Genesis Healthcare, Inc. - Quarter Report: 2013 September (Form 10-Q)

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

FORM 10-Q

(Mark One)



R	Quarterly Report Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934

For the quarterly period ended September 30, 2013.



£	Transition Report Pursuant to Section 13 or 15(d) of the Securities Exchange Act of 1934

For the transition period from to .

Commission file number: 001-33459

Skilled Healthcare Group, Inc.

(Exact name of registrant as specified in its charter)



Delaware		20-3934755
(State or other jurisdiction of incorporation or organization)		(IRS Employer Identification No.)

27442 Portola Parkway, Suite 200
Foothill Ranch, California		92610
(Address of principal executive offices)		(Zip Code)

(949) 282-5800

(Registrant’s telephone number, including area code)

Indicate by check mark whether the registrant (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding 12 months (or for such shorter period that the registrant was required to file such reports) and (2) has been subject to such filing requirements for the past 90 days. Yes þ No £

Indicate by check mark whether the registrant has submitted electronically and posted on its corporate Web site, if any, every Interactive Data File required to be submitted and posted pursuant to Rule 405 of Regulation S-T during the preceding 12 months (or for such shorter period that the registrant was required to submit and post such files). Yes þ No £

Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, or a smaller reporting company. See the definitions of “large accelerated filer,” “accelerated filer” and “smaller reporting company” in Rule 12b-2 of the Exchange Act.



Large accelerated filer	£		Accelerated filer	þ

Non-accelerated filer	£	(do not check if smaller reporting company)	Smaller reporting company	£

Indicate by check mark whether the registrant is a shell company (as defined in Rule 12b-2 of the Exchange Act). Yes £ No þ

The number of shares outstanding of each of the issuer’s classes of common stock, as of the close of business on November 1, 2013, was:

Class A common stock, $0.001 par value – 23,686,684 shares

Class B common stock, $0.001 par value –15,515,050 shares

Table of Contents

Skilled Healthcare Group, Inc.

Form 10-Q

For the Quarterly Period Ended September 30, 2013

Index



		Page Number
Part I.	Financial Information
Item 1.	Financial Statements	3
	Condensed Consolidated Balance Sheets — September 30, 2013 (unaudited) and December 31, 2012	3
	Condensed Consolidated Statements of Operations — Three and Nine months ended September 30, 2013 (unaudited) and September 30, 2012 (unaudited)	4
	Condensed Consolidated Statements of Comprehensive (Loss) Income — Three and Nine months ended September 30, 2013 (unaudited) and September 30, 2012 (unaudited)	5
	Condensed Consolidated Statements of Cash Flows — Nine months ended September 30, 2013 (unaudited) and September 30, 2012 (unaudited)	6
	Notes to Unaudited Condensed Consolidated Financial Statements	8
Item 2.	Management’s Discussion and Analysis of Financial Condition and Results of Operations	24
Item 3.	Quantitative and Qualitative Disclosures About Market Risk	50
Item 4.	Controls and Procedures	50
Part II.	Other Information
Item 1.	Legal Proceedings	52
Item 1A.	Risk Factors	52
Item 2.	Unregistered Sales of Equity Securities and Use of Proceeds	67
Item 3.	Defaults Upon Senior Securities	67
Item 4.	Mine Safety Disclosures	67
Item 5.	Other Information	68
Item 6.	Exhibits	69
Signatures		70
Exhibit Index		71

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PART I — FINANCIAL INFORMATION

Item 1. Financial Statements.

Skilled Healthcare Group, Inc.

Condensed Consolidated Balance Sheets

(In thousands)



	September 30, 2013			December 31, 2012
	(Unaudited)			(Audited)
ASSETS
Current assets:
Cash and cash equivalents	$	2,595		$	2,003
Accounts receivable, less allowance for doubtful accounts of $13,548 and $15,646 at September 30, 2013 and December 31, 2012, respectively	107,109			107,245
Deferred income taxes	11,055			11,696
Prepaid expenses	8,983			7,569
Other current assets	10,580			10,312
Total current assets	140,322			138,825
Property and equipment, less accumulated depreciation of $135,885 and $118,141 at September 30, 2013 and December 31, 2012, respectively	362,908			370,745
Leased facility assets, less accumulated depreciation of $4,310 and $3,935 at September 30, 2013 and December 31, 2012, respectively	9,538			9,913
Other assets:
Notes receivable	784			2,055
Deferred financing costs, net	8,060			6,355
Goodwill	69,065			85,609
Intangible assets, less accumulated amortization of $4,465 and $4,218 at September 30, 2013 and December 31, 2012, respectively	18,983			22,035
Deferred income taxes	10,192			7,362
Other assets	42,060			39,737
Total other assets	149,144			163,153
Total assets	$	661,912		$	682,636
LIABILITIES AND STOCKHOLDERS’ EQUITY
Current liabilities:
Accounts payable and accrued liabilities	$	53,660		$	48,780
Employee compensation and benefits	39,383			42,185
Current portion of long-term debt	17,446			13,338
Total current liabilities	110,489			104,303
Long-term liabilities:
Insurance liability risks	27,035			27,396
Other long-term liabilities	12,480			15,477
Long-term debt, less current portion	417,363			435,629
Total liabilities	567,367			582,805
Commitments and contingencies — Note 7
Stockholders’ equity:
Class A common stock, 175,000 shares authorized, $0.001 par value per share; Issued and outstanding - 23,524 and 22,967 at September 30, 2013 and December 31, 2012, respectively	24			23
Class B common stock, 30,000 shares authorized, $0.001 par value per share; Issued and outstanding - 15,515 and 15,576 at September 30, 2013 and December 31, 2012 respectively	16			16
Additional paid-in-capital	378,071			376,027
Accumulated deficit	(283,589		)	(276,108		)
Accumulated other comprehensive income (loss)	23			(127		)
Total stockholders’ equity	94,545			99,831
Total liabilities and stockholders’ equity	$	661,912		$	682,636

The accompanying notes are an integral part of these unaudited condensed consolidated financial statements.

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Skilled Healthcare Group, Inc.

Condensed Consolidated Statements of Operations

(In thousands, except per share data)

(Unaudited)



	Three Months Ended September 30,						Nine Months Ended September 30,
	2013			2012			2013			2012
Revenue:
Net patient service revenue	$	211,658		$	215,854		$	642,677		$	651,120
Leased facility revenue	787			769			2,335			2,291
	212,445			216,623			645,012			653,411
Expenses:
Cost of services (exclusive of rent cost of revenue and depreciation and amortization shown below)	184,627			182,243			561,140			545,589
Rent cost of revenue	4,950			4,639			14,590			13,734
General and administrative	6,490			6,021			19,782			18,548
Change in fair value of contingent consideration	79			85			(2,082		)	715
Depreciation and amortization	6,130			6,173			18,396			18,409
Impairment of long-lived assets	19,000			—			19,000			—
	221,276			199,161			630,826			596,995
Other (expenses) income:
Interest expense	(8,744		)	(8,790		)	(26,153		)	(28,876		)
Interest income	63			125			287			402
Other (expense) income, net	(49		)	(57		)	(111		)	20
Equity in earnings of joint venture	508			461			1,469			1,422
Debt modification/retirement costs	(432		)	(168		)	(1,520		)	(4,126		)
Total other (expenses) income, net	(8,654		)	(8,429		)	(26,028		)	(31,158		)
(Loss) income before (benefit) provision for income taxes	(17,485		)	9,033			(11,842		)	25,258
(Benefit) provision for income taxes	(5,410		)	2,965			(4,360		)	9,356
Net (loss) income	$	(12,075	)	$	6,068		$	(7,482	)	$	15,902

Net (loss) income per share, basic	$	(0.32	)	$	0.16		$	(0.20	)	$	0.42
Net (loss) income per share, diluted	$	(0.32	)	$	0.16		$	(0.20	)	$	0.42

Weighted-average common shares outstanding, basic	37,499			37,431			37,567			37,372
Weighted-average common shares outstanding, diluted	37,499			37,503			37,567			37,534

The accompanying notes are an integral part of these unaudited condensed consolidated financial statements.

