CONTRACT BETWEEN RESIDENT AND COUNTRYVIEW TERRACE

This Contract is made by and between Countryview Terrace, hereinafter referred to as “the Facility”, and , hereinafter referred to as “the Resident”, and , hereinafter referred to as “the Responsible Party”. Now, in consideration of the mutual covenants contained herein, the above said parties do hereby agree to the following terms and conditions and arrangements regarding the provision of nursing and/or personal care to the Resident:

1. EFFECTIVE DATE, TERM AND TERMINATION:

A. Effective Date : This Contract shall be effective and commence on .

B. Term : This Contract shall remain in effect for the term of one (1) year and shall be automatically renewed for successive one (1) year terms until such time as the Resident is voluntarily or involuntarily transferred or discharged from the Facility.

C. Termination : Prior notice is generally required to terminate this Contract, and charges will continue to accrue during the notice period even if the Resident has left the Facility.

-If the Resident is compelled by a change in physical or mental health to leave the Facility, the Contract and all obligations thereunder shall terminate upon seven (7) days written notice.

-In all other situations, the Resident may terminate the Contract and all obligations thereunderupon thirty (30) days written notice.

-No prior notice of termination is required in the case of a Resident’s death.

-In the absence of actual notice, the notice period shall begin on the last day of the Resident’s stay at the Facility.

Additional terms providing for the responsibility of the Facility and the Resident or Responsible Party are detailed in other parts of the Contract.

2. RESPONSIBLE PARTY: Any person or persons, in addition to the Resident or any other funding source, who will be liable for the payment of the charges, fees and expenses enumerated herein shall be known as the Responsible Party and shall sign this Contract on the line designated for such Responsible Party. By so signing the Contract, the Responsible Party agrees that he/she shall guarantee and be jointly and severally liable for the payment of all charges accruing under this Contract. No Responsible Party is required or requested by the Facility for the payment of any items or services covered or paid pursuant to the State and Federal Medicaid and/or Medicare programs. Notwithstanding the above, any person who is designated as the Representative Payee for purposes of receiving Social Security benefits on behalf of a Resident receiving or applying for Medicaid benefits shall be responsible for the payment of the Social Security benefits to the Facility. The Representative Payee must sign this Contract to acknowledge the obligation to pay those funds to the Facility. The Resident has the option of designating the Facility as his or her Representative Payee for Social Security benefits.

3. NURSING CARE: The Facility agrees to provide to the Resident general nursing care, room and board and other health care services for the comfort and well-being of the Resident as provided below. The Resident agrees to obey all rules, policies and procedures of the Facility either contained in this Contract or as posted within the Facility.

4. RESIDENT’S PAYMENT STATUS: On the effective date of this Contract, the Resident is a (Check all that apply): [ ] Private Pay Resident [ ] Medicare Recipient/Applicant [ ] Medicaid Recipient/Applicant

5. SERVICES AND COSTS FOR PRIVATE PAY RESIDENTS: Services for Private Pay Residents shall be provided at the following costs:

A. Prepayment of Services : Upon execution of this Contract, prepayment of services in the amount of $ (daily rate x (times) number of days remaining in the month) shall be paid to the Facility and a bed will be reserved for the Resident. In the event the Resident determines that he or she will not be residing at the Facility, the Resident or the Responsible Party must give the Facility written notice within three (3) calendar days of the date the Resident or Responsible Party executed the Contract. Upon receipt of the timely written notice, an amount equal to said prepayment less three(3) days cancellation charge will be refunded.

B. Basic Services and Costs : The base rate for the basic items of services listed in this paragraph shall be $ per DAY, payable in advance on the 1st of each month. Payment is due no later than the 1st day of the month for services provided during the following month. This base rate shall include the following items and services:

(1) Room(2) Food(3) Nursing Care – 24 hrs. /day(4) Social Service(5) Activity Programs(6) Housekeeping(7) Laundry (includes all personal clothing and bedding)(8) Pharmaceutical Consultation(9) Dietetics Consultation(10) Medical Consultation(11) Other:

C. Supplemental Services and Items : The following services and products are offered by the Facility or are available to the Facility and will be provided to the Resident as needed per the Facility’s assessment, at the Resident’s request and/or physician’s order. The costs of these Supplemental Services and Items are not covered by the Basic Rate described in Paragraph 5B. The Facility shall charge an additional fee as set forth on Exhibit “A” for each supplemental service. The Resident, Responsible Party or the Resident’s Representative will receive an invoice for the cost of such Supplemental Services or Items either from the Facility or from the provider of the service. Payment for all such Supplemental Services and Items shall be due immediately upon receipt of the invoice unless otherwise stated in the invoice.

