0 0 11,837 26 27 Other (specify):* (133,460) 0 52,138 1,871 5,288 0 0 0 0 0 0 (74,163) 27 28 TOTAL General Administration (286,650) 32,946 (828,491) 19,473 88,662 0 0 0 0 0 0 (974,060) 28 TOTAL Operating Expense 29 (sum of lines 8,16 & 28) (266,541) 32,946 (734,244) 3,789 90,401 0 (140) 0 0 0 0 (873,789) 29

STATE OF ILLINOIS 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 (12,907) 425,864 2,842 0 1,348 0 0 0 0 0 0 417,147 30 31 Amortization of Pre-Op. & Org. 0 0 0 0 0 0 0 0 0 0 0 0 31 32 Interest (68,052) 688,753 106,640 0 6,845 0 0 0 0 0 0 734,186 32 33 Real Estate Taxes 17,674 685,358 4,949 0 395 0 0 0 0 0 0 708,376 33 34 Rent-Facility & Grounds 0 (1,683,952) 0 0 0 0 0 0 0 0 0 (1,683,952) 34 35 Rent-Equipment & Vehicles 0 0 41,376 0 0 0 0 0 0 0 0 41,376 35 36 Other (specify):* 0 70,595 0 0 0 0 0 0 0 0 0 70,595 36 37 TOTAL Ownership (63,285) 186,618 155,807 0 8,588 0 0 0 0 0 0 287,728 37 Ancillary Expense E. Special Cost Centers 38 Medically Necessary Transportation 0 0 0 0 0 0 0 0 0 0 0 0 38 39 Ancillary Service Centers 0 0 0 (51,627) (177,171) 75,706 0 0 0 0 0 (153,092) 39 40 Barber and Beauty Shops 0 0 0 0 0 0 0 0 0 0 0 0 40 41 Coffee and Gift Shops 0 0 0 0 0 0 0 0 0 0 0 0 41 42 Provider Participation Fee 0 0 0 0 0 0 0 0 0 0 0 0 42 43 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 43 44 TOTAL Special Cost Centers 0 0 0 (51,627) (177,171) 75,706 0 0 0 0 0 (153,092) 44 GRAND TOTAL COST 45 (sum of lines 29, 37 & 44) (329,826) 219,564 (578,437) (47,838) (78,182) 75,706 (140) 0 0 0 0 (739,153) 45

STATE OF ILLINOIS 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. 1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES Name Ownership % Name City Name City Type of Business The Alden Group, Ltd. 100 See Pg 6K See Pg 6K 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 Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 1 V 34 Lease Revenue $ 1,683,952 Orland Associates Limited Liability Corporation $ $ (1,683,952) 1 2 V 32 Interest Income - RR 2,554 Orland Associates Limited Liability Corporation (2,554) 2 3 V 32 Interest Income - Interco. 146,233 Orland Associates Limited Liability Corporation (146,233) 3 4 V 32 Interest Income 26 Orland Associates Limited Liability Corporation (26) 4 5 V 19 Accounting Fees Orland Associates Limited Liability Corporation 11,350 11,350 5 6 V 21 Misc. Adm. Fees Orland Associates Limited Liability Corporation 9,975 9,975 6 7 V 33 Real Estate Tax Expense Orland Associates Limited Liability Corporation 685,358 685,358 7 8 V 26 Insurance Expense Orland Associates Limited Liability Corporation 11,621 11,621 8 9 V 36 Mortgage Ins Expense Orland Associates Limited Liability Corporation 70,595 70,595 9 10 V 32 Interest Expense Orland Associates Limited Liability Corporation 836,670 836,670 10 11 V 30 Depreciation Orland Associates Limited Liability Corporation 425,864 425,864 11 12 V 32 Amortization Orland Associates Limited Liability Corporation 896 896 12 13 V 13 14 Total $ 1,832,765 $ 2,052,329 $ * 219,564 14 * Total must agree with the amount recorded on line 34 of Schedule VI.