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Skilled Healthcare Group, Inc.

Condensed Consolidated Statements of Comprehensive Income

(In thousands)

(Unaudited)



	Three Months Ended September 30,						Nine Months Ended September 30,
	2013			2012			2013			2012

Net (loss) income	$	(12,075	)	$	6,068		$	(7,482	)	$	15,902
Other comprehensive income:
Unrealized (loss) on interest rate swap - net of income tax (benefit) of ($2) for the three months ended September 30, 2012; net of income tax (benefit) of ($16) for the nine months ended September 30, 2012.	—			(2		)	—			(25		)
Unrealized (loss) gain on Investment available for sale - net of income tax (benefit) expense of ($2) and $3 for the three months ended September 30, 2013 and 2012, respectively; net of income tax (benefit) expense of ($13) and $30 for the nine months ended September 30, 2013 and 2012, respectively.	(3		)	6			(19		)	48
Reclassification adjustments:
Interest expense on interest rate swap - net of income tax expense of $55 for the three months ended September 30, 2012; net of income tax expense of $107 and $163 for the nine months ended September 30, 2013 and 2012, respectively.	—			86			169			257
Other comprehensive (loss) income, net of tax	(3		)	90			150			280
Comprehensive (loss) income	(12,078		)	6,158			(7,332		)	16,182

The accompanying notes are an integral part of these unaudited condensed consolidated financial statements.

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Skilled Healthcare Group, Inc.

Condensed Consolidated Statements of Cash Flows

(In thousands)

(Unaudited)



	Nine Months Ended September 30,
	2013			2012
Cash Flows from Operating Activities
Net (loss) income	$	(7,482	)	$	15,902
Adjustments to reconcile net (loss) income to net cash provided by operating activities:
Depreciation and amortization	18,396			18,409
Change in fair value of contingent consideration	(2,082		)	715
Provision for doubtful accounts	8,758			5,302
Non-cash stock-based compensation	2,235			3,567
Disposal of fixed assets	379			(121		)
Excess tax benefits from stock-based payment arrangements	—			242
Amortization of deferred financing costs	2,102			2,173
Debt modification/retirement costs	1,520			4,126
Deferred income taxes	(2,284		)	1,015
Impairment of long lived assets	19,000			—
Amortization of discount on debt	710			588
Changes in operating assets and liabilities:
Accounts receivable	(8,528		)	(14,973		)
Payments on notes receivable	2,304			2,299
Other current and non-current assets	(3,036		)	85
Accounts payable and accrued liabilities	2,462			(2,378		)
Employee compensation and benefits	(3,658		)	(2,977		)
Insurance liability risks	6,949			(93		)
Other long-term liabilities	(913		)	(2,945		)
Net cash provided by operating activities	36,832			30,936
Cash Flows from Investing Activities
Additions to property and equipment	(9,977		)	(12,513		)
Acquisition of healthcare facilities and businesses, net of cash acquired	—			(1,053		)
Proceeds from divestitures	—			1,050
Net cash used in investing activities	(9,977		)	(12,516		)
Cash Flows from Financing Activities
Borrowings under line of credit	254,083			234,500
Repayments under line of credit	(287,583		)	(199,000		)
Repayments of long-term debt	(67,055		)	(161,008		)
Excess tax benefits from stock-based payment arrangements	—			(242		)
Taxes paid related to net share settlement of equity awards	(188		)	(231		)
Proceeds from issuance of long-term debt	79,806			98,000
Payment of financing costs	(5,326		)	(3,257		)
Net cash used in financing activities	(26,263		)	(31,238		)
Increase (decrease) in cash and cash equivalents	592			(12,818		)
Cash and cash equivalents at beginning of period	2,003			16,017
Cash and cash equivalents at end of period	$	2,595		$	3,199

The accompanying notes are an integral part of these unaudited condensed consolidated financial statements.

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	Nine Months Ended September 30,
	2013		2012
Supplemental cash flow information
Cash paid for:
Interest expense	$	23,743	$	31,743
Income taxes, net	$	184	$	7,218
Non-cash activities:
Conversion of accounts receivable into notes receivable	$	—	$	359
Liabilities issued as purchase consideration for purchase of business	$	—	$	261
Insurance premium financed	$	5,875	$	4,628

The accompanying notes are an integral part of these unaudited condensed consolidated financial statements.

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SKILLED HEALTHCARE GROUP, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(UNAUDITED)

1. Description of Business

Current Business

Skilled Healthcare Group, Inc. ("Skilled") is a holding company that owns subsidiary companies that in turn own and operate long-term care facilities and provide a wide range of post-acute care services, with a strategic emphasis on sub-acute specialty medical care. Skilled and its consolidated wholly-owned companies are collectively referred to as the "Company." As of September 30, 2013, the Company operated facilities in California, Iowa, Kansas, Missouri, Nevada, Nebraska, New Mexico and Texas, including 74 skilled nursing facilities ("SNFs"), which offer sub-acute care, rehabilitative, specialty healthcare, and skilled nursing care, and 22 assisted living facilities ("ALFs"), which provide room and board and assistance with activities of daily living. The Company leases five skilled nursing facilities in California to an unaffiliated third party operator. In addition, through its Hallmark Rehabilitation subsidiary ("Hallmark"), the Company provides a variety of rehabilitative services such as physical, occupational and speech therapy in Company-operated facilities and unaffiliated facilities. Furthermore, as of September 30, 2013, the Company provided hospice care and home health services in Arizona, California, Idaho, Montana, Nevada and New Mexico. The Company also provides private duty care services in Idaho, Montana, and Nevada. The Company has an administrative services company that provides a full complement of administrative and consultative services that allows affiliated operators and third-party operators with whom the Company contracts to better focus on delivery of healthcare services. The Company currently has one such service agreement with an unrelated skilled nursing facility operator. The Company is also a member in a joint venture located in Texas that provides institutional pharmacy services, which currently serves eight of the Company's SNFs and other facilities unaffiliated with the Company.

2. Summary of Significant Accounting Policies

Basis of Presentation

The accompanying condensed consolidated financial statements as of September 30, 2013 and for the three and nine months ended September 30, 2013 and 2012 (collectively, the "Interim Financial Statements"), are unaudited. Certain information and footnote disclosures normally included in the Company’s annual consolidated financial statements have been condensed or omitted, as permitted under applicable rules and regulations. Readers of the Interim Financial Statements should refer to the Company's audited consolidated financial statements and notes thereto, updated for Note 3, "Summary of Significant Accounting Policies", to this filing, for the year ended December 31, 2012, which are included in the Company's 2012 Annual Report on Form 10-K filed with the Securities and Exchange Commission ("SEC"). Management believes that the Interim Financial Statements reflect all adjustments that are of a normal and recurring nature necessary to fairly present the Company's financial information in all material respects as of the dates and for the periods presented. The results of operations presented in the Interim Financial Statements are not necessarily indicative of operations for the entire year or any other period.

