DOWNTOWN BROOKLYN NURSING AND REHABILITATION CENTER

ADMISSION AGREEMENT

Agreement dated

20 (hereinafter the “Agreement”) between Downtown Brooklyn
Nursing and Rehabilitation Center at 727 Classon Avenue, Brooklyn, New York 11238 (hereinafter “Facility”) and
(hereinafter referred to as “Resident”), whose community residence is located
at
and
(hereinafter “Resident Representative”) residing at

The Facility accepts the Resident for admission upon the following terms and conditions:

I. ADMISSION AND CONSENT

The undersigned hereby agrees, subject to federal and state laws, rules and regulations, that the Resident will be
admitted to the Facility only upon the order of a New York State licensed physician and upon a determination that the
Resident satisfies the admission assessment criteria set by the New York State Department of Health (“DOH”) and by
the Facility. The Resident and/or Resident Representative hereby consent to such routine care and treatment as may
be provided by the Facility and/or ancillary providers in accordance with the Resident’s plan of care, including but not
limited to, transfer to an acute care hospital when necessary, dental, medical and/or surgical consultation, examination
by medical and nursing staff, telemedicine services, routine diagnostic tests and procedures, nursing services, and
medication administration. The Resident and Resident Representative shall have the right to participate in the
development of the plan of care and shall be provided with information concerning his or her rights to consent or refuse
treatment at any time to the extent allowable under applicable law. The Resident hereby understands and agrees
that admission to the Facility is conditioned upon the review and execution of this Agreement and related
documents as more fully set forth herein.

The Facility will arrange for the transfer of the Resident to a hospital or other health care facility when any such
transfer is ordered by the attending physician or a substitute physician. The Facility is not responsible for payment for
care and services rendered to the Resident by any hospital or any other health care facility.

II. MUTUAL CONSIDERATION OF THE PARTIES

The Facility agrees to provide all basic (routine) services to the Resident, as well as either provide or arrange for
available ancillary services, that the Resident may require. Attachment “A” lists the routine, ancillary and additional
services provided and/or arranged for by the Facility. A list of private pay charges for certain ancillary and other
available services is included in your admission package.

By entering into this Agreement, the Resident and/or the Resident Representative on the Resident’s behalf,
understand and agree to the following Resident payment obligations. The Resident agrees to pay for, or arrange to
have paid for by Medicaid, Medicare or other insurers, all services provided under this Agreement, and agrees to pay
any required third-party deductibles, coinsurance or monthly income budgeted by the Medicaid program. The
Resident accepts the responsibility to ensure continuity of payment, including the obligation to arrange for timely
Medicaid coverage, if Medicaid coverage becomes necessary.

The Resident and Resident Representative understand and agree that the Facility’s acceptance of the Resident is
based on the representation that the Resident has financial resources, third party insurance coverage and/or is eligible
for government benefits (including Medicare and/or Medicaid) to cover the cost of care at the Facility. The Resident
and Resident Representative to the extent that the Resident Representative has access to this information may be
required to make full and complete disclosure to the Facility of all income including, but not limited to, Social Security
and pension(s), assets, insurance coverage and any other resources available to the Resident that could be available
to pay for the cost of care.

The Resident and/or Resident Representative agree to comply with all applicable policies, procedures,
regulations and rules of the Facility.

III. ANTICIPATED SERVICES

Generally, residents are admitted to the Facility for one of the following reasons: sub-acute care*; long term care, or
hospice care.

* Downtown Brooklyn Nursing and Rehabilitation Center defines sub-acute care as goal oriented, comprehensive,
inpatient care designed for an individual who has an acute illness, injury, or exacerbation of a disease process.
Generally, sub-acute care is rendered at the Facility immediately after, or instead of, acute hospitalization. Sub-acute
care lasts for a limited time or until a condition is stabilized or a predetermined treatment course is completed.

Residents, who are admitted for sub-acute care, are admitted with the expectation that they will be discharged once
short-term services are no longer required, unless continued placement in the Facility is medically appropriate. It is the
mutual goal of the Resident and the Facility that the Resident returns to his/her home or a less restrictive setting, if
appropriate. The Resident and/or Resident Representative agree to facilitate discharge as soon as medically
appropriate, and hereby represent and agree that they will work with the Facility staff to secure an appropriate and
timely discharge. The Resident’s failure to cooperate with discharge constitutes a waiver of any limitation that might
otherwise apply to private collection.

Residents admitted for sub-acute care are responsible for applicable copayments, deductibles, and/or coinsurance,
and for any charges that may accrue after termination of their third-party coverage if they remain in the Facility for any
reason. Residents covered by Medicare Part A are responsible for a daily coinsurance amount for days 21 to 100 of a
Part A covered stay.

If the Resident is admitted for sub-acute services and thereafter remains in the Facility for long term care, an
intra-facility room change or transfer to a more appropriate setting may be necessary. Any such room change
will be conducted in accordance with applicable law and the Facility’s policies and procedures.