(1) Pharmacy Products and Medications(2) Physician Services(3) Dental Services

(4) Medical Supplies(5) Cable TV(6) Barber and Beauty Shop(7) Podiatric Services and Supplies(8) Physical Therapy/ Occupational Therapy/Speech Therapy(9) Transportation(10) Other:

D. Changes in Rates : The Resident, Responsible Party, and any other person signing this Contract on behalf of the Private Pay Resident shall be given thirty (30) days advanced written notice of any changes in the rates for Basic Services and/or Supplemental Services during the term of the Contract. The Resident, Responsible Party or Resident’s Representative may assent to the rate change or choose to terminate this Contract within thirty (30) days of the receipt of the written notice.

6. SERVICES AND COSTS FOR PUBLIC PAY RESIDENTS: Services for Public Pay Residents shall be provided as follows:

A. Services Included in Medicaid or Medicare Payment : During the course of a covered Medicaid or Medicare stay the Facility may not charge the Medicaid or Medicare Resident for the following items or services:

(1) Nursing services and specialized rehabilitative services;(2) Dietary Services;(3) An activities program; Social Services;(4) Room/bed maintenance services;(5) Routine Personal hygiene items and services.

B. Items and Services That May Be Charged to a Medicaid or Medicare Resident’s Personal Funds: If an item or service is requested by a Resident and payment is not made by Medicare or Medicaid, the Facility may charge to the Resident’s Personal Funds the cost of Supplement Items or Services including, but not limited to the following items:

(1) Telephone;(2) Television and/or radio for personal use;(3) Personal comfort items, including smoking materials, notion and novelties, and confections;(4) Cosmetic and grooming items and services, including but not limited to barber and beautician services, in excess of those for which payment is made under Medicare or Medicaid;(5) Personal clothing;(6) Personal reading material;(7) Gifts purchased on behalf of Resident;(8) Flowers and plants;(9) Social events and entertainment offered off the premises and outside the scope of the activities program;(10) Non-covered special care services such as private duty nurses;(11) Private room except when therapeutically required;(12) Specially prepared or alternative food requested by the Resident instead

of the food generally prepared by the Facility, if it is documented that the requested food costs more than the food provided to other residents;(13) Non-emergency transportation for Medicare residents.

7. PUBLIC PAY TERMS AND CONDITIONS:

A. The Facility accepts Medicaid and Medicare clients. No deposit of the Resident or the Resident’s family is required prior to or as a condition of the establishment of Medicaid or Medicare eligibility. In the event a Private Pay Resident establishes eligibility for Medicaid or Medicare, any deposit required of the Resident at admission shall be refunded within thirty (30) days of the date the Resident establishes eligibility for Medicaid or Medicare.

B. All newly admitted Residents shall be considered private pay Residents for purposes of payment until such time as Medicaid or Medicare eligibility is confirmed. Newly admitted Residents shall be billed at private pay rates until Medicaid or Medicare determines the monthly benefit that will be paid on behalf of the Resident. Residents and/or the Responsible Party will be required to pay the Resident’s Social Security benefits less $30.00 per month to the Facility for each month, including the month of admission, while the Resident is awaiting Medicaid or Medicare certification. Upon Medicaid or Medicare certification any overpayment will be refunded to the Resident or Responsible Party. The Representative Payee should be aware that the Social Security benefits are the property of the Resident and must be used for the Resident’s benefit. The Representative Payee can be held responsible for the improper distribution of the Social Security benefits.

C. As a condition of admission, Facility requires all Residents whose charges are expected to be partially paid by Medicare or Medicaid to either direct deposit the Resident’s Social Security Income or SSI Benefits into the Facility’s Resident Trust Fund or designate Facility as Representative Payee of the Resident’s Social Security Income. Resident’s Social Security Income or SSI Benefits will be applied to the Resident’s monthly charges owed the Facility in the amount determined by Medicare or Medicaid. Any amount remaining will be placed in Facility’s Resident Trust Fund account for use by Resident.