STATE OF ILLINOIS 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. 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 Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 5 Utilities $ Alden Management Services, Inc. 0.00% $ 3,307 $ 3,307 15 16 V 24 Travel / Seminar Alden Management Services, Inc. 3,847 3,847 16 17 V 25 Other Admin Travel Alden Management Services, Inc. 13,205 13,205 17 18 V 26 Insurance Alden Management Services, Inc. 216 216 18 19 V 20 Dues / Subscriptions 24,600 Alden Management Services, Inc. 598 (24,002) 19 20 V 30 Depreciation Alden Management Services, Inc. 2,842 2,842 20 21 V 32 Amortization Alden Management Services, Inc. 67 67 21 22 V 33 Real Estate Tax Alden Management Services, Inc. 4,949 4,949 22 23 V 35 Rent-Equip/Vehicle Alden Management Services, Inc. 41,376 41,376 23 24 V 32 Interest Alden Management Services, Inc. 106,573 106,573 24 25 V 1 Dietary Salary Alden Management Services, Inc. 6,262 6,262 25 26 V 3 Housekeeping Salary Alden Management Services, Inc. 4,396 4,396 26 27 V 7 Employee Benef-Gen'l Servs Alden Management Services, Inc. 5,932 5,932 27 28 V 10 Nurs/Med Rec Salary Alden Management Services, Inc. 50,146 50,146 28 29 V 15 Employee Benef-Health Care Alden Management Services, Inc. 8,451 8,451 29 30 V 17 Administrative Salary Alden Management Services, Inc. 107,453 107,453 30 31 V 27 Employee Benef-Administrative Alden Management Services, Inc. 52,138 52,138 31 32 V 19 Professional Fees 1,287,377 Alden Management Services, Inc. 43,867 (1,243,510) 32 33 V 21 Gen'l & Admin Alden Management Services, Inc. 262,162 262,162 33 34 V 6 Repair & Mainten. 21,521 Alden Management Services, Inc. 37,274 15,753 34 35 V 35 36 V 36 37 V 37 38 V 38 39 Total $ 1,333,498 $ 755,061 $ * (578,437) 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

STATE OF ILLINOIS 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. 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 Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 1 Dietary Consultant $ 10,800 Prism Health Care Services, Inc. 0.00% $ 2,733 $ (8,067) 15 16 V 1 Dietary Sal & Wages Prism Health Care Services, Inc. 6,315 6,315 16 17 V 2 Tube Feeding 24,675 Prism Health Care Services, Inc. 6,840 (17,835) 17 18 V 10 Equipment Rental-patient care 6,660 Prism Health Care Services, Inc. 9,911 3,251 18 19 V 39 Ancillary Supplies 103,025 Prism Health Care Services, Inc. 51,398 (51,627) 19 20 V 27 Employee Benefits Prism Health Care Services, Inc. 1,871 1,871 20 21 V 21 Gen'l & Admin Salaries Prism Health Care Services, Inc. 10,577 10,577 21 22 V 7 Employee Benefits Prism Health Care Services, Inc. 652 652 22 23 V 21 Gen'l & Admin Prism Health Care Services, Inc. 7,025 7,025 23 24 V 24 25 V 25 26 V 26 27 V 27 28 V 28 29 V 29 30 V 30 31 V 31 32 V 32 33 V 33 34 V 34 35 V 35 36 V 36 37 V 37 38 V 38 39 Total $ 145,160 $ 97,322 $ * (47,838) 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