IV. FINANCIAL ARRANGEMENTS

(a) Obligations of Resident and/or Resident Representative

1. Resident: The Resident agrees to pay, or arrange for payment of, any portion or all of the applicable
   private pay room and board rate and the ancillary charges incurred for services not covered by third party
   payors and/or required third party deductibles and/or coinsurance including the monthly income contribution
   (NAMI) budgeted by the Medicaid program. If the Resident has no third-party coverage, or if the Resident
   remains in the Facility after any such coverage terminates because covered services are deemed no longer
   “medically necessary” or for any other reason consistent with applicable law, the Resident agrees to pay or
   arrange for payment at the private pay rate for room and board and the ancillary charges incurred until
   discharge or until another source of coverage becomes available. The Resident agrees to take the necessary
   steps to ensure that the Facility and its ancillary providers receive payment from all third-party payors,
   including the timely disclosure of available insurance coverage, timely appeal of insurance coverage denials,
   and production of information and documentation needed to meet the eligibility criteria of the Medicaid
   program (e.g., proof of income, resources, residency, citizenship, and explanation of past financial
   transactions). The Resident hereby agrees to indemnify and hold the Facility harmless from any loss, damage
   or expense the Facility may suffer or incur as a result of a breach of the foregoing obligations.
2. Resident Representative. The Resident Representative is the individual designated, by either a
   Court of law, the Resident or a family member or other party(ies) having an interest in the well-being of the
   resident, including but not limited to the Resident Representative’s self-designation by signing this Agreement,
   to receive information and assist and/or act on behalf of the Resident to the extent permitted by State law. By
   signing this Agreement, the Resident Representative hereby agrees (i) to the extent he/she has legal access
   to the Resident’s funds, to access and use the Resident’s funds to pay for the Resident’s care at the Facility;
   and (ii) to the extent that the Resident Representative has access, to cooperate with the Facility and timely
   provide information and documentation requested by the Facility or a third party payor including, but not limited
   to, insurance and/or Medicaid (e.g., a request for documentation needed to complete a Medicaid application or
   insurance policy information); and regarding such matters as the Resident’s financial resources, citizenship or
   immigration status and third party insurance coverage.
3. Resident and/or Resident Representative. The Resident and Resident Representative understand
   that the Facility is available to assist with securing third party coverage (including but not limited to Medicaid),
   but it is ultimately the responsibility of the Resident and, to the extent he/she has legal access, the Resident
   Representative I to take all necessary steps to apply for, and qualify for, such coverage in a timely manner.
   Care provided to a Resident who does not meet the eligibility criteria for coverage by third party payors will be
   billed to the Resident at the Facility’s private pay room and board rate.

The Resident and, to the extent he/she has access, the Resident Representative agree to provide the
Facility with all relevant information and documentation regarding potential third-party payors, including
insurance and managed care plans, and to promptly notify the Facility of any changes in insurance status or
coverage. Additional charges, such as co-insurance, deductibles, and co-payments, may apply based on the
insurance coverage, managed care plan, or any written agreement with the Facility. Prior authorization from an
insurance carrier or managed care plan does not guarantee coverage or reimbursement. If a third-party payor
denies payment, benefits are exhausted, or coverage is terminated, the Resident is responsible for payment to
the Facility. Additionally, the Resident must immediately inform the Facility of any notice of discontinued
payment (coverage) from a third-party payor.

The Resident Representative’s execution of this Agreement and agreement to undertake the
obligations of the Resident Representative as specifically set forth in this Agreement shall not be deemed an
agreement by the Resident Representative to pay for the Resident’s stay and care at the Facility from the
Resident Representative’s personal funds. The Resident Representative is not a guarantor of payment and is
not obligated to pay for the cost of the Resident’s stay and care at the Facility from his/her own funds.

Nothing herein relieves the Resident Representative of his/her obligations set forth in the Agreement
nor restricts or otherwise limits the remedies legally available to the Facility in the event the Resident
Representative fails to comply with his/her agreements and/or obligations set forth in this Agreement.