Should Resident utilize the Social Security Administration’s Direct Express prepaid debit card to receive Social Security Income or SSI Benefits, Resident agrees to place the Direct Express prepaid debit card in Facility’s possession and provide Facility with the Resident’s PIN number to access the Direct Express debit card. Resident hereby authorizes Facility to access the Direct Express prepaid debit card for purposes of paying Resident’s monthly charges owed the Facility. Facility will place any remaining amount on the debit card in Facility’s Resident Trust Fund account for use by Resident.

Any violation of section 7(C) by the Resident shall subject the Resident to Involuntary Discharge from the Facility.

D. The Facility shall not require that a third party (Responsible Party) guarantee payment to the Facility by a Medicaid or Medicare Recipient or applicant regarding items or services covered or paid for under the State or Federal Medicaid or Medicare program as a condition of admission (or expected admission) to, or continued stay in, the Facility.

E. In the case of a Medicaid or Medicare client, the Facility shall not charge, solicit, accept or receive, in addition to any amount otherwise required to be paid under the State or Federal Medicaid or Medicare program, any gift, money, donation, or other consideration as a precondition of admitting (or expediting the admission of) the individual to the Facility or as a requirement for the Resident’s continued stay in the Facility.

F. However, Paragraphs 7D and 7E shall not be construed as preventing the Facility from charging Medicaid or Medicare clients for items and services the Resident has requested and received and that are not covered or paid for under the Medicaid and/or Medicare programs.

G. The Facility may not impose a charge against the personal funds of a Resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and co-insurance amounts). However, the Facility may charge the Resident for requested services that are more expensive than or in excess of covered services.

H. The Facility may not charge the Medicaid or Medicare Resident (or his or her Representative) for any item or service not requested by or on behalf of the Resident.

I. The Facility shall inform the Medicaid or Medicare Resident (or his or her Representative) requesting the item or service for which a charge will be made that there will be a charge for the item or service and the amount of the charge.

J. The Facility shall not require a Medicaid or Medicare Resident to request any item or service as a condition of admission or continued stay.

K. The costs of itemized services or products to be provided to the Medicaid or Medicare Resident upon the Resident’s request cannot be established or predicted with definiteness at the time of the Resident’s admission. However, the Resident shall be liable for non-covered items and services as described above and will receive a bill for any requested item or service not covered by Medicaid or Medicare in addition to and beyond any payments made under Medicaid or Medicare. The Resident and the Responsible Party shall be obligated to pay for these additional requested items or services.

THE FOLLOWING APPLIES TO ALL RESIDENTS REGARDLESS OF THE SOURCE OF PAYMENT:

8. SOURCES OF PAYMENT: The source for payment of the allowable charges and fees assessed pursuant to this Contract are as follows:

A. Any and all resources, assets or monies available to the Resident;B. Any and all resources, assets or monies available to the Responsible Party, if any;C. Any and all resources, assets or monies available from any private or public insurance

policy or program;D. Any and all Social Security payments;E. Other (specify):

9. REPRESENTATIVE PAYEE – SOCIAL SECURITY BENEFITS: In the event the Resident has appointed a Representative Payee for the purpose of receiving Social Security benefits on the Resident’s behalf, the Representative Payee must pay to the Facility the entire amount of the Resident’s Social Security benefits less $30.00 which is reserved for the use of the Resident and should be deposited to the Resident’s

account with the Facility.

10. PERSONAL PHYSICIAN: The Resident shall be entitled to retain the services of his or her own personal physician at his or her sole expense or under the terms of an individual or group plan of health insurance, or under the terms of any public or private assistance program providing such coverage. The Facility is not responsible for the negligence of any such personal physician. In the event the Resident’s Personal Physician cannot be contacted and a medical emergency requires immediate medical care, the Facility’s Medical Director is hereby authorized to provide such medical care.

11. VOLUNTARY DISCHARGE: The Resident may be voluntarily discharged from the Facility at any time immediately after the Resident or Responsible Party gives the Nursing Home Administrator, a physician, or a nurse of the Facility thirty (30) days written notice of the Resident’s desire to be discharged. In such cases, and in all other cases involving a voluntary discharge of the Resident as described in this Contract, the Facility is relieved from any responsibility for the Resident’s care, safety or well-being effective upon the date of the Resident’s discharge.