The accompanying Interim Financial Statements include the accounts of Skilled and its consolidated wholly-owned subsidiaries. All significant intercompany transactions have been eliminated in consolidation.

Estimates and Assumptions

The interim consolidated financial statements have been prepared in conformity with accounting principles generally accepted in the United States of America ("U.S. GAAP"), which require the Company to consolidate company financial information and make estimates and assumptions that affect the reported amounts of assets and liabilities, disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenue and expenses during the reporting period. The most significant estimates in the Company’s consolidated financial statements relate to revenue, allowance for doubtful accounts, self-insured liability risks, income taxes, valuation of contingent consideration and impairment of long-lived assets and goodwill. Actual results could differ materially from those estimates. The Company estimated a $5.6 million increase in insurance expense in the nine months ended September 30, 2013 due to an increase in the reserves on professional liability claims from prior years.

Reclassifications

Certain items previously reported in specific financial statement captions have been reclassified to conform to the current period presentation. Such reclassifications do not impact previously reported revenue, operating loss, net loss, total assets, liabilities, or stockholders' equity.

Revenue and Accounts Receivables

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SKILLED HEALTHCARE GROUP, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(UNAUDITED)

Revenue and accounts receivable are recorded on an accrual basis as services are performed at their estimated net realizable value. The Company derives a majority of its revenue from funds under federal Medicare and state Medicaid assistance programs, the continuation of which are dependent upon governmental policies and are subject to audit risk and potential recoupment.

Overall payments made by Medicare for hospice services are subject to an annual cap amount on a per hospice agency basis. Total Medicare payments received for services rendered during the applicable Medicare hospice cap year by each Medicare-certified agency during this period are compared to the cap amount for the relevant period. Payments in excess of the cap are subject to recoupment by Medicare. For the three months ended September 30, 2013 and 2012, the Company recorded hospice Medicare cap reserves of $0.5 million and $3.0 million, respectively, as adjustments to revenue. Of the $0.5 million hospice cap reserves recorded in the three months ended September 30, 2013, $0.3 million was related to the 2013 cap year and $0.2 million was related to the 2012 cap year. Of the $3.0 million recorded in the three months ended September 30, 2012, $0.9 million was related to the 2012 cap year and $2.1 million was related to the 2011 cap year. For the nine months ended September 30, 2013 and 2012, the Company recorded hospice Medicare cap adjustment of $3.4 million and $4.2 million respectively, as adjustments to revenue. Of the $3.4 million, $0.9 million was related to the 2013 cap year, $2.3 million was related to the 2012 cap year, and $0.2 million was related to the 2011 cap year. Of the $4.2 million recorded in the nine months ended September 30, 2012, $2.4 million was related to the 2012 cap year and $1.8 million was related to the 2011 cap year.

Notes Receivable

As of September 30, 2013 and December 31, 2012, net notes receivable were approximately $2.8 million and $5.2 million, respectively, of which $2.0 million and $3.1 million was reflected as current assets as of September 30, 2013 and December 31, 2012, with the remaining balances reflected as long-term assets. Interest rates on these notes approximated market rates as of the date the notes were originated.

As of September 30, 2013, two of the Company's rehabilitation therapy services business customers were responsible for 100% of the net notes receivable balance. These notes receivable, as well as the trade receivables from these customers, are secured by the assets of the customers as well as a personal guaranty by the principal owners of the customers. As of September 30, 2013, these two customers represented $9.7 million, or 46.3% of the net accounts receivable for the Company's rehabilitation therapy services business and approximately $32.3 million, or 40.9%, of the external revenue of the rehabilitation therapy services business for the nine months ended September 30, 2013.

The Company also had a note receivable of $0.2 million which had an allowance for uncollectibility of $0.2 million and $0.1 million, as of September 30, 2013 and December 31, 2012, respectively.

Goodwill and Other Long Lived Assets

Goodwill represents the excess of the purchase price over the fair value of identifiable net assets acquired in business combinations accounted for as purchases. Goodwill is subject to periodic testing for impairment. Goodwill of a reporting unit is tested for impairment on an annual basis, or, if an event occurs or circumstances change that would reduce the fair value of a reporting unit below its carrying amount, between annual testing. The Company has selected October 1 as the date to test goodwill for impairment on an annual basis. As a result of the proposed reimbursement reductions by the Centers for Medicare & Medicaid Services ("CMS") going into effect on January 1, 2014 combined with the recent operational under-performance of the home health care business unit were identified as factors for a potential impairing event. The Company conducted an interim goodwill impairment analysis as of September 30, 2013.

The Company periodically evaluates the carrying value of our long−lived assets other than goodwill, primarily consisting of our investments in real estate, for impairment indicators. If indicators of impairment are present, the carrying value of the related real estate investments in relation to the future discounted cash flows of the underlying operations is evaluated to assess recoverability of the assets. Measurement of the amount of the impairment, if any, may be based on independent appraisals, established market values of comparable assets or estimates of future cash flows expected. The estimates of these future cash flows are based on assumptions and projections believed by management to be reasonable and supportable. They require management's subjective judgments and take into account assumptions about revenue and expense growth rates. These assumptions may vary by type of long-lived asset.

Goodwill and Long-Lived Asset Impairment Testing

As of September 30, 2013, the Company determined the fair value of the long-term care, therapy services and hospice & home health services reporting units for goodwill and intangible assets based upon a combination of the discounted cash flow (income approach) and guideline public company method (market approach). After the fair value was determined and compared to the carrying value of each reporting entity, the Company concluded that the carrying value of the home health care reporting unit exceeded its fair value and step two of the analysis was performed. The fair value of the long-term care, therapy services, and hospice reporting units exceeded their carrying value.

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SKILLED HEALTHCARE GROUP, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(UNAUDITED)

Upon completion of step two, the Company recorded a goodwill impairment charge as of and for the three and nine month period ended September 30, 2013 of $16.5 million with respect to the home health services reporting unit as the carrying value of goodwill exceeded its implied fair value. This amount is included within the caption "Impairment of long-lived assets" in the accompanying statement of operations. Additionally, after evaluating its long-lived assets, an impairment charge of $2.5 million was recognized within the home health services reporting unit related to the home health licenses and is included within the caption "Impairment of long-lived assets" in the accompanying statement of operations for the three and nine months ended September 30, 2013.

As of September 30, 2013, goodwill in the amount of $69.1 million was recorded on our condensed consolidated balance sheet, of which $9.7 million related to the rehabilitation therapy unit, $53.7 million related to the hospice reporting unit and $5.7 million related to the home health reporting unit.

The Company did not record a goodwill impairment or an impairment of long-lived assets charge in 2012.

Recent Accounting Pronouncements

In November 2011, the FASB issued ASU No. 2011-11, Balance Sheet (Topic 210): Disclosures about Offsetting Assets and Liabilities, ("ASU 2011-11"). This ASU require an entity to disclose information about offsetting and related arrangements to enable users of its financial statements to understand the effect of those arrangements on its financial position. The adoption of ASU 2011-11 becomes effective for the Company's interim and annual periods beginning on or after January 1, 2013. The adoption of this guidance did not have a material impact on the Company's consolidated financial statements.