(b) Private Payment

If the Resident does not have a third-party payment source in place or if the Resident remains in the Facility after any
such coverage terminates because it is deemed no longer “medically necessary” or for any other reason consistent
with applicable law, his/her care will be billed at private pay rates. The private pay room and board rate (“Daily Basic
Rate”) is $ 665 per day for a private room and $625 per day for a semi-private room. In addition, New York State
Health Facility Cash Assessment Progrm (HFCAP) imposes an additional six and eight tenths (6.8%) percent, which is
added to the Daily Basic Rate. Ancillary services are not included in the Daily Basic Rate. Ancillary services, such as
physician services, rehabilitation therapies, oxygen, dental and diagnostic services, laboratory, x-ray, podiatry,
optometry, pharmacy services, urinary care supplies, trach and ostomy supplies, surgical supplies, parenteral and
enteral feeding supplies, transportation services, and extraordinary rehabilitative devices, are provided by independent
service providers who contract with the Facility and will be billed separately according to the Facility’s and/or the
service providers’ charge schedules. Rates of payment to the Facility may differ for individuals with additional sources
of payment such as third-party coverage. A copy of the Facility charge schedule for ancillary services is attached to
this Agreement and included in your admission package. In addition, certain items and services, such as beauty/barber
services; personal telephone, newspaper delivery etc. (see Attachment “A” – Non-Clinical Services) are not covered in
the Daily Basic Rate or by health insurance plans and the Resident is responsible to pay for such services. Room and
board charges are billed monthly on a one-month advance basis. Ancillary charges are billed in the month following
the month that the services were provided. Bills are generated at the end of each month and cover the next month of
room and board charges (“Monthly Advance Payment”) and the previous month’s ancillary charges. All payments are
due upon receipt of the monthly bill. The Daily Basic Rate and charges for ancillary and/or additional services are
subject to increase upon thirty (30) days’ written notice to the Resident and/or Resident Representative.

(c) Prepaid Deposits/Advance Payment

Unless otherwise specified prior to admission herein and/or restricted by law, the Facility requires an advance payment
in cash or certified check equal to three (3) months of services at the Facility’s Daily Basic Rate from private pay
residents. Such sum represents a two (2) month prepaid security deposit (“Prepaid Deposit”) and the Monthly
Advance Payment for the first month stay at the Facility. The Prepaid Deposit, including any interest accrued, shall
continue to be the property of the depositor. However, the Facility shall have the right to apply, at its sole discretion,
the Prepaid Deposit toward payment for services provided under this Agreement. The Resident agrees to deposit
additional funds with the Facility to replenish the Prepaid Deposit to a sum equivalent to two (2) months of the current
Daily Basic Rate within ten (10) days of written notice to the Resident. To the extent that the Resident Representative
has legal access to the Resident’s funds, the Resident Representative shall take all steps necessary to assist the
Resident in fulfilling the foregoing obligation. The Facility may deduct a fee of one percent (1%) per year from Prepaid
Deposit amounts to cover administrative costs in accordance with applicable law. Upon Resident’s discharge from the
Facility, the balance of the prepaid amount in excess of outstanding bills will be refunded in accordance with Facility’s
policy within thirty (30) days of the discharge. However, if a private paying Resident leaves the Facility for reasons
within the Resident’s control without giving five (5) days’ prior notice, the Facility will retain an additional amount not to
exceed one (1) day’s Daily Basic Rate.

Prepaid deposits/advance payment are not required upon admission from individuals eligible for Medicare,
Medicaid and/or Veterans Administration benefits. However, immediately upon the ineligibility of a Resident
and/or the expiration or discontinuation of coverage for services at the Facility by such government
programs, a Prepaid Deposit and Monthly Advance Payment will be required in accordance with the above-
mentioned Prepaid Deposit policies of the Facility.

(d) Late Charges

Interest at the rate of fifteen (15%) percent per annum [1 % per month] or the maximum allowed by State law will be
assessed on all accounts more than thirty (30) days overdue.

(e) Collection Costs, Including Reasonable Attorneys’ Fees and Related Expenses

In the event of any arbitration or litigation arising from this Agreement, the Facility, if it prevails, shall be entitled to
reasonable attorneys’ fees. The Resident shall be responsible for the expenses related to collecting damages
hereunder, including but not limited to reasonable attorneys’ fees and other collection-related costs and disbursements,
in addition to the late charges imposed on any overdue payments.

(f) Third Party Private Insurance and Managed Care

If the Resident is covered by a private insurance plan or under a managed care benefit plan that has a contract with
the Facility, payment will be according to the rates for coverage of skilled nursing facility benefits agreed upon by such
plan and the Facility. Residents who are members of a managed care benefit plan that has a contract with the Facility
to provide specified services to plan members will have such services covered as long as the Resident meets the
eligibility requirements of the managed care benefit plan. To the extent the Resident meets the eligibility requirements
of the managed care benefit plan, he or she will be financially responsible only for payment for those services not
covered under his or her plan and for applicable copayments, coinsurance and/or deductibles.

If the Resident is covered by a private insurance plan or managed care benefit plan that does not have a contract with
the Facility, and where the private insurance or managed care plan reimbursement is insufficient to cover the cost of
care, the Resident will be responsible for any difference in accordance with federal and State laws and regulations.
The Facility will bill the Resident for any such difference on a monthly basis as described in the “Private Payment”
section above. The coverage requirements for nursing home care vary depending on the terms of the insurance or
managed care plan. Questions regarding private insurance and managed care coverage should be directed to the
social work staff and/or the Resident’s insurance or managed care plan, carrier or agent. The Resident and/or
Resident Representative shall notify the Facility immediately of any change in Resident’s insurance status or coverage
including, but not limited to, ineligibility, termination, discontinuation of coverage, and/or any decrease or increase in
benefits.