12. ROOM AND ROOMMATE ASSIGNMENTS: The Facility reserves the right to assign or transfer the Resident within the Facility to an available room or roommate as needed. However, the Resident shall be given notice before the room or roommate is changed. The Facility will provide reasonable accommodation of individual needs and preferences regarding room and roommate, except where the health and safety of the individual or other residents would be endangered.

13. RESIDENT PERSONAL PROPERTY: The Facility shall provide a means of safeguarding small items of value for the Resident and the Resident may have daily access to such items. Resident may also keep money in the Facility’s resident trust account. Any Resident who wishes to have a small item of value safeguarded by the Facility must deliver the item to the Administrator. The Facility shall not be responsible for the loss, theft, or destruction of any of Resident’s personal property except for small items of value physically delivered to the Administrator for safeguarding or money deposited in Facility’s resident trust account.

14. CHARGES AND OBLIGATIONS UPON TERMINATION: All charges due the Facility shall be calculated and prorated through the last day of the notice periods provided in Paragraph 1, above. If any payments have been made in advance, the excess shall be refunded to the Resident or Responsible Party. The Resident or Responsible Party will continue to be liable for all payments due through the end of the notice period regardless of whether the Resident resides at the Facility. For example, if the Resident voluntarily terminates the Contract and gives the required thirty (30) day notice then promptly leaves the Facility, the Resident or Responsible Party must pay all charges through the end of the thirty (30) day period even though the Resident left before the thirty (30) days expired.

15. PERSONS PROHIBITED FROM FACILITY: This facility does not accept as residents any person who is a sex offender as that term is defined in the rules promulgated by the Illinois Department of Public Health. Any person admitted to the facility who is determined to be a sex offender will be immediately discharged from the facility. In order to be admitted to this facility, Resident must represent and warrant that he or she is not a sex offender.

16. INVOLUNTARY TRANSFER OR DISCHARGE OF RESIDENT BY FACILITY: A Facility may transfer or discharge a Resident contrary to the Resident’s wishes (hereafter “Involuntary Transfer or Discharge”) during the term of this Contract or at the expiration of this Contract only for one or more of the following reasons:

A. For medical reasons;

B. For the Resident’s physical safety;C. For the physical safety of other residents, other individuals, the Facility staff or Facility

visitors;D. For either late payment or non-payment for the Resident’s stay (except as prohibited

by Title XVIII or Title XIX of the Federal Social Security Act) after reasonable notice, or also due to the Resident’s failure to have payment made either under Titles XVIII or Title XIX of the Federal Social Security Act and the Public Aid Code.

17. NOTICE OF INVOLUNTARY TRANSFER OR DISCHARGE BY FACILITY: All involuntary transfers and discharges shall be in compliance with Sections 45/3-401 through 45/3-414 of the Nursing Home Care Act (210 ILCS 45/3-401 through 45/3-414). If it is necessary to involuntarily transfer or discharge the Resident for one of the reasons indicated in Paragraph 16, the Facility shall give the Resident and the Responsible Party at least twenty-one (21) days written notice.

18. EMERGENCY INVOLUNTARY TRANSFER OR DISCHARGE BY FACILITY: The twenty-one (21) day advance notice for involuntary transfer or discharge shall not apply in the following situations:

A. When an emergency transfer or discharge is ordered by the Resident’s attending physician because of the Resident’s health care needs or urgent medical needs; or

B. When the transfer or discharge is mandated by the health or physical safety of other residents, other individuals, the Facility staff or Facility visitors as documented in the clinical records.

19. EFFECTIVE DATE OF CONTRACT TERMINATION UPON INVOLUNTARY TRANSFER OR DISCHARGE BY FACILITY: Resident and Facility hereby agree that if the Facility involuntarily transfers or discharges the Resident this Contract shall terminate as follows:

A. If no request for a hearing to contest the involuntary transfer or discharge is timely filed by a person having standing to request such a hearing, then this Contract shall terminate effective upon either 1) expiration of the right to contest such involuntary discharge or transfer; or 2) the Resident’s physical departure from the Facility; whichever is later.

B. If a request for a hearing to contest the involuntary transfer or discharge is timely filed by a person having standing to request such a hearing, then this Contract shall terminate upon either 1) the failure to timely appeal any Administrative or Judicial Order upholding such transfer or discharge; or 2) the Resident’s physical departure from the Facility; whichever is later.