In February 2013, the Financial Accounting Standards Board (“FASB”) issued Accounting Standards Update (“ASU”) No. 2013-02, Reporting of Amounts Reclassified Out of Accumulated Other Comprehensive Income. The amendments in this update require an entity to provide information about the amounts reclassified from accumulated other comprehensive income by component. In addition, an entity is required to present, either on the face of the income statement or in the notes, significant amounts reclassified from accumulated other comprehensive income by the net income line item. The adoption of this guidance did not have a material impact on the Company's consolidated financial statements.

3. Net (Loss) Income Per Share of Class A Common Stock and Class B Common Stock

The Company computes net (loss) income per share of Class A common stock and Class B common stock using the two-class method. The Company's Class A common stock and Class B common stock are identical in all respects, except with respect to voting rights and except that each share of Class B common stock is convertible into one share of Class A common stock under certain circumstances. Net (loss) income is allocated on a proportionate basis to each class of common stock in the determination of income per share.

Basic net (loss) income per share was computed by dividing net income by the weighted-average number of outstanding shares for the period. Dilutive earnings per share is computed by dividing net (loss) income plus the effect of assumed conversions (if applicable) by the weighted-average number of outstanding shares after giving effect to all potential dilutive common stock, including options, warrants, common stock subject to repurchase and convertible preferred stock, if any. The following table sets forth the computation of basic and diluted net (loss) income per share of Class A common stock and Class B common stock for the three and nine months ended September 30, 2013 and 2012 (amounts in thousands, except per share data):



	Three months ended September 30, 2013									Three months ended September 30, 2012
	Class A			Class B			Total			Class A		Class B		Total
Net (loss) income per share, basic
Numerator:
Allocation of net income	$	(7,071	)	$	(5,004	)	$	(12,075	)	$	3,486	$	2,582	$	6,068
Net (loss) income per share, diluted
Numerator:
Allocation of net (loss) income	$	(7,071	)	$	(5,004	)	$	(12,075	)	$	3,491	$	2,577	$	6,068
Denominator for basic and diluted net (loss) income per share:
Weighted average common shares outstanding, basic	21,959			15,540			37,499			21,504		15,927		37,431
Plus: incremental shares related to dilutive effect of stock options and restricted stock, if applicable	—			—			—			72		—		72
Adjusted weighted-average common shares outstanding, diluted	21,959			15,540			37,499			21,576		15,927		37,503

Net (loss) income per share, basic	$	(0.32	)	$	(0.32	)	$	(0.32	)	$	0.16	$	0.16	$	0.16

Net (loss) income per share, diluted	$	(0.32	)	$	(0.32	)	$	(0.32	)	$	0.16	$	0.16	$	0.16



	Nine months ended September 30, 2013									Nine months ended September 30, 2012
	Class A			Class B			Total			Class A		Class B		Total
Net (loss) income per share, basic
Numerator:
Allocation of net (loss) income	$	(4,382	)	$	(3,100	)	$	(7,482	)	$	8,894	$	7,008	$	15,902
Net (loss) income per share, diluted
Numerator:
Allocation of net (loss) income	$	(4,382	)	$	(3,100	)	$	(7,482	)	$	8,925	$	6,977	$	15,902
Denominator for basic and diluted net (loss) income per share:
Weighted average common shares outstanding, basic	22,003			15,564			37,567			20,903		16,469		37,372
Plus: incremental shares related to dilutive effect of stock options and restricted stock, if applicable	—			—			—			162		—		162
Adjusted weighted-average common shares outstanding, diluted	22,003			15,564			37,567			21,065		16,469		37,534

Net (loss) income per share, basic	$	(0.20	)	$	(0.20	)	$	(0.20	)	$	0.42	$	0.42	$	0.42

Net (loss) income per share, diluted	$	(0.20	)	$	(0.20	)	$	(0.20	)	$	0.42	$	0.42	$	0.42

The following were excluded from the weighted-average diluted shares computation for the three and nine months ended September 30, 2013 and 2012, as their inclusion would have been anti-dilutive (shares in thousands):



	Three Months Ended September 30,		Nine Months Ended September 30,
	2013	2012	2013	2012
Options to purchase common shares	807	464	807	464
Non-vested common shares	528	1,018	536	898
Total excluded	1,335	1,482	1,343	1,362

4. Business Segments

The Company has three reportable operating segments: (i) long-term care services ("LTC"), which includes the operation of SNFs and ALFs which is the most significant portion of the Company's business, the Company's administrative services

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SKILLED HEALTHCARE GROUP, INC.

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provided to an unrelated SNF operator, and the facility lease revenue from a third-party operator; (ii) the Company's rehabilitation therapy services business; and (iii) the Company's hospice and home health businesses. The "other" column in the table below includes general and administrative items. The Company's reporting segments are business units that offer different services, and that are managed differently due to the nature of the services provided.

At September 30, 2013, LTC services included 74 wholly-owned SNF operating companies that offer post-acute, rehabilitative custodial and specialty skilled nursing care, as well as 22 wholly-owned ALF operating companies that provide room and board and social services. Therapy services included rehabilitative services such as physical, occupational and speech therapy provided in the Company's facilities and in unaffiliated facilities. Hospice and home health services were provided by the Company's wholly-owned subsidiaries to patients.

The Company evaluates performance and allocates capital resources to each segment based on an operating model that is designed to maximize the quality of care provided and profitability. Accordingly, earnings from operations before net interest, tax, depreciation and amortization, non-core expenses ("Adjusted EBITDA") and rent cost of revenue ("Adjusted EBITDAR") is used as the primary measure of each segment’s operating results because it does not include such costs as interest expense, income taxes, depreciation, amortization and rent cost of revenue which may vary from segment to segment depending upon various factors, including the method used to finance the original purchase of assets within a segment or the tax law of the states in which a segment operates. By excluding these items, the Company is better able to evaluate operating performance of the segment by focusing on more controllable measures. Adjusted EBITDA and Adjusted EBITDAR are non‑GAAP financial measures. For a full discussion of the definitions of these terms and the reasons why the Company utilizes such measures, see Item 2, Management's Discussion and Analysis of Financial Condition and Results of Operations, of this filing. General and administrative expenses are not allocated to any segment for purposes of determining segment profit or loss, and are included in the "other" category in the selected segment financial data that follows. Intersegment sales and transfers are recorded at cost plus standard mark-up; intersegment transactions have been eliminated in consolidation.

The following table sets forth selected financial data consolidated by business segment (dollars in thousands):



	Long-Term Care Services		Therapy Services		Hospice & Home Health Services			Other			Elimination			Total
Three months ended September 30, 2013
Net patient service revenue from external customers	$	161,207	$	25,313	$	25,138		$	—		$	—		$	211,658
Leased facility revenue	787		—		—			—			—			787
Intersegment revenue	598		13,888		—			—			(14,486		)	—
Total revenue	$	162,592	$	39,201	$	25,138		$	—		$	(14,486	)	$	212,445
Operating (loss) income	$	11,598	$	2,740	$	(16,523	)	$	(6,646	)	$	—		$	(8,831	)
Interest expense, net of interest income														(8,681		)
Other expense														(49		)
Equity in earnings of joint venture														508
Debt modification/retirement costs														(432		)
Loss before benefit from income taxes														$	(17,485	)
Depreciation and amortization	$	5,669	$	170	$	136		$	155		$	—		$	6,130
Segment capital expenditures	$	3,323	$	18	$	579		$	76		$	—		$	3,996
Adjusted EBITDA	$	17,232	$	3,335	$	2,720		$	(5,574	)	$	—		$	17,713
Adjusted EBITDAR	$	21,724	$	3,335	$	3,178		$	(5,574	)	$	—		$	22,663
Three months ended September 30, 2012
Net patient service revenue from external customers	$	163,815	$	26,161	$	25,878		$	—		$	—		$	215,854
Leased facility revenue	769		—		—			—			—			769
Intersegment revenue	675		15,479		—			—			(16,154		)	—
Total revenue	$	165,259	$	41,640	$	25,878		$	—		$	(16,154	)	$	216,623
Operating income (loss)	$	17,353	$	3,708	$	2,620		$	(6,219	)	$	—		$	17,462