STATE OF ILLINOIS 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. 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 Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 39 Drugs $ 519,920 Forum Extended Care Services II, Inc. 0.00% $ 755,905 $ 235,985 15 16 V 39 I.V. 482,624 Forum Extended Care Services II, Inc. 70,367 (412,257) 16 17 V 39 Wound Care 4,434 Forum Extended Care Services II, Inc. 3,535 (899) 17 18 V 10 House Stock 10,625 Forum Extended Care Services II, Inc. 10,021 (604) 18 19 V 10 Pharmacy Consult. 5,500 Forum Extended Care Services II, Inc. 7,843 2,343 19 20 V 27 Employ. Vaccin. 2,794 Forum Extended Care Services II, Inc. 2,228 (566) 20 21 V 27 Emp. Benef: G & A Forum Extended Care Services II, Inc. 5,854 5,854 21 22 V 21 Salary: G & A Forum Extended Care Services II, Inc. 50,402 50,402 22 23 V 21 Gen'l & Admin Forum Extended Care Services II, Inc. 32,972 32,972 23 24 V 32 Interest Forum Extended Care Services II, Inc. 6,845 6,845 24 25 V 33 Real Estate Tax Forum Extended Care Services II, Inc. 395 395 25 26 V 30 Depreciation Forum Extended Care Services II, Inc. 1,348 1,348 26 27 V 27 28 V 28 29 V 29 30 V 30 31 V 31 32 V 32 33 V 33 34 V 34 35 V 35 36 V 36 37 V 37 38 V 38 39 Total $ 1,025,897 $ 947,715 $ * (78,182) 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

STATE OF ILLINOIS 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. 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 Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 39 $ 1,906,017 Community Physical Therapy & Associates, Ltd. 0.00% $ 1,981,723 $ 75,706 15 16 V 16 17 V 17 18 V 18 19 V 19 20 V 20 21 V 21 22 V 22 23 V 23 24 V 24 25 V 25 26 V 26 27 V 27 28 V 28 29 V 29 30 V 30 31 V 31 32 V 32 33 V 33 34 V 34 35 V 35 36 V 36 37 V 37 38 V 38 39 Total $ 1,906,017 $ 1,981,723 $ * 75,706 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

STATE OF ILLINOIS 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. 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 Amount Name of Related Organization of of Related Related Organization Ownership Organization Costs (7 minus 4) 15 V 6 Repairs & Maintenance $ 24,569 Alden Bennett Construction Company, Inc. 0.00% $ 24,429 $ (140) 15 16 V 16 17 V 17 18 V 18 19 V 19 20 V 20 21 V 21 22 V 22 23 V 23 24 V 24 25 V 25 26 V 26 27 V 27 28 V 28 29 V 29 30 V 30 31 V 31 32 V 32 33 V 33 34 V 34 35 V 35 36 V 36 37 V 37 38 V 38 39 Total $ 24,569 $ 24,429 $ * (140) 39 * Total must agree with the amount recorded on line 34 of Schedule VI.

STATE OF ILLINIOS Page 6K Facility Name & ID Number Alden Orland Park Rehab & Health Care Center Provider No. 0042192 Report Period Beginning: 1/1/08 Ending: 12/31/08 RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES Name City Name City Type of Business The Forum Professional Center, LP Chicago Home Office rental Heather Health Care Center, Inc. Harvey Alden-Long Grove Rehabilitation and Health Care Center, Inc. Long Grove Forum Extended Care Services II, Inc. Chicago Pharmacy Alden-Lincoln Park Rehabilitation and Health Care Center, Inc. Chicago Alden Management Services, Inc. Chicago Management Alden-Northmoor Rehabilitation and Health Care Center, Inc. Chicago Alden-Lakeland Rehabilitation and Health Care Center, Inc. Chicago Alden of Old Town East, Inc. Bloomingdale Alden Garden Courts of DesPlaines, LLC DesPlaines Assisted Living/Alzheimers Facility Alden Terrace of McHenry Rehabilitation and Health Care Center, Inc. McHenry Alden Courts of Waterford, LLC Aurora Alzheimers Facility Alden - Wentworth Rehabilitation and Health Care Center, Inc. Chicago Alden Gardens of Waterford, LLC Aurora Assisted Living Alden Estates of Naperville, Inc. Naperville Prism Health Care Services, Inc. Schaumburg Nursing and Durable Equipment Alden - Valley Ridge Rehabilitation and Health Care Center, Inc. Bloomingdale Community Physical Therapy & Associates, Ltd. Wood Dale Therapy Provider Alden Village Health Facility for Children and Young Adults, Inc. Bloomingdale Alden Bennett Construction Company, Inc. Chicago General Contractor Alden - Orland Park Rehabilitation and Health Care Center, Inc. Orland Park Alden - Princeton Rehabilitation and Health Care Center, Inc. Chicago Alden of Old Town West, Inc. Bloomingdale Alden - Town Manor Rehabilitation and Health Care Center, Inc. Cicero Alden Trails, Inc. Bloomingdale Alden - Poplar Creek Rehabilitation and Health Care Center, Inc. Hoffman Estates Alden - North Shore Rehabilitation and Health Care Center, Inc. Skokie Alden - Des Plaines Rehabilitation and Health Care Center, Inc. Des Plaines Alden Estates of Evanston, Inc. Evanston Alden - Alma Nelson Manor, Inc. Rockford Alden - Park Strathmoor, Inc. Rockford Alden - Meadow Park Health Care Center, Inc. Clinton, WI Alden Estates of Barrington, Inc. Barrington Alden of Waterford, LLC Aurora Alden Springs, Inc. Bloomingdale Alden Village North, Inc. Chicago