20. NOTICE OF TRANSFER UPON EXHAUSTION OF PRIVATE FUNDS: Any Resident who has exhausted his or her private funds and has made an application for Medicaid or Medicare will not be involuntarily discharged under the provisions of Paragraph 16(D) for non-payment during the application period. However, if the Resident is denied Medicaid or Medicare assistance, the Facility will immediately commence involuntary discharge procedures.

21. BED HOLDS DURING HOSPITALIZATION AND THERAPEUTIC LEAVE:

A. Private Pay Residents: If a Private Pay Resident leaves the Facility for hospitalization or for therapeutic leave, the Facility shall hold the Resident’s bed continuously available for the Resident so long as the basic rate is paid in advance.

B. Medicaid Recipients: If a Medicaid Recipient is hospitalized, the Resident’s bed will be held for up to ten (10) days if such bed hold is 1) requested on behalf of the Resident; 2) authorized by a physician; 3) approved by the Illinois Department of Public Aid (IDPA); and 4) is authorized according to all applicable IDPA Rules. A Medicaid Recipient or applicant shall be considered a Resident in the Facility during any hospital stay totaling ten (10) days or less following a hospital admission. In the event that a Medicaid Recipient departs the Facility for therapeutic leave or a home visit, the Resident’s bed will be held for up to seven (7) consecutive days if such bed hold is 1) requested on behalf of the Resident; and 2) is authorized according to all applicable IDPA Rules. If a Medicaid Recipient’s hospitalization exceeds a period of ten (10) consecutive days or if a therapeutic leave exceeds seven (7) consecutive days, then the Facility may treat the Resident’s bed as open and available and place another resident into the bed immediately. If a Medicaid Recipient is hospitalized for a period in excess of the ten (10) day Medicaid payment limit for bed holds, the Medicaid Recipient may elect to make bed hold payments to reserve the bed until he or she returns from the hospital. The bed hold payments will be at the current daily rate.

C. Veterans Administration Residents: If a Resident whose care is paid for under a Contract with the Veterans Administration leaves the Facility for hospitalization or therapeutic leave, the Facility shall hold the Resident’s bed continuously available for the Resident if 1) a bed hold is requested on behalf of the Resident; and 2) such bed hold is authorized and paid for pursuant to the Veterans Administration Contract and all applicable Federal and State regulations. If no bed hold is requested or authorized for the Resident, then upon the Resident’s departure the Facility may treat the Resident’s bed as open and available and may place another resident into the bed immediately.

D. Readmission Without a Bed Hold: A Resident on therapeutic leave or hospitalized without a bed hold or a Resident whose hospitalization or therapeutic leave exceeds the bed hold period shall nonetheless be readmitted to the Facility upon request upon the first availability of a bed in a semi-private room if the Resident requires the services provided by the Facility and if funding is available for the Resident’s readmission. If no beds are available at the time the Resident seeks readmission, then the Resident shall be offered the opportunity to be placed on a waiting list wherein former residents seeking readmission are given priority over new applicants seeking initial admission.

E. Termination of Contract and Voluntary Discharge of Resident Upon Resident’s Failure to Return to Facility from Hospital Visit, Home Leave or Therapeutic Leave: After a Resident requests readmission to the Facility from a hospital visit, home leave or therapeutic leave, this Contract shall be terminated and the Resident shall be deemed to have been voluntarily discharged from the Facility effective immediately without any right of readmission if the Resident, for any reason, 1) refuses an available bed offered by the Facility; or 2) fails to return to an available bed offered by the Facility within seven (7) days of the offer; or 3) refuses an offer to be placed on a waiting list.

22. APPOINTMENT OF RESIDENT’S REPRESENTATIVE (OPTIONAL): The Resident hereby designates(name a person): to be the “Resident’s Representative” asdefined by Section 45/1-123 of the Nursing Home Care Act (210 ILCS 45/1-123). The Resident shall provide to the Facility a copy of any written agreement between the Resident and the Resident’s Representative which authorizes the Resident’s Representative to inspect and copy the Resident’s records and/or authorizes the Resident’s Representative to execute this Contract on behalf of the Resident.