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	Long-Term Care Services		Therapy Services		Hospice & Home Health Services			Other			Elimination			Total
Interest expense, net of interest income														(8,665		)
Other expense														(57		)
Equity in earnings of joint venture														461
Debt modification/retirement costs														(168		)
Income before provision for income taxes														$	9,033
Depreciation and amortization	$	5,661	$	164	$	157		$	191		$	—		$	6,173
Segment capital expenditures	$	4,268	$	369	$	171		$	608		$	—		$	5,416
Adjusted EBITDA	$	22,985	$	3,871	$	2,960		$	(5,692	)	$	—		$	24,124
Adjusted EBITDAR	$	27,214	$	3,871	$	3,362		$	(5,684	)	$	—		$	28,763
Nine months ended September 30, 2013
Net patient service revenue from external customers	$	487,132	$	79,057	$	76,488		$	—		$	—		$	642,677
Leased facility revenue	2,335		—		—			—			—			2,335
Intersegment revenue	1,792		43,078		—			—			(44,870		)	—
Total revenue	$	491,259	$	122,135	$	76,488		$	—		$	(44,870	)	$	645,012
Operating income (loss)	$	36,024	$	8,399	$	(9,942	)	$	(20,295	)	$	—		$	14,186
Interest expense, net of interest income														(25,866		)
Other income														(111		)
Equity in earnings of joint venture														1,469
Debt modification/retirement costs														(1,520		)
Loss before benefit from income taxes														$	(11,842	)
Depreciation and amortization	$	16,937	$	520	$	426		$	513		$	—		$	18,396
Segment capital expenditures	$	8,885	$	111	$	792		$	189		$	—		$	9,977
Adjusted EBITDA	$	52,864	$	9,345	$	7,503		$	(16,429	)	$	—		$	53,283
Adjusted EBITDAR	$	66,078	$	9,345	$	8,879		$	(16,429	)	$	—		$	67,873
Nine months ended September 30, 2012
Net patient service revenue from external customers	$	493,440	$	78,661	79,019			$	—		$	—		$	651,120
Leased facility revenue	2,291		—		—			—			—			2,291
Intersegment revenue	2,030		47,278		—			—			(49,308		)	—
Total revenue	$	497,761	$	125,939	79,019			$	—		$	(49,308	)	$	653,411
Operating income (loss)	$	53,618	$	10,199	11,673			$	(19,074	)	$	—		$	56,416
Interest expense, net of interest income														(28,474		)
Other income														20
Equity in earnings of joint venture														1,422
Debt modification/retirement costs														(4,126		)
Income before provision for income taxes														$	25,258
Depreciation and amortization	$	16,962	$	496	$	448		$	503		$	—		$	18,409
Segment capital expenditures	$	9,567	$	686	$	717		$	1,543		$	—		$	12,513
Adjusted EBITDA	$	70,483	$	10,838	$	13,083		$	(17,422	)	$	—		$	76,982
Adjusted EBITDAR	$	83,168	$	10,838	$	14,109		$	(17,399	)	$	—		$	90,716

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A reconciliation of Adjusted EBITDA and Adjusted EBITDAR to net income is as follows (in thousands):



	Three Months Ended September 30,						Nine Months Ended September 30,
	2013			2012			2013			2012
Adjusted EBITDAR	$	22,663		$	28,763		$	67,873		$	90,716
Rent cost of revenue	(4,950		)	(4,639		)	(14,590		)	(13,734		)
Adjusted EBITDA	17,713			24,124			53,283			76,982
Depreciation and amortization	(6,130		)	(6,173		)	(18,396		)	(18,409		)
Interest expense	(8,744		)	(8,790		)	(26,153		)	(28,876		)
Interest income	63			125			287			402
Change in fair value of contingent consideration	(79		)	(85		)	2,082			(715		)
Organization restructure costs	(457		)	—			(2,006		)	—
Debt modification/retirement costs	(432		)	(168		)	(1,520		)	(4,126		)
Impairment of long-lived assets	(19,000		)	—			(19,000		)	—
Closure of California home health agency	(419		)	—			(419		)	—
Benefit (provision) for income taxes	5,410			(2,965		)	4,360			(9,356		)
Net (loss) income	$	(12,075	)	$	6,068		$	(7,482	)	$	15,902

The following table presents the segment assets as of September 30, 2013 compared to December 31, 2012 (in thousands):



	Long-Term Care Services		Therapy Services		Hospice & Home Health Services		Other		Total
September 30, 2013:
Segment total assets	$	457,564	$	50,274	$	80,989	$	73,085	$	661,912
Goodwill and intangibles included in total assets	$	1,463	$	23,693	$	62,893	$	—	$	88,049
December 31, 2012:
Segment total assets	$	471,129	$	52,559	$	103,800	$	55,148	$	682,636
Goodwill and intangibles included in total assets	$	1,670	$	23,693	$	82,281	$	—	$	107,644

5. Property and Equipment

Property and equipment consisted of the following as of September 30, 2013 and December 31, 2012 (in thousands):



	September 30, 2013			December 31, 2012
Land and land improvements	$	64,983		$	64,983
Buildings and leasehold improvements	336,101			331,316
Furniture and equipment	87,661			83,949
Construction in progress	10,048			8,638
	498,793			488,886
Less accumulated depreciation	(135,885		)	(118,141		)
	$	362,908		$	370,745

Leased facility assets consisted of the following as of September 30, 2013 and December 31, 2012 (in thousands):

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	September 30, 2013			December 31, 2012
Leased facility assets	$	13,848		$	13,848
Less accumulated depreciation	(4,310		)	(3,935		)
	$	9,538		$	9,913

The Company began leasing five skilled nursing facilities in California to an unaffiliated third party operator in April 2011 and at that time signed a 10-year lease with two 10-year extension options exercisable by the lessee.

6. Income Taxes

For the three months ended September 30, 2013, the Company recorded an income tax benefit of $5.4 million representing an effective tax benefit rate of 30.9% compared to an income tax expense of $3.0 million for the same period in 2012. For the nine months ended September 30, 2013 and 2012 the Company recorded an income tax benefit of $4.4 million and expense of $9.4 million respectively. The effective tax benefit rate for the nine months ended September 30, 2013 was less than the statutory rate primarily due to a $2.3 million increase to the state valuation allowance as a result of legislation in California limiting the Company’s ability to utilize its unused enterprise zone ("EZ") tax credits in future years, partially offset by the federal benefit resulting from the increase in state valuation allowance of $0.8 million and a $1.2 million benefit from the resolution and ultimate disposition of remaining funds related to the 2010 settlement of the Humboldt County Action. See Note 7, "Commitments and Contingencies - Legal Matters," for additional detail.

On July 11, 2013, legislation was enacted in California that will limit the carryover period for unused EZ tax credits to 10 years beginning in 2014. Prior to this legislation, unused EZ tax credits could be carried over indefinitely.