If the Resident is covered by a private insurance plan or under a managed care benefit plan for either all or a portion of
the Facility’s charges pursuant to the terms of the Resident’s plan, by execution of this Agreement the Resident hereby
authorizes the Facility to utilize participating physicians and providers of ancillary services or supplies, if required by
the plan for full benefit coverage, unless the Resident specifically requests a nonparticipating provider with the
understanding that there may be additional charges to the Resident for using such nonparticipating providers.

Alternate Physician or Professional Provider of Service: The Resident and/or Designated Representative agree that if
the physician or any other professional provider of service designated by the Resident and/or Designated
Representative is not available to serve the Resident, fails to serve the Resident, or fails to comply with any
applicable provision of federal or state law, the Facility is authorized to obtain the services of a substitute physician or
professional provider of service. Payment for such services will be made in accordance with this Agreement.

The Resident is responsible for timely advising the Facility of what benefits, if any, may be available from his or her
private insurance and/or managed care plan. Charges may be assessed above the covered benefit for skilled nursing
facility care depending on the insurance coverage, managed care plan and/or written agreement with the Facility.
Furthermore, the Resident’s coverage may be subject to co-insurance, deductibles and/or co-payments which will be
the Resident’s responsibility and billed according to the terms for private payment stated above.

In the event of denial of payment by a third-party payor, exhaustion of benefits and/or termination of coverage, the
Resident and/or Designated Representative shall be responsible (in accordance with the terms and provisions of this
Agreement) for payment to the Facility as described in the “Private Pay” section above and in accordance with
applicable law.

(g) Medicare

Medicare Part A: If the Resident meets the eligibility requirements for skilled nursing facility benefits under the
Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the
Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification
within the Medicare guidelines. If the Resident continues to be eligible, Medicare may provide coverage of up to 100
days of care. The first 20 days of covered services are fully paid for by Medicare and the next 80 days (days 21
through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which
the Resident is responsible.

Medicare Part B and/or Part D coverage. If a Resident exhausts his/her Part A coverage or no longer needs a
skilled level of care under Part A, the Resident may still be eligible for coverage of certain services under Medicare
Part B and/or Part D. The Resident will be responsible for all deductible and copayments associated with Part B and
Part D services. Any charges for services that Medicare Part B, Part D, or other third-party payers do not cover will
also be the Resident’s responsibility.

Medicare will terminate coverage for therapy services (physical, occupational and/or speech therapy) if the
beneficiary does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any
reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis
for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another
payor source is available.

If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the
Resident hereby agrees to pay to the Facility any outstanding amounts for unpaid services not covered by
other third-party payers, subject to applicable federal and state laws and regulations. Such amounts shall be
calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and
additional services provided to the Resident.

(h) Medicaid

If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise
satisfies the Medicaid eligibility requirements and is not entitled to any other third-party coverage, the Resident may be
eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT AND, TO THE EXTENT HE/SHE
HAS LEGAL ACCESS, THE RESIDENT REPRESENTATIVE AGREE TO NOTIFY THE FACILITY AT LEAST THREE
(3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR
INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED
TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT AND
RESIDENT REPRESENTATIVE AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS
PRIOR TO THE EXHAUSTION OF THE RESIDENT’S RESOURCES. Services reimbursed under Medicaid are
outlined in Attachment “A” to this Agreement.

Once a Medicaid application has been submitted on the Resident’s behalf, the Resident and Resident
Representative to the extent that he/she has legal access to the Resident’s funds, agree to pay to the Facility
the Resident’s monthly income, which will be owed to the Facility under the Resident’s Medicaid budget.
Medicaid recipients are required to pay their Net Available Monthly Income (“NAMI”) to the Facility on a
monthly basis as a co-payment obligation as part of the Medicaid rate. A Resident’s NAMI equals his or her
income (e.g., Social Security, pension, etc.), less allowed deductions. The Facility has no control over the
determination of NAMI amounts, and it is the obligation of the Resident and/or Resident Representative to
appeal any disputed NAMI calculation with the appropriate government agency. Once Medicaid eligibility is
established, the Resident and/or Resident Representative to the extent he/she has legal access agree to pay
NAMI to the Facility or to arrange to have the income redirected by direct deposit to the Facility and to ensure
timely Medicaid recertification. The Resident and Resident Representative agree to provide the Facility with
copies of any notices (such as requests for information, budget letters, recertification, denials, etc.) received
from the Department of Social Services related to the Resident’s Medicaid coverage.