23. BINDING ARBITRATION OF DISPUTES: The parties expressly incorporate into this contract the document entitled Agreement to Resolve Disputes by Binding Arbitration should the document be separately executed and further agree that the terms of said Agreement shall apply to all disputes under this contract except those specifically excluded in the Agreement to Resolve Disputes by Binding Arbitration.

24. CHOICE OF LAW AND FORUM SELECTION CLAUSE: Any dispute arising from this contract or resident’s stay at facility shall be governed by the law of the State in which the Facility is located. Any dispute shall be solely and exclusively venued in the State or Federal courts located in the County in which the Facility is located.

25. PARTIAL INVALIDITY DOES NOT INVALIDATE WHOLE CONTRACT: If any clause, part of clause, term or condition of this Contract should be ruled invalid by a court of competent jurisdiction or is in violation of any local, state or federal law, then such clause, word, term or condition shall be considered deleted from this Contract and the balance of this Contract shall be continued in full force and effect.

26. QUALIFICATION FOR FUNDING SOURCES: The Facility does not make any assurance of any kind whatsoever that a Resident’s care will be covered by Medicare, Medicaid or Insurance Companies, and the undersigned hereby releases the Facility, its agents, servants, and employees from any liability or responsibility in connection with the undersigned’s potential claim for such coverage.

27. WRITTEN ACKNOWLEDGEMENT OF RECEIPT OF RESIDENT RIGHTS: The Resident and all persons signing this Contract on behalf of the Resident do hereby acknowledge by signing this Contract that he or she has received a written copy of and has been informed both orally and in writing in a language that the Resident and/or person understands of his or her rights and all rules and regulations governing Resident conduct and responsibilities during the Resident’s stay in the Facility, such rights including a summary of all rights enumerated in Article II, Part I of the Nursing Home Care Act (210 ILCS 45/2-201 et seq.) and all applicable Resident rights embodied in or promulgated pursuant to the Federal Social Security Act at 42U.S.C.A. 1396r. The Resident and all persons signing this Contract on behalf of the Resident hereby acknowledge by signing this Contract that he or she has received a written copy of the summary of the Facility’s Policies and Procedures currently in force to implement the responsibilities and rights set forth above. In addition, the Resident and all persons signing this Contract on behalf of the Resident hereby acknowledge receipt of the written explanation of the spousal impoverishment rights as defined Section 5-4 of the Illinois Public Aid Code (305 ILCS 5/5-4) and at Section 303 of Title II of the Medicare Catastrophic Coverage Act of 1988 (42 U.S.C.A. §139r-s). The Resident and all persons signing this Contract further acknowledge receipt of a duplicate original of this Contract.

28. TEMPORARY ABSENCE FROM THE FACILITY: Pursuant to the abovesaid Resident’s rights, the Resident may have the right to leave and be absent from the Facility and grounds during reasonable hours. The Facility assumes no responsibility or liability in regard to the Resident’s welfare once the Resident is removed from the Facility or while the Resident is not on the Facility premises.

29. SIGNATURES: The Contract MUST be signed on behalf of the Resident by one or more of the following: (1) the Resident; (2) the Resident’s Guardian; (3) a member of the Resident’s immediate family (“immediate family” means the spouse, an adult child, a parent, an adult brother or sister, or an adult grandchild of a Resident); (4) the Resident’s Representative Payee under the Social Security Act; (5) if the Resident has given written authorization to a “Resident’s Representative” to sign this Contract then the “Resident’s Representative” may sign the Contract on behalf of the Resident; (6) if the Resident has executed a Power of Attorney for Health Care pursuant to the “Powers of Attorney for Health Care Law” (755 ILCS 45/31 et seq .)

then the Resident’s Agent pursuant to such Power of Attorney for Health Care may sign this Contract on behalf of the Resident. However, the execution of such a Power of Attorney for Health Care is not a condition or requirement for admission to the Facility.

30. PERSONAL FINANCIAL LIABILITY: Resident and the Responsible Party shall be jointly and severally personally liable for all charges incurred by the Resident pursuant to this Contract. Any person executing this Contract only in the capacity of a Resident’s guardian, Resident Representative, immediate family member or agent shall not be a Responsible Party unless such person expressly assumes that obligation by also signing this Contract on the signature line denoted “Responsible Party”. Any person signing on the Responsible Party signature line becomes jointly and severally personally liable for all charges incurred by the Resident, even if the person signing on the Responsible Party line places a designation after the signature of Guardian, POA, Agent, or Representative.