7. Commitments and Contingencies

Legal Matters

General

Skilled and its subsidiaries are party to various legal actions and administrative proceedings and are subject to various claims arising in the ordinary course of business, including without limitation claims that their services have resulted in injury or death to patients who receive care from the Company's businesses and claims related to employment, staffing requirements and commercial and other matters. Although Skilled and its subsidiaries intend to vigorously defend themselves in these matters, there can be no assurance that the outcomes of these matters will not have a material adverse effect on the Company's results of operations and financial condition.

Skilled and its subsidiaries operate in a highly regulated industry. They are subject to ongoing regulatory oversight by state and federal regulatory authorities. Actual or alleged failure to comply with legal and regulatory requirements could subject Skilled and its subsidiaries to civil, administrative or criminal fines, penalties or restitutionary relief, and authorities could seek the suspension or exclusion of the offending provider or individual from participation in government healthcare programs and could lead to recoupment claims on prior payments by government healthcare programs. Adverse determinations in legal and regulatory investigations, actions and proceedings, whether currently asserted or arising in the future, could have a material adverse effect on the Company's financial position, results of operations and cash flows.

See also Part II, Item 1A -- Risk Factors, included elsewhere in this report, including without limitation the sections therein entitled "Significant legal actions, which are commonplace in our professions, could subject us to increased operating costs and substantial uninsured liabilities, which would materially and adversely affect our results of operations, liquidity and financial condition," "Revenue we receive from Medicare and Medicaid is subject to potential retroactive reduction or repayment," "We are subject to extensive and complex laws and government regulations. If we are not operating in compliance with these laws and regulations or if these laws and regulations change, we could be required to make significant expenditures or change our operations in order to bring our facilities and operations into compliance" and "We face reviews, audits and investigations under federal and state government programs and contracts. These audits could have adverse findings that may negatively affect our business."

Humboldt County Litigation

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In connection with the September 2010 settlement of the class action litigation against Skilled and certain of its subsidiaries related to, among other matters, alleged understaffing at certain California skilled nursing facilities operated by Skilled's subsidiaries (the "Humboldt County Action"), Skilled and its defendant subsidiaries (collectively, the "Defendants”) entered into settlement agreements with the plaintiffs and intervenor and agreed to an injunction. The settlement was approved by the Superior Court of California, Humboldt County on November 30, 2010. Under the terms of the settlement agreements, the defendant entities deposited a total of $50.0 million into escrow accounts to cover settlement payments to class members, notice and claims administration costs, reasonable attorneys' fees and costs and certain other payments, including $5.0 million to settle certain government agency claims and potential government claims that may arise. Of the $5.0 million provided for such government claims, $1.0 million was initially released by the court to the Humboldt County Treasurer-Tax Collector on behalf of the People of the State of California for their release of the Defendants. The remaining $4.0 million was available for the settlement and releases by the California Attorney General and certain other District Attorneys. However, in the event that any of these government authorities were to instead file certain actions against the Defendants by the second anniversary of the effective date of the settlement agreement, which occurred in February 2013, the entire $4.0 million would have reverted to the Defendants upon their request to the Settlement Administrator. No such actions were filed, however, resulting in an additional $1.0 million distribution to the Humboldt County District Attorney's Office and the remaining $3.0 million was distributed to the class settlement fund, as required by the settlement agreement.

In addition to the payments to the Humboldt County Treasurer-Tax Collector on behalf of the People of the State of California, the court also approved payments from the escrow of up to approximately $24.8 million for plaintiff attorneys' fees and costs and $10,000 to each of the three named plaintiffs. Pursuant to the injunction, the twenty-two Defendants that operated California nursing facilities were required to provide specified nurse staffing levels, comply with specified state and federal regulations governing staffing levels and posting requirements, and provide reports and information to a court-appointed auditor. The injunction was to remain in effect for a period of twenty-four months unless extended for additional three-month periods as to those Defendants that may be found in violation. Defendants demonstrating compliance for an eighteen-month period that ended September 30, 2012 were permitted to petition for early termination of the injunction. The Defendants were required to demonstrate over the term of the injunction that the costs of the injunction met a minimum threshold level pursuant to the settlement agreement, which level, initially $9.6 million, was reduced by the portion attributable to any Defendant in the case that no longer operated a skilled nursing facility during the injunction period.

In April 2011, five of the subsidiary Defendants transferred their operations to an unaffiliated third party skilled nursing facility operator (the “Former Humboldt County Facilities”). On November 14, 2012, the Defendants filed a motion to terminate the injunction and vacate the final judgment in the Humboldt County Action. Based upon compliance with the injunction through the requisite eighteen-month period, on December 21, 2012, the Superior Court of California, Humboldt County granted the Defendants' motion for early termination of the injunction, and the injunction has now ended with respect to the 17 California nursing facilities that the subsidiary Defendants still operate. In its order, the court determined that the injunction termination did not apply to the Former Humboldt County Facilities. However, the 2010 court-approved stipulation and order establishing the injunction provides that the injunction applies to the named defendants and any successor licensees of the applicable nursing facilities, but only if those successor licensees are affiliates of the named defendants. As noted above, the Former Humboldt County Facilities have been operated by an unaffiliated third party since April 2011. Therefore, under the terms of the injunction it does not apply to the Former Humboldt County Facilities unless an affiliate of the Defendants operates them. Pursuant to the BMFEA matter discussed below the California theories in this context were released in February 2013.

In the course of ongoing communications with the California Attorney General's Bureau of Medi-Cal Fraud & Elder Abuse ("BMFEA") related to the BMFEA matter discussed below, representatives of the California Attorney General and the U.S. Department of Justice ("DOJ") indicated an interest in pursuing an action under the False Claims Act ("FCA"). The DOJ has expressed that it believes the company has FCA and other legal liabilities based upon the jury findings in the Humboldt County Action and otherwise related to staffing considerations related thereto. While the Company continues to cooperate with the government's evaluation of the matter, the Company views the government's apparent legal theories, including the False Claims Act theories, as lacking support in the established case law. The Company intends to vigorously defend any such action if brought.

BMFEA Matter

On April 15, 2009, two of Skilled's wholly-owned companies, Eureka Healthcare and Rehabilitation Center, LLC (“EHRC”), which at the time operated Eureka Healthcare and Rehabilitation Center (the "Facility"), and Skilled Healthcare, LLC (“SHC”), the administrative services provider for the Facility, were served with a search warrant that related to an investigation of the Facility by the BMFEA. The search warrant related to, among other things, records, property and information regarding certain enumerated patients of the Facility and covered the period from January 1, 2007 through the date of the search. On October 31, 2012, the BMFEA filed a criminal complaint (the “BMFEA Action”) in California Superior

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Court, Humboldt County against EHRC, SHC and Skilled alleging elder endangerment in nine misdemeanor counts under Penal Code Section 368(c) and two felony counts under Penal Code Section 368(b)(1) related to the care of certain patients at the Facility in 2008. No individuals were named as defendants in the complaint. The Company disputed the BMFEA's theories of alleged criminal liability and vigorously defended the action. The charges filed by the BMFEA, if proven, would have carried fines of up to $6,000 for each of the two felony counts and $2,000 for each of the nine misdemeanor counts. Convictions could also lead to exclusion from participation in federal healthcare programs under federal laws such as the Federal False Claims Act and the Civil Monetary Penalty Law, which could be materially adverse to Skilled's business. EHRC transferred its operations in April 2011 to an unaffiliated third party skilled nursing facility operator, and has not had any ongoing operations since that time.