Until Medicaid is approved, the Facility may bill the Resident’s account as private pay and the Resident will be
responsible for the Facility’s private pay rate. If Medicaid denies coverage, the Resident or the Resident’s
authorized representative can appeal such denial; however, payment for any uncovered services will be owed
to the Facility at the private pay rate pending the appeal determination. If Medicaid eligibility is established
and retroactively covers any period for which private payment has been made, the Facility agrees to refund or
credit any amount in excess of the NAMI owed during the covered period.

(i) Direct Deposit

All long-term residents and all short-term residents transferred to long-term care may have their Net Available Monthly
Income or NAMI (Social Security, pension benefits, etc.) deposited in the Facility’s account and/or their “personal
income allowance” deposited in their personal account via electronic direct deposit. If you would like the Facility to
assist you/the Resident in obtaining direct deposit of these income sources, please initial all that apply below. By
initialing below you are agreeing to allow the Facility to become representative payee for direct deposit purposes.

I understand that the Facility will apply any income received towards my/the Resident’s NAMI obligation in accordance
with applicable Social Services Law and regulations and/or towards my/the Resident’s anticipated NAMI obligation and
that the Facility will deposit my/the Resident’s “personal income allowance” in my/the Resident’s personal account at
the Facility.

I understand that during the pendency of my/the Resident’s Medicaid application that the Resident’s “estimated” NAMI
should be turned over to the Facility to be applied on the Resident’s account either via direct deposit as indicated
above or by submitting a check for such income or by turning over such income checks on a monthly basis on or
before the 5th day of the month. I understand that the Resident’s NAMI is determined by the applicable Department of
Social Services and that the amount of such NAMI is subject to change upon the issuance of a budget. I understand
that the Resident is responsible for any differences between the “estimated” NAMI and the actual budgeted NAMI.
Similarly, credit balances, if any, resulting from such “estimated” NAMI payments made to the Facility during the
pendency of the Resident’s Medicaid application will be refunded less any payments, monies, or balance due to the
Facility for the services rendered to the Resident pursuant to terms of this Agreement.

V. AUTHORIZATIONS AND ASSIGNMENTS FROM RESIDENT TO THE FACILITY

(a) Authorization to Release Information

By execution of this Agreement, the Resident and Resident Representative authorize the Facility to release to
government agencies, insurance carriers or others who could be financially liable for any medical care provided to the
Resident, all information needed to secure and substantiate payment for such medical care and to permit
representatives thereof to examine and copy all records relating to such care.

(b) Authorization to Obtain Records, Statements and Documents

By execution of this Agreement, the Resident and Resident Representative authorize the Facility, its agents,
representatives, successors and assigns to obtain from financial institutions, including, but not limited to, banks,
insurance companies, broker and credit unions, and government agencies, such as the Social Security Administration
and Department of Social Services, records, statements, correspondence and other documents pertaining to the
Resident for the purposes of payment to the Facility and/or securing Medicaid coverage.

(c) Assignment of Benefits and Authorization to Pursue Third Party Payment

By execution of this Agreement, the Resident and Resident Representative agree to assign to the Facility any and all
applicable insurance benefits and other third-party payment sources to the extent required by the Facility to secure
reimbursement for the care provided to the Resident and authorize the Facility to seek and obtain all information and
documentation necessary for the processing of any third-party claim.

(d) Designation and Authorization for External Appeal of Medical Necessity Denials

Except where a designee is appointed, only a Resident may request an “external” or independent appeal of benefit
denials based on lack of medical necessity. The Resident and/or Resident Representative appoints the Facility as
designee authorizing it to request an external appeal of a health plan denial or limitation of coverage because of
medical necessity and agrees to sign any form needed to effectuate such appointment.

(e) Authorization to Represent Resident Regarding Medicaid

By execution of this Agreement, the Facility, its agents, representatives, successors and assigns shall be authorized to
have access to the Resident’s Medicaid file, and, if the Facility so elects, to act on behalf of the Resident in connection
with any and all matters involving Medicaid, including, but not limited to, representation of the Resident at
Administrative Fair Hearings and Article 78 judicial appeals. The Facility will appeal a Medicaid determination only if it
deems an appeal has merit and is necessary and prudent.

(f) Authorization to Take Resident’s Photograph

By execution of this Agreement, the Resident and/or Resident Representative authorize the Facility to photograph the
Resident for identification purposes and to photograph any part of the Resident to document certain physical
conditions, e.g., wounds or skin discolorations, for treatment purposes. I understand that the Facility retains ownership
rights to these photographs but that the Resident will be allowed access to view them or obtain copies.

(g) Authorization to Take Resident’s Photograph for Public Relations Purposes

By execution of this Agreement, the Facility shall be authorized to take and use photographs of the Resident during the
normal routine of activities and/or events at the Facility, which photographs may be used for the purpose of marketing,
publicity, social media, and advertising, including but not limited to web content, Instagram and Facebook. By
execution of this Agreement, the Resident and/or Designated Representative understand that there will be no
remuneration or compensation for any such use. All such photographs, images and stories regarding such activities
and/or events will be used and displayed with discretion by the Facility carefully respecting the Resident’s rights.