STATE OF ILLINOIS Page 7 Facility Name & ID Number Alden Orland Park Rehab & Health Care C # 0042192 Report Period Beginning: 1/1/08 Ending: 12/31/08 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 3 4 5 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 Floyd A. Schlossberg President CEO 100.00 171,931 1.792 Salary $ 8,069 17-7 1 2 Lauren Magnusson Dir. Of Clinical Servi Technical Nursing 0.00 64,192 1.792 Salary 3,013 10-7 2 3 Terry Magnusson Dir. of Purchasing Supervise Mainten 0.00 37,346 1.792 Salary 1,753 6-7 3 4 4 5 5 6 A. Floyd Schlossberg is the President and sole stockholder of Alden Management Services, Inc. 6 7 B. Lauren Magnusson is the daughter of Floyd Schlossberg. Lauren is the Director of Clinical Services and provides technical support for the entire nursing staff. 7 8 C. Terry Magnusson is the son-in-law of Floyd Schlossberg. Terry coordinates the purchase of all building maintenance items as well as supervise building engineers. 8 9 9 10 10 11 11 12 12 13 TOTAL $ 12,835 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 COMPENSATION

STATE OF ILLINOIS Page 8 VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization Alden Management Services, Inc. A. Are there any costs included in this report which were derived from allocations of central office Street Address 4200 W. Peterson or parent organization costs? (See instructions.) YES X NO City / State / Zip Code Chicago, IL 60646 Phone Number ( 773 ) 286-3883 B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( 773 ) 286-8038 1 2 3 4 5 6 7 8 9 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 5 Utilities patient days * 1,216,590 30 $ 73,771 $ 54,535 $ 3,307 1 2 24 Travel/Seminar patient days * 1,216,590 30 85,812 54,535 3,847 2 3 25 Other Admin Travel patient days * 1,216,590 30 294,582 54,535 13,205 3 4 26 Insurance patient days * 1,216,590 30 4,828 54,535 216 4 5 20 Dues/Subscriptions patient days * 1,216,590 30 13,344 54,535 598 5 6 30 Depreciation no. of providers 30 30 98,652 1 2,842 6 7 31 Amortization patient days * 1,216,590 30 1,500 54,535 67 7 8 33 Real Estate Tax patient days * 1,216,590 30 125,958 54,535 4,949 8 9 35 Rent-Equip/Vehic patient days * 1,216,590 30 923,032 54,535 41,376 9 10 32 Interest patient days * 1,216,590 30 1,783,086 54,535 106,573 10 11 1 Dietary Salary patient days * 1,216,590 30 139,689 139,689 54,535 6,262 11 12 3 Housekeeping Salary patient days * 1,216,590 30 98,076 98,076 54,535 4,396 12 13 7 Employee Benef-Gen'l Servs patient days * 1,216,590 30 132,325 54,535 5,932 13 14 10 Nurs/Med Rec Salary patient days * 1,216,590 30 1,256,694 1,256,694 54,535 50,146 14 15 15 Employee Benef-Health Care patient days * 1,216,590 30 188,531 54,535 8,451 15 16 17 Administrative Salary patient days * 1,216,590 30 2,118,865 2,118,865 54,535 107,453 16 17 27 Employee Benef-Administrative patient days * 1,216,590 30 1,163,122 54,535 52,138 17 18 19 Professional Fees patient days * 1,216,590 30 978,599 605,253 54,535 43,867 18 19 21 Gen'l & Admin patient days * 1,216,590 30 5,848,424 5,104,656 54,535 262,162 19 20 6 Repair & Mainten. patient days * 1,216,590 30 831,505 644,276 54,535 37,274 20 21 21 22 22 23 23 24 24 25 TOTALS $ 16,160,395 $ 9,967,509 $ 755,061 25