On February 15, 2013, the parties reached a mutually satisfactory settlement of the BMFEA Action. Pursuant to the settlement: (i) Skilled and SHC were dismissed from the case with prejudice; (ii) EHRC pled no contest to a single misdemeanor count of elder endangerment under Penal Code Section 368(c) and agreed to pay a statutory fine of $680, pay $145,000 to the California Attorney General for its costs of investigation, and to serve two (2) years of summary probation; and (iii) the California Attorney General granted Skilled, SHC, and twenty-five (25) of their affiliates who currently or formerly operated skilled nursing facilities in California, a release of any potential liability to the California Attorney General under certain civil statutes based upon conduct occurring through the effective date of the settlement (including the FCA theories discussed under Humboldt County Litigation above). The court accepted EHRC's misdemeanor plea and the other relevant terms of the settlement on February 15, 2013. Notwithstanding EHRC's no contest plea to the single misdemeanor charge, the Company, SHC and EHRC continue to deny any liability for the allegations in the BMFEA Action. The release granted by the California Attorney General may not apply to the DOJ should it choose to pursue action against us.

Pursuant to the settlement, Skilled, SHC and their twenty (20) affiliated current California skilled nursing facility operators also agreed to a 2-year staffing agreement (the “2013 Staffing Agreement”) with the California Attorney General that essentially continues the requirements of the staffing-related injunction that was in effect until December 2012 as a result of the September 2010 settlement of the Humboldt County Action. Similar to the former staffing-related injunction, the 2013 Staffing Agreement requires the applicable nursing facility operators to provide a minimum of 3.2 nursing hours per patient day as required by applicable California regulation and to adhere to related regulatory requirements, as well as to submit to periodic compliance audits of the same. Unlike the former staffing-related injunction, however, the 2013 Staffing Agreement does not provide for early termination based on demonstrated compliance and does not contain a minimum spend requirement. To date the 2013 Staffing Agreement has not, and the Company does not believe it will, require the Company or its affected affiliates to incur any material staffing or other costs beyond what they would otherwise incur in the ordinary course of business.

Creekside Hospice Investigation

On August 2, 2013, the United States Attorney for the District of Nevada indicated that its Civil Division is investigating the Company, as well as its subsidiary, Creekside Hospice II, LLC, for possible violations of federal and state healthcare fraud and abuse laws and regulations. These laws could include the federal False Claims Act ("FCA") and the Nevada False Claims Act ("NFCA"). The FCA provides for civil and administrative fines and penalties, including civil fines ranging from $5,500 to $11,000 per claim plus treble damages. The NFCA provides for similar fines and penalties, including treble damages. Violations of these federal or state laws could also subject the Company and/or its subsidiaries to exclusion from participation in the Medicare and Medicaid programs. Any damages, fines, penalties, other sanctions and costs that we may incur as a result of any state or federal FCA suit could be significant and could have a material and adverse effect on our results of operations and financial condition. At this time, we cannot predict what effect, if any, the investigation or any potential claims arising under the FCA, the NFCA, or other statutes or regulations, could have on the Company.

Insurance

The Company maintains insurance for workers' compensation, general and professional liability, employee benefits liability, property, casualty, directors’ and officers’ liability, inland marine, crime, boiler and machinery, automobile, employment practices liability and earthquake and flood. The Company believes that its insurance programs are adequate and appropriate, and where there has been a direct transfer of risk to the insurance carrier, the Company does not recognize a liability in the consolidated financial statements.

Workers' Compensation. The Company has maintained workers' compensation insurance as statutorily required. Most of its commercial workers' compensation insurance purchased is loss sensitive in nature, except as noted below. As a result, the Company is responsible for adverse loss development. Additionally, the Company self-insures the first unaggregated $1.0 million per workers' compensation claim for all California, New Mexico and Nevada skilled nursing and assisted living businesses. The Company has elected not to carry workers' compensation insurance in Texas and it may be liable for

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negligence claims that are asserted against it by its Texas-based employees. For the policy periods up to December 31, 2011, the Company has purchased guaranteed cost policies for its Kansas, Missouri, Iowa and Nebraska skilled nursing and assisted living businesses, as well as all of its hospice and home health businesses. There are no deductibles associated with these programs. Since January 1, 2013, the Company self-insures the first $0.5 million for these businesses. The Company recognizes a liability in its interim consolidated financial statements for its estimated self-insured workers' compensation risks. Historically, estimated liabilities have been sufficient to cover actual claims.

General and Professional Liability. The Company's services subject it to certain liability risks. Malpractice and similar claims may be asserted against the Company if its services are alleged to have resulted in patient injury or other adverse effects. The Company is subject to malpractice and similar claims and other litigation in the ordinary course of business.

Effective September 1, 2008, the Company's California-based skilled nursing facility companies purchased individual general and professional liability insurance policies for claims reported through August 31, 2011, with a per occurrence and annual aggregate coverage limit of $1.0 million and $3.0 million, respectively, and an unaggregated $0.1 million per claim self-insured retention. Effective September 1, 2008, the Company also had an excess liability policy for claims reported through August 31, 2011, with a $14.0 million per loss limit and an $18.0 million annual aggregate limit for losses arising from claims in excess of $1.1 million for the California skilled nursing facilities and in excess of $1.0 million for all other businesses.

Effective September 1, 2011, the Company purchased excess liability policies with $25.0 million per loss and annual aggregate limits for claims in excess of $1.0 million per loss for all businesses. Effective September 1, 2011, the Company also self-insures professional liability claims at its California based SNF subsidiaries through its wholly-owned offshore captive insurance company, Fountain View Reinsurance, Ltd., for claims up to $1.0 million. Effective September 1, 2012, the Company self-insures professional liability claims for all of its SNF and ALF subsidiaries through its wholly-owned off shore captive company for claims up to $1.0 million.

The Company retains an unaggregated self-insured retention of $1.0 million per claim for all of its businesses other than its hospice and home health businesses, which are insured under a separate general and professional liability insurance policy with a $1.0 million per loss limit. The excess liability policy referenced above is also applicable to this policy.

Employee Medical Insurance. Medical preferred provider option programs are offered as a component of the Company's employee benefits. The Company retains a self-insured amount up to a contractual stop loss amount of $0.25 million deductible for most participants on its preferred provider organization plan. All other employee medical plans are guaranteed cost plans.

A summary of the liabilities related to insurance risks are as follows (dollars in thousands):



	As of September 30, 2013:											As of December 31, 2012
	General and Professional			Employee Medical			Workers’ Compensation			Total		General and Professional			Employee Medical			Workers’ Compensation			Total
Current	$	8,318	⁽¹⁾	$	2,381	⁽²⁾	$	5,492	⁽²⁾	$	16,191	$	5,622	⁽¹⁾	$	2,143	⁽²⁾	$	5,328	⁽²⁾	$	13,093
Non-current	13,498			—			13,537			27,035		15,587			—			11,809			27,396
	$	21,816		$	2,381		$	19,029		$	43,226	$	21,209		$	2,143		$	17,137		$	40,489


(1)	Included in accounts payable and accrued liabilities.


(2)	Included in employee compensation and benefits.