(h) Authorization to Search Resident’s Room

By execution of this Agreement, the Resident and/or Designated Representative hereby authorize the Facility to enter
and search the Resident’s room as it deems necessary. Facility staff may enter resident rooms to respond to health or
safety concerns, enforce facility policies and procedures, to respond to a complaint, or to ensure that state and federal
laws, rules and regulations are not being violated. Facility staff may repair any situation that is considered necessary
by Facility staff.

(i) Authorization for Emailed Invoices

The Resident and/or Designated Representative do hereby consent to the Facility sending any and all invoices for
services rendered hereunder via email to the Resident and/or Designated Representative, as applicable.

VI. TEMPORARY ABSENCE (also referred to as “bed hold” or “bed reservation”)

If the Resident leaves the Facility due to hospitalization or therapeutic leave, the Facility is NOT obligated to hold the
Resident’s bed until his or her return unless prior arrangements have been made for a bed hold pursuant to the
Facility’s “Bed Reservation Policy and Procedure” or it is required by law. In the absence of a bed hold, the Resident
may be placed in any appropriate semi-private bed in the Facility at the time of return from hospitalization or
therapeutic leave provided a bed is available and the Resident’s re-admission is appropriate.

Before a Resident is transferred to a hospital, the attending physician or a Facility designee will inform the Designated
Representative or other responsible family member accordingly, except in an extreme emergency, when the Facility
staff has tried but has been unable to reach the Designated Representative or family member. In that circumstance,
the Designated Representative or family member will be forwarded a letter restating when and where the Resident was
transferred and restating the Facility’s bed hold policy and procedure.

(a) Private Pay Residents

Private Pay Residents who elect to retain a bed in the Facility during a period of hospitalization or therapeutic
leave may do so by notifying the Admission Department and signing a bed hold reservation form with the Admission
Department stating their intent to hold, and pay for the bed at the Facility’s private pay rate, and continuing payment at
the private pay rate. The bed hold will be in effect until the Facility received written notice of discontinuance by the
Resident/Designated Representative or payment if discontinued.

(b) Medicare Residents

Medicare Residents are not entitled to reimbursement for Bed Hold or Therapeutic Leave under the Medicare
Program. Medicare Residents who are absent from the Facility past twelve (12) midnight on any given day are deemed
to be discharged from the Facility. However, a Medicare Resident may elect to retain his/her bed in the Facility by
following the Private Pay Resident Bed Reservation policy above.

(c) Medicaid Recipients:

Medicaid regulations provide that when a Medicaid recipient has been a resident
in the Facility for a minimum of thirty (30) days and the Facility’s vacancy rate is less than five (5%) percent,
the Resident’s bed will be reserved for: (1) Residents under 21 years of age for temporary hospitalization and
therapeutic leave; (2) Residents 21 and over who are receiving hospice services for temporary
hospitalization. The Medicaid bed hold is limited for fourteen (14) days in any twelve (12) month period; (3)
Residents 21 and over for non-hospitalization therapeutic leaves of absence (“Therapeutic Leave”). The
Medicaid bed hold for Therapeutic Leave is limited to ten (10) days in a twelve (12) month period.

There is no Medicaid paid bed hold for a Resident 21 years of age or older who is temporarily hospitalized
unless such Resident is receiving hospice services within the Facility.

Medicaid recipients who do not meet the bed hold eligibility requirements, who do not have a paid bed hold,
whose bed hold has expired or has been terminated, may elect to reserve/hold the same bed in the Facility by
notifying the Admission Department and signing a bed hold reservation form with the Admission Department
stating their intent to hold, and pay for, the bed at the Facility’s private pay rate.

In the absence of a bed hold, a Medicaid resident, has the right to, and will be given priority for readmission
when an appropriate bed in a semi-private room becomes available if the Resident requires the services
provided by the Facility and is eligible for Medicaid nursing home services, unless there are special
circumstances which would preclude the Resident’s return.

For additional information, please contact our Admissions Department, Monday through Friday from 9 am to
5pm.

VII. DISCHARGE, TRANSFER AND INTRA-FACILITY ROOM CHANGES

(a) Involuntary Discharge for Non-Payment

To the extent authorized by applicable law, the Facility reserves the right to discharge the Resident if the Resident-fails
to pay for, or secure third-party coverage of the Resident’s care at the Facility, including failing to pay applicable co-
insurance and/or NAMI.

(b) Involuntary Discharge for Non-Financial Matters

The Facility may transfer or discharge the Resident if the transfer or discharge is necessary for the Resident’s welfare
and the Resident’s needs cannot be met in the Facility; the Resident’s health has improved sufficiently so the Resident
no longer needs the services provided by the Facility; the health or safety of individuals in the Facility would otherwise
be endangered; or the Resident has failed to pay for (or have paid under Medicare, Medicaid, or third-party insurance)
a stay at the Facility, or for any other reason permitted by applicable law.