STATE OF ILLINOIS Page 9 Facility Name & ID Number Alden Orland Park Rehab & Health Care Cen # 0042192 Report Period Beginning: 1/1/08 Ending: 12/31/08 IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.) 1 2 3 4 5 6 7 8 9 10 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 Cambridge X Mortgage $84,306.29 4/2003 $ 12,105,000 $ 11,498,979 4/2043 5.9300 $ 690,461 1 2 Cambridge X Operating $13,979.00 4/2003 2,499,003 2,434,971 4/2043 5.9300 146,209 2 3 Bank of Leumi X LOC Varies 12/2008 1,617,441 1,617,441 12/2009 Varies 3,568 3 4 Amortization X Refin. Fees 1,801 4 5 Insurance Reclass (Interest) X 4,086 5 Working Capital 6 6 7 Related Party-AMS X Working Capital 106,640 7 8 Related Party-FECII X Working Capital 6,845 8 9 TOTAL Facility Related $98,285.29 $ 16,221,444 $ 15,551,391 $ 959,610 9 B. Non-Facility Related* 10 Interest Income on Corp X (496) 10 11 Patient Interest Income on Corp X (840) 11 12 Interest Income on RR X (2,554) 12 13 Interest-Leumi LP Accts. X (26) 13 14 TOTAL Non-Facility Related $ $ $ (3,916) 14 15 TOTALS (line 9+line14) $ 16,221,444 $ 15,551,391 $ 955,694 15 16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ 70,595 Line # 36 *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.)

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 2007 report. bill must accompany the cost report. $ 628,500 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.) $ 655,932 2 3. Under or (over) accrual (line 2 minus line 1). $ 27,432 3 4. Real Estate Tax accrual used for 2008 report. (Detail and explain your calculation of this accrual on the lines below.) $ 675,600 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. $ 703,032 7 Plus: Related Party Taxes - See Pg 10A 5344 Real Estate Tax History: $ 708,376 Real Estate Tax Bill for Calendar Year: 2003 414,031 8 FOR BHF USE ONLY 2004 535,736 9 2005 598,653 10 13 FROM R. E. TAX STATEMENT FOR 2007 $ 13 2006 610,196 11 2007 655,932 12 14 PLUS APPEAL COST FROM LINE 5 $ 14 The current year accrual is based on an estimated 3% increase of the prior year tax. 15 LESS REFUND FROM LINE 6 $ 15 16 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.