31. DEFAULT: In the event that Resident or Responsible Party fails to pay the fees set forth herein as required, in addition to the Facility’s right to involuntarily discharge the Resident, the Facility shall be entitled to use any remedy available at law or equity to collect the amount due and shall be entitled to all costs including, but not limited to, reasonable attorney’s fees incurred in collection of the amount owed.

32. OBLIGATION TO PAY CHARGES FROM RESIDENT’S FUNDS: Any person who is not a Responsible Party, but who nonetheless signs the Contract in any capacity and who has legal access to a Resident’s income and resources available to pay for care in the Facility hereby promises (without incurring personal financial liability) to provide payment from the Resident’s income or resources for such care.

33. ACKNOWLEDGEMENT OF BACKGROUND CHECK: Pursuant to the Illinois Nursing Home Act and the regulations issued by the Illinois Department of Public Health, the Facility is required to perform a search of the State Police Sex Offender List and to request criminal history record information for all residents and potential residents of the Facilities. Resident hereby consents to such background check.

34. DECEASED RESIDENT’S FUNDS: Should a Resident pass away with funds remaining in his facility account or cash within the Facility, Facility will only release the funds upon receipt of “letters of office” from the executor or administrator of the Resident’s estate or upon a validly executed “small estate’s affidavit.” Should Resident be a Medicaid recipient, Facility must notify the Department of Human Services local office of any resident funds held by the Facility using Form DPA 1156(Long Term Care Facility notification) within 30 days.

35. RETURN OF RESIDENT FUNDS: Any and all monies remaining after Resident discharges from the facility will be returned to the resident after facility has received all payments from third party payor sources.

Facility:

(Administrator/ Admissions Coordinator)

FOR RESIDENT:

(Resident) (Resident’s Representative Payee–Social Security)

(Responsible Party) (Responsible Party)

(Resident’s Guardian) (Resident’s Immediate Family Member)

(Resident’s Agent) (Resident’s Attorney in Fact-Health Care)

(Resident’s Representative) (Resident’s Attorney in Fact-Business)

This facility is operated by Petersen Health Network, LLC, an Illinois limited liability company.

AGREEMENT TO RESOLVE DISPUTES BY BINDING ARBITRATION

This Agreement to Resolve Disputes by Binding Arbitration (“Agreement”) is made and entered into this day day of , 20 , by and between Countryview Terrace (“Facility”) and (“Resident”).The parties wish to work together to resolve any disputes in a timely fashion and in a manner that minimizes both of their legal costs. Therefore, in consideration of the mutual promises contained in the Agreement, Resident and Facility agree as follows:

A. Disputes to Be Arbitrated. Any legal controversy, dispute, disagreement or claim of any kind now existing or occurring in the future between the parties arising out of or in any way relating to this Agreement, the admission contract signed between the parties (entitled Contract Between Resident and Countryview Terrace) or the Resident’s stay at the Facility shall be settled by binding arbitration, including, but not limited to, all claims based on breach of contract, negligence, medical malpractice, tort, breach of statutory duty, resident’s rights, the Nursing Home Care Act, any departures from accepted standards of care, and all disputes regarding the interpretation of this Agreement, allegations of fraud in the inducement or requests from rescission of this Agreement. This includes claims against Facility, its employees, agents, officers, or directors, any parent, subsidiary or affiliate of Facility. All claims based in whole or in part on the same incident, transaction, or related course of care and services provided by Facility to Resident shall be arbitrated in one proceeding. A claim shall be waived and forever barred if it arose prior to the date upon which notice of arbitration is given to Facility or received by Resident, and is not presented in the arbitration proceeding.

Notwithstanding the foregoing, any legal controversy, dispute disagreement or claim of any kind between Resident and Facility regarding nonpayment by Resident for monies due to Facility shall be adjudicated in a court of law.

B. Binding Nature of Arbitration. The decision rendered by the arbitrator shall be final and binding, and judgment on the award, if any, shall be entered in accordance with applicable law in any court having jurisdiction thereof. The decision of the arbitrator shall be binding on all of the parties to the arbitration, and also on their successors and assigns, including the agents and employees of Facility, and all persons whose claim is derived through or on behalf of Resident, including, but not limited to, that of any parent, spouse, child, guardian, executor, administrator, legal representative, or heir of Resident.