(c) Voluntary Discharge

If the Resident no longer requires the services provided by the Facility, or voluntarily wishes to be discharged, the
Resident and Resident Representative agree to cooperate fully with the Facility in the development and
implementation of a safe, appropriate, and timely discharge plan.

The Resident will be informed of his or her due process rights in the event that the Facility initiates a transfer or
discharge and may appeal the Facility’s determination in accordance with applicable regulations.

(d) Intra-facility Room Change

The Facility reserves the right to transfer the Resident to a new room on an as-needed basis, consistent with
applicable law. Residents who are admitted as short-term residents who subsequently become long-term residents,
will be the subject of an intra-Facility transfer to rooms that are better suited for long term Residents. If the Resident
occupies a private room, the Resident understands and agrees that when he/she no longer pays the private rate or
upon Medicaid coverage, he/she may be moved to a semi-private room unless the private room is medically
necessary. The Facility may also initiate a room change for medical, social and/or other reason consistent with
applicable law and the Resident’s rights.

VIII. RESIDENT’S PERSONAL PROPERTY

Each Resident may request a locked drawer in his/her room for the storage of personal property. It is not
recommended that valuable personal property (such as jewelry, money, or other valuable items, etc.) be kept in the
Resident’s room. In the event of lost personal property, the Facility will conduct an investigation to determine the
cause of the loss. Liability for the loss shall be borne by the party found responsible at the conclusion of the
investigation. Further, it is the responsibility of the Resident and/or Resident Representative to arrange for disposition
of the Resident’s property upon discharge or death of the Resident. Property left in the Facility for more than thirty (30)
days after discharge will be disposed of at the discretion of the Facility.

IX. SMOKING AND VAPING POLICY

The Facility is committed to maintaining a smoke-free and vape-free environment. The Resident agrees that under no
circumstances will he/she and/or his/her visitors smoke or vape anywhere on the grounds or in the buildings of the
Facility, nor will he/she maintain or store any smoking or vaping material, electronic nicotine delivery systems or
devices, oils, paraphernalia or other flammable, spark, smoke or vape producing device(s) in his/her room at the
Facility. The use of spark producing devices is strictly prohibited in all areas of the Facility. The Resident agrees to
comply with the Facility’s non-smoking and non-vaping policy.

X. FACILITY SECURITY

In order to safeguard the safety and security of our residents and staff, the facility has implemented 24-hour video
surveillance of the facility grounds and/or public/common areas in the facility, including the lobby, unit corridors, dining/
day rooms and exit areas. The cameras do not record audio. All video recordings remain in the possession of the
facility until erased or otherwise destroyed and will only be released in accordance with applicable State and federal
laws and regulations. By executing this Agreement, you consent to the video surveillance system.

XI. GENERAL PROVISIONS

(a) Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of New York without
giving effect to conflict of law provisions. Any and all actions arising out of or related to this Agreement, unless
otherwise required by law to be brought in another jurisdiction, shall be brought in, and the parties agree to exclusive
jurisdiction of, the New York State Supreme Court, located in New York County, New York.

(b) Assignment

This Agreement may not be assigned by either party without the prior written consent of the other party.
Notwithstanding the foregoing, this Agreement may be assigned by Facility in connection with the transfer of Facility
operations to a new operator. Upon such assignment, Facility is relieved of further duties and obligations under the
Agreement.

(c) Binding Effect

Notwithstanding the foregoing, all covenants, conditions, and obligations contained herein shall be binding upon, and
shall inure to the benefit of the parties and their respective heirs, executors, administrators, successors and assigns.

(d) Continuation of This Agreement

Temporary transfer of the Resident to another health care facility for medical or surgical treatment, or the Resident’s
authorized temporary absence from the Facility for any other purpose, where such transfer or absence does not
exceed a period of sixty (60) days, shall not terminate this Agreement. Upon the Resident’s return and re-admission in
accordance with the admission assessment criteria set by the DOH and by the Facility, this Agreement shall continue
in full force and effect.

(e) Entire Agreement

This Agreement and addenda, which are incorporated herein, contain the entire understanding between the Resident
and/or Resident Representative and the Facility. This Agreement cannot be modified orally, and any changes must be
in writing, signed by the parties to this Agreement.

(f) Severability

Any provision in this Agreement determined to be inconsistent with applicable law or to be unenforceable will be
deemed amended so as to render it legal and enforceable and to give effect to the intent of the provision; however, if
any provision cannot be so amended, it shall be deemed deleted from this Agreement without affecting or impairing
any other part of this Agreement.

(g) Waiver

The failure of any party to enforce any term of this Agreement or the waiver by any party of a breach of this Agreement
will not prevent the subsequent enforcement of such term, and no party will be deemed to have waived subsequent
enforcement.