IMPORTANT NOTICE TO: Long Term Care Facilities with Real Estate Tax Rates RE: 2007 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 2007 real estate tax costs, as well as copies of your original real estate tax bills for calendar 2007. Please complete the Real Estate Tax Statement below and forward with a copy of your 2007 real estate tax bill to Healthcare and Family Services, Bureau of Health Finance, 201 South Grand Avenue East, Springfield, Illinois 62763. Please send these items in with your completed 2008 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, l ll th B f H lth Fi t (217) 782 1630 2007 LONG TERM CARE REAL ESTATE TAX STATEMENT FACILITY NAME Alden Orland Park Rehab & Health Care Center COUNTY Cook FACILITY IDPH LICENSE NUMBER 0042192 CONTACT PERSON REGARDING THIS REPORTSteven M. Kroll TELEPHONE (773) 286-3883 FAX #: (773) 286-8038 A. Summary of Real Estate Tax Cost Enter the tax index number and real estate tax assessed for 2007 on the lines provided below. Enter only the portion of th cost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursin home property which is vacant, rented to other organizations, or used for purposes other than long term care must not b entered in Column D. Do not include cost for any period other than calendar year 2007 (A) (B) (C) (D) Tax Applicable to Tax Index Number Property Description Total Tax Nursing Home 1. See attached supplement Related Party-Alden Management Ser $ 295,853.00 $ 4,949.00 2. See attached supplement Related Party-Forum Extended Care $ 28,917.00 $ 395.00 3. 27-21-401-003-0000 Nursing Home Facility $ 655,932.00 $ 655,932.00 4. $ $ 5. $ $ 6. $ $ 7. $ $ 8. $ $ 9. $ $ 10. $ $ B. Real Estate Tax Cost Allocations TOTALS $ 980,702.00 $ 661,276.00 Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not direct 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 hom (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 2007 tax bills which were listed in Section A to this statement. Be sure to use the 200 tax bill which is normally paid during 2008 PLEASE NOTE: Payment 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

STATE OF ILLINOIS Page 11 X. BUILDING AND GENERAL INFORMATION: A. Square Feet: 92,048 B. General Construction Type: Exterior Brick Frame Steel Number of Stories 3 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, CNA training facilities, etc.) List entity name, type of business, square footage, and number of beds/units available (where applicable) F. Does this cost report reflect any organization or pre-operating costs which are being amortized? YES X NO If so, please complete the following: 1. Total Amount Incurred: 2. Number of Years Over Which it is Being Amortized: 3. Current Period Amortization: 4. Dates Incurred: Nature of Costs: (Attach a complete schedule detailing the total amount of organization and pre-operating costs.) XI. OWNERSHIP COSTS: 1 2 3 4 A. Land. Use Square Feet Year Acquired Cost 1 Nursing Home 350,871 1997 $ 584,920 1 2 2 3 TOTALS 350,871 $ 584,920 3