C. Who Will Conduct Arbitration. The parties shall mutually agree on an arbitration service to utilize. If the parties cannot mutually agree on an arbitration service, the arbitration shall be conducted by the American Health Lawyers Association through its Alternative Dispute Resolution Service. If the American Health Lawyers Association process is no longer in existence at the time of the dispute, or the American Health Lawyers Association is unwilling or unable to conduct the arbitration, then Facility shall choose another independent entity that is regularly engaged in providing arbitration services to conduct the arbitration.

D. Costs of Arbitration. All expenses of the arbitration shall be shared equally by the parties to this Agreement. Each party agrees to be responsible for their own attorney fees and costs, if any, incurred in relation to this Agreement.

E. How to Request Arbitration. Any party desiring arbitration shall file a Request for arbitration with the other party by certified mail, return receipt. Once the Request for Arbitration has been submitted the parties shall attempt to choose an arbitrator pursuant to paragraph C above.

F. Rules of Arbitration. The arbitration shall be conducted in Peoria, IL or, in the alternative, in a location mutually agreed to by the parties. The arbitration shall be conducted in accordance with the Rules of Procedure for Arbitration of the ADR service chosen (hereinafter “arbitration rules”). Except as set forth in the Arbitration Rules, the arbitration proceedings shall follow all rules of civil procedure and evidence that would be applicable to a comparable civil action brought in the State court of the county in which the Facility is located. All claims based in whole or in part on the same incident, transaction, or related course of care and services provided by Facility to Resident shall be arbitrated in one proceeding. A claim shall be waived and forever barred if it arose prior to the date upon which notice of arbitration is given to Facility or received by Resident, and is not presented in the arbitration proceeding.

G. Laws Governing Arbitration. Resident and Facility are entering into this arbitration agreement in connection with a transaction involving interstate commerce. Accordingly, this arbitration agreement, and any proceedings hereunder, shall be governed by the Federal Arbitration Act (“FAA”), 9 U.S.C. sections 1-16.

H. Acknowledgement of Resident. By signing this Agreement, the Resident acknowledges that he/she has been informed that: (1) This provision shall not limit in any way Resident’s right to file formal or informal grievances with Facility or the State or Federal government; (2) Signing this Agreement is not a condition of admission, and that care and treatment will be provided whether or not Resident signs this Agreement; (3) The decision whether to sign the Agreement is solely a matter for the Resident’s determination without any influence; (4) The Agreement waives Resident’s right to a trial in court and a trial by a jury for an future legal claims Resident may have against Facility; and (5) Resident has the right to seek legal counsel regarding this Agreement.

I. Severability. If any provision of this Agreement is determined by a court of competent jurisdiction to be invalid or unenforceable, in whole or in part, the remaining provisions, and partially invalid or unenforceable provisions, to the extent valid and enforceable, shall nevertheless be binding and valid and enforceable.

RESIDENT RIGHT TO CANCEL AGREEMENT

The Resident, or the Resident’s spouse or the personal representative of the Resident’s estate in the event of the Resident’s death or incapacity, has the right to cancel this Agreement by notifying the Facility in writing. Such notice must be sent via certified mail to the attention of the Administrator of the Facility, and the notice must be post marked within thirty days of the date upon which this Agreement was signed. The notice may also be hand-delivered to the Administrator within the same thirty day time period. The filing of a claim in a court of law within the thirty days provided for above will cancel the agreement without any further action by the Resident. This agreement cannot be canceled if it is not canceled within thirty days of the date upon which this Agreement was signed.

IN WITNESS WHEREOF, the parties, intending to be legally bound, have signed this Agreement as of the date first above written.

RESIDENT FACILITY

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If Resident is unable to sign this Agreement, then a legal representative of the Resident may sign on Resident’s behalf. The person signing below certifies that he/she has the legal authority to enter into this Agreement on Resident’s behalf either through a valid Power of Attorney for Property or a Guardianship of the Resident’s Estate.

Legal Representative

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The parties understand that they would have had a right or opportunity to litigate disputes through a court and to have a judge or jury decide their case, but they choose to have any disputes resolved through arbitration. Resident understands that this includes malpractice claims and claims under the Nursing Home Care Act that Resident may have against the Facility or Facility’s employees.