(h) Counterparts

For the convenience of the parties hereto, this Agreement may be executed in counterparts and all such counterparts
shall together constitute the same agreement and facsimile and electronic signatures shall be accepted and deemed to
be original signatures and shall be binding on the parties upon signing.

(i) Relationship between Parties

Execution of this Agreement is not intended, nor shall it be deemed, to create a landlord-tenant relationship between
the Facility and the Resident.

(j) Section Headings

The section headings used herein are for convenience of reference only and shall not limit or otherwise affect any of
the terms or provisions hereof.

(k) Representations

The Resident and Resident Representative warrant and represent that the information (both written and oral) provided
during the admission process is complete and accurate, and acknowledge that the Facility has relied upon such
information in entering into this Agreement and admitting the Resident.

(l) Attachments

Attachments “A” and “B”, as cited and referenced in this Admission Agreement, are intended to be informational only;
they are not otherwise incorporated into the Admission Agreement, and they confer no legal rights or obligations.

(m) Non-Discrimination

THE REMAINDER OF THIS PAGE IS LEFT BLANK INTENTIONALLY.

By execution of this Agreement, Resident and/or Resident Representative acknowledge receipt of the
following documents and information:

1. Schedule of Coverage and Fees for Ancillary Services (Attachment A)
2. Medicare and Medicaid Information (Attachment B)
3. Voluntary Arbitration Agreement
4. Statement of Resident’s Rights and Responsibilities; Facility Rules and Regulations
5. Contact information for the Resident’s Attending Physician (name, address, and telephone number); and
   information and contact information for filing grievances, including the name, business address, email address,
   and phone number of the Facility’s grievance official; the telephone numbers for the DOH “Hot Line” and the
   NYS Office of Aging Ombudsman Program; and a list of legal service agencies and community resources
   providing resident advocacy services.
6. Information about advance directives including: A summary of the Facility’s policy and DOH pamphlets:
   Deciding about Health Care: A Guide for Patients and Families; Health Care Proxy: Appointing your Health
   Care Agent in New York; and Do Not Resuscitate Orders A Guide for Patients and Families.
7. State-required disclosures: CMS and DOH websites access information, and common/familial ownership of
   any entity or individual providing services to the facility.
8. Statement regarding the use of the Medicare Minimum Data Set (MDS) and the Privacy Act of 1974.
9. Notice of Privacy Practices for Protected Health Information
10. Veterans Information
11. Addenda:
    1. Assignment of benefits form (Signature on File form)
    2. Acknowledgment of receipt of the Notice of Privacy Practices
    3. Designation and authorization for external appeal of medical necessity denials
    4. Authorizations for Medicaid
    5. Request for facility to maintain personal fund account

THE UNDERSIGNED HAVE READ, UNDERSTAND AND AGREE TO BE LEGALLY BOUND BY THE TERMS AND
CONDITIONS AS SET FORTH HEREIN, AND IN ALL ADDENDA TO THIS AGREEMENT.

ACCEPTED AND AGREED:

*If Mark, signature of two witnesses:

DOWNTOWN BROOKLYN NURSING AND REHABILITATION CENTER

ATTACHMENT “A”

BASIC SERVICES

ADDITIONAL CLINICAL SERVICES

THE FOLLOWING ADDITIONAL CLINICAL SERVICES ARE AVAILABLE TO ALL RESIDENTS. THE CHART BELOW DESCRIBES
MEDICARE, MEDICAID AND PRIVATE RATE COVERAGE OF THESE SERVICES.

If your stay is covered under Medicare Part A:

• Medicare will pay up to 100 days for your stay (assuming eligibility criteria are met and benefits are still available).
• Co-insurance payments for 2025 are $209.50 per day for days 21 through 100.

** It is the responsibility of the Resident and/or Representative to verify co-insurance coverage by secondary insurance with the Business Office at

If you are covered by Medicare Part B, for 2025:

• Annual Medicare Part B Deductible is $257.00.
• Co-Insurance payments are 20% of the approved Medicare Part B charge for all Part B covered services.
• Physical and speech therapy benefits (combined) are capped at $2,410.00, and occupational therapy benefits are capped at $2,410.00 per year
  (including co-insurance).
• Beneficiary may qualify for Therapy Cap Exception Process. However, your request for additional services (over the cap) is denied, you will be
  responsible for 100% of the Medicare Approved Charge once the cap is reached.

(1) May be billed by outside vendor to DMERC or Intermediary

(2) Billed by Facility.

(3) Billed direct by Provider or Vendor.

(4) Patient/Resident responsible for co-insurance and deductible.

(5) Coverage depends on services provided.

ADDITIONAL NON-CLINICAL SERVICES

ATTACHMENT “B”

SPECIAL RULES REGARDING SELECTED PAYORS