STATE OF ILLINOIS Page 12 XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar 1 2 3 4 5 6 7 8 9 FOR BHF USE ONLY Year Year Current Book Life Straight Line Accumulated Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation 4 200 1998 1997 12,679,210 314,835 40 316,980 2,145 3,485,299 4 5 5 6 6 7 7 8 Related Party-Forum 1978 14,056 25 14,056 8 Improvement Type** 9 RUN CABLE TO BUILDING/INSTALL 6 OUTLETS 1998 2,975 73 10 73 2,975 9 10 RELOCATION OF OUTLETS & POWER CIRCUIT 1998 1,648 13 10 13 1,648 10 11 INSTALL 6 WALL JACKS 1998 2,158 5 2,158 11 12 INSTALL CABLE 1998 4,446 10 4,446 12 13 REPLACE SPRINKLER HEADS 1998 6,236 259 10 259 6,236 13 14 INSTALL WALL PLATES 1998 4,608 5 4,608 14 15 Climate Service(boiler maintenance) 1999 14,529 726 20 726 7,263 15 16 Directional Boring(sprinkler system) 1999 5,400 360 15 360 3,540 16 17 Chicago Cooling(a/c unit repair) 1999 2,070 138 15 138 1,322 17 18 Church Landscape(floating swan island) 1999 3,400 5 3,400 18 19 Church Landscape(floating swan island) 1999 2,000 5 2,000 19 20 Watermangement(compressor) 1999 2,625 175 15 175 1,648 20 21 New Horizons Communications (light telephone sys) 2000 9,767 977 10 977 8,791 21 22 New Horizons Communications (light telephone sys) 2000 7,765 777 10 777 6,990 22 23 System Electric (wiring) 2000 1,384 69 20 69 622 23 24 Climate Services ( pipe ) 2000 1,674 84 20 84 754 24 25 Climate Services ( pipe ) 2000 1,689 84 20 84 759 25 26 Climate Services ( pipe ) 2000 1,684 84 20 84 757 26 27 Climate Services ( pipe ) 2000 2,376 119 20 119 1,070 27 28 GT Mechanical (heating/compressor repair ) 2000 5,079 508 10 508 4,571 28 29 New Horizons Communications (light telephone sys) 2000 7,765 777 10 777 6,990 29 30 Alden Bennett Cons (time and billning material) 2000 2,073 207 10 207 1,726 30 31 Alden Bennett Cons (time and billning material) 2000 2,798 280 10 280 2,263 31 32 New Horizons Comm. (phone insall) 2000 4,437 444 10 444 3,994 32 33 Fox Valley Fire & Safety (sprinkler system) 2000 2,290 153 15 153 1,248 33 34 Alden Bennett Construction (time and material) 2000 2,915 292 10 292 2,358 34 35 Capps Plumbing (srvc/repair pump) 2001 1,977 132 15 132 1,022 35 36 Alden Bennett Construction (paving) 2001 9,328 622 15 622 4,405 36 *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

STATE OF ILLINOIS Page 12A XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar 1 3 4 5 6 7 8 9 Year Current Book Life Straight Line Accumulated Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation 37 Capps Plumbing (repair pump) 2002 $ 7,214 $ 481 15 $ 481 $ $ 4,248 37 38 Med-Con (alarm system) 2002 813 81 10 81 541 38 39 Alden Bennett Construction (time & material) 2002 4,008 267 15 267 1,781 39 40 Alden Bennett Construction (time & material) 2002 2,809 187 15 187 1,263 40 41 Alden Bennett Construction (time & material) 2002 2,365 158 15 158 1,078 41 42 42 43 Alden Bennett Cons..auto. Door opener 2003 3,915 391 10 391 2,152 43 44 Alden Bennet Cons. laundry press/gas/ellec 2003 6,825 455 15 455 2,730 44 45 GT Mechanical-repair heat pump 2003 1,797 31 5 31 1,797 45 46 CSI Coker-rebuild dishwasher 2003 4,333 433 10 433 2,418 46 47 Real Green-sprinkler system repair 2003 3,600 300 5 300 3,600 47 48 Real Green-sprinkler system repair 2003 1,750 87 5 87 1,750 48 49 CSI Coker kitchen exhaust pipe repair 2003 1,728 201 5 201 1,728 49 50 CSI Coker-walk in freezer repair 2003 1,560 182 5 182 1,560 50 51 Alden Bennett Cons.-ejector pump repair 2003 1,182 139 5 139 1,182 51 52 Controlled Irrigation-sprinkler systen repair 2003 2,552 341 5 341 2,552 52 53 Alden Bennett Cons-ejector pump repairs 2003 2,991 349 5 349 2,991 53 54 B&K Lawnscaping-crushed stone walkway base 2003 1,400 140 10 140 712 54 55 55 56 Alden Bennett - Repairs 2004 1,700 113 15 113 462 56 57 Top Notch - Repairs 2004 2,189 146 15 146 596 57 58 Alden Bennett Construction - laundry press/gas/electric/pipe 2004 4,062 203 20 203 964 58 59 GT Mechanical-repair heat pump 2004 1,083 54 20 54 257 59 60 GT Mechanical-replace A/C compressor unit 2004 8,600 573 15 573 2,579 60 61 Insurance refund on above asset 2004 (3,600) (240) 15 (240) (1,080) 61 62 GT Mechanical-repair heater leak 2004 583 117 5 117 506 62 63 GT Mechanical-repair valve leak 2004 718 144 5 144 600 63 64 GT Mechanical-heater repair 2004 753 151 5 151 629 64 65 New Horizons - Phone line repair 2004 2,793 279 10 279 1,163 65 66 B & K Lawnscaping- crushedstone walkway base 2004 2,420 161 15 161 752 66 67 Alden Bennett - Plumbing Repair 2004 866 173 5 173 750 67 68 GT Mechanical - Repair compressor leak 2004 700 140 5 140 618 68 69 69 70 TOTAL (lines 4 thru 69) $ 12,884,069 $ 328,424 $ 330,569 $ 2,145 $ 3,631,798 70 **Improvement type must be detailed in order for the cost report to be considered complete

STATE OF ILLINOIS Page 12B XI. OWNERSHIP COSTS (continued) B. Building Depreciation-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar 1 3 4 5 6 7 8 9 Year Current Book Life Straight Line Accumulated Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation 1 Totals from Page 12A, Carried Forward $ 12,884,069 $ 328,424 $ 330,569 $ 2,145 $ 3,631,798 1 2 GT Mechanical - Repair cooling fan 2004 1,256 251 5 251 1,088 2 3 GT Mechanical - Repairs 2004 679 136 5 136 576 3 4 Top Notch - Repairs 2004 839 168 5 168 770 4 5 GT Mechanical - AC maintenance/repair 2004 1,108 222 5 222 1,054 5 6 GT Mechanical - Replace CFM & contactor 2004 1,126 113 10 113 527 6 7 Replace condenser fan motor 2004 1,204 120 10 120 571 7 8 Building Repairs 2004 5,871 391 15 391 1,695 8 9 A&B Custom Cable TV Service, Inc. - Inst cable jacks 2004 8,120 812 10 812 4,060 9 10 GTMECH-Replace Gas Valve in the RTU 2005 2,165 144 15 144 576 10 11 TOPNOT Commercial Kitchen 2005 1,735 116 15 116 464 11 12 New Horizons Phone Repair 2005 2,461 246 10 246 923 12 13 Dryer and Condensing Unit 2005 1,309 131 10 131 491 13 14 14 15 ABC Installed Cabinets and Drawers 2005 5,332 355 15 355 1,243 15 16 New Horizons CRD 6 Circuit 2005 2,285 229 10 229 744 16 17 New Furnance 2005 2,299 460 5 460 1,457 17 18 12 New Phones 2005 3,559 356 10 356 1,098 18 19 ABC repair work on entry ramp and ramp walls 2005 5,211 347 15 347 1,041 19 20 Millcar Milliken Carpets 2005 18,160 1,816 10 1,816 6,205 20 21 Asphalt the Parking Lot 2005 1,806 181 10 181 588 21 22 Asphalt the Parking Lot 2005 1,787 179 10 179 582 22 23 Millcar Milliken Carpets 2005 (15,609) (1,561) 10 (1,561) (6,894) 23 24 Parking Lot 2006 217,356 27,170 8 27,170 65,660 24 25 Installed new seal and started on HP-1 2006 2,528 253 10 253 738 25 26 Installed new power supply 2006 4,274 214 20 214 624 26 27 Removed and replaced carpet 2006 3,848 770 5 770 2,053 27 28 Repair Generator 2006 2,819 564 5 564 1,551 28 29 Installed new vanity countertop 2006 3,277 328 10 328 901 29 30 Installed sewage ejector pump 2006 4,453 297 15 297 643 30 31 Carpet for the second floor 2006 31,104 6,221 5 6,221 12,960 31 32 32 33 33 34 TOTAL (lines 1 thru 33) $ 13,206,431 $ 369,450 $ 371,595 $ 2,145 $ 3,735,786 34 **Improvement type must be detailed in order for the cost report to be considered complete