Hallmark Indemnification

Hallmark, the Company's rehabilitation services subsidiary, provides physical, occupational and speech therapy services to various unaffiliated skilled nursing facilities. These unaffiliated skilled nursing facilities are reimbursed for these services from the Medicare Program and other third-party payors. Hallmark has indemnified these unaffiliated skilled nursing facilities from a portion of certain disallowances of these services. Additionally, to the extent a Recovery Auditors ("RA") or other regulatory authority or contractor is successful in making a claim for recoupment of revenue from any of these skilled nursing facilities, Hallmark will typically be required to indemnify them against their charges associated with this loss. No material indemnification payments were required to be made in the three or nine month periods ended September 30, 2013 or 2012.

Financial Guarantees

Substantially of all Skilled's wholly-owned subsidiaries guarantee the Company's first lien senior secured credit facility, excluding the subsidiaries that are pledged as collateral for the nine mortgage loans insured by the U.S. Department of Housing

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and Urban Development Program ("HUD"). These guarantees are full and unconditional and joint and several. Other subsidiaries of Skilled that are not guarantors are considered minor. On May 12, 2012, the Company redeemed the entire $130.0 million of its then outstanding 11.0% senior subordinated notes due 2014 (the "2014 Notes"). The 2014 Notes were guaranteed by substantially all of Skilled's wholly-owned subsidiaries on terms similar to their guarantees of the Company's first lien senior secured credit facility.

8. Stockholders' Equity

Accumulated Other Comprehensive (Loss) Income

Accumulated other comprehensive (loss) income refers to gains and losses that are recorded as an element of stockholders' equity but are excluded from net income. The Company's other comprehensive (loss) income consists of net deferred gains and losses on certain derivative instruments accounted for as cash flow hedges and gains and losses from investments available for sale. Details of other comprehensive (loss) income are included in the accompanying condensed consolidated Statement of Comprehensive (Loss) Income.

2007 Incentive Award Plan

There were no new stock options granted in the three months ended September 30, 2013 and 2012. There were zero and 106,748 new stock options granted in the nine months ended September 30, 2013 and 2012, respectively.

The fair value of the stock option grants for the nine months ended September 30, 2012 was estimated on the dates of the grants using the Black-Scholes option pricing model with the following assumptions:



	Nine Months Ended September 30,
	2013	2012
Risk-free interest rate	n/a	1.75		%
Expected Life	n/a	6.25 years
Dividend yield	n/a	—		%
Volatility	n/a	70.81		%
Weighted-average fair value	n/a	$	5.44

There were no options exercised during the three and nine months ended September 30, 2013 or 2012. As of September 30, 2013, there was $0.4 million of unrecognized compensation cost related to outstanding stock options, net of estimated forfeitures. This amount is expected to be recognized over a weighted-average period of 1.17 years. To the extent the forfeiture rate is different than the Company has anticipated, stock-based compensation related to these awards will be different from the Company's expectations.

The following table summarizes stock option activity during the nine months ended September 30, 2013 under the Skilled Healthcare Group, Inc. Amended and Restated 2007 Incentive Award Plan:



	Number of Shares		Weighted- Average Exercise Price		Weighted- Average Remaining Contractual Term (in years)	Aggregate Intrinsic Value (in thousands)
Outstanding at January 1, 2013	1,122,195		$	8.83
Granted	—		$	—
Exercised	—		$	—
Forfeited or cancelled	(59,202	)	$	7.21
Outstanding at September 30, 2013	1,062,993		$	8.83	4.68	$	—
Fully vested and expected to vest at September 30, 2013	1,055,881		$	8.85	4.66	$	—
Exercisable at September 30, 2013	879,061		$	9.31	4.16	$	—

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SKILLED HEALTHCARE GROUP, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(UNAUDITED)

Aggregate intrinsic value represents the value of Skilled's closing stock price on the New York Stock Exchange on the last trading day of the fiscal period in excess of the exercise price, multiplied by the number of options outstanding or exercisable.

Compensation related to stock option grants and stock awards included in general and administrative expenses was $0.3 million for the three months ended September 30, 2013 and $0.8 million for the three months ended September 30, 2012. The amount of compensation included in general and administrative expenses was $1.1 million and $2.2 million for the nine months ended September 30, 2013 and 2012 respectively. The amount of compensation included in cost of services was $0.3 million and $0.5 million for the three months ended September 30, 2013 and 2012, respectively. The amount of compensation included in the cost of services for the nine months ended September 30, 2013 and 2012 was $1.1 million and $1.3 million, respectively.

9. Fair Value Measurements

Fair value measurements are based on a three-tier hierarchy that prioritizes the inputs used to measure fair value. These tiers include: Level 1, defined as observable inputs such as quoted prices in active markets; Level 2, defined as inputs other than quoted prices in active markets that are either directly or indirectly observable; and Level 3, defined as unobservable inputs for which little or no market data exists, therefore requiring an entity to develop its own assumptions. The following table summarizes the valuation of the Company’s interest rate hedge transaction, marketable securities, and contingent consideration as of September 30, 2013 (dollars in thousands):



	September 30, 2013						December 31, 2012
	Level 1		Level 2		Level 3		Level 1		Level 2			Level 3
Interest rate hedges	$	—	$	—	$	—	$	—	$	(277	)	$	—
Available for sale securities	$	—	$	1,038	$	—	$	—	$	1,070		$	—
Contingent consideration – acquisitions	$	—	$	—	$	3,356	$	—	$	—		$	6,238

In accordance with FASB ASC Topic 350, "Intangibles - Goodwill and Other," as of September 30, 2013, goodwill with a carrying amount of $85.6 million was written down to its implied fair value of $69.1 million resulting in an impairment charge of $16.5 million. Additionally, after evaluating its long-lived assets, an impairment charge of $2.5 million was recognized within the home health services reporting unit related to home health licenses. The assets were measured using an income and market approach with significant unobservable inputs (Level 3). As of September 30, 2012 there was no goodwill related to the long-term care reporting unit, $9.7 million related to the rehabilitation therapy reporting unit, $53.7 million related to the hospice reporting unit and $22.2 million related to the home health reporting unit.

In June 2010, the Company entered into an interest rate cap agreement (which expired December 31, 2011) and an interest rate swap agreement in order to manage fluctuations in cash flows resulting from interest rate risk (which expired June 30, 2013). The interest rate swap agreement was for a notional amount of $70.0 million with a LIBOR rate not to exceed 2.3% from January 2012 to June 2013. The Company continues to assess its exposure to interest rate risk on an ongoing basis.

The interest rate swap is required to be measured at fair value on a recurring basis. The fair value of the interest rate swap contract is determined by calculating the value of the discounted cash flows of the difference between the fixed interest rate of the interest rate swap and the counterparty’s forward LIBOR curve, which is the input used in the valuation. The forward LIBOR curve is readily available in public markets or can be derived from information available in publicly quoted markets. Therefore, the Company has categorized the interest rate swap as Level 2. For periods ended prior to the expiration of the swap agreement, the Company obtained the counterparty’s calculation of the valuation of the interest rate swap as well as a forward LIBOR curve from another investment bank and independently recalculated the valuation of the interest rate swap, which agreed with the counterparty’s calculation.

The Company's wholly-owned offshore captive insurance company is required by regulatory agencies to set aside assets to comply with the laws of the jurisdiction in which it operates. These assets consist of restricted cash and available for sale securities, which are included in other assets in the Company's consolidated September 30, 2013 balance sheet. The Company's available for sale securities are U.S. government securities with an amortized cost basis and aggregate fair value of $1.0 million as of September 30, 2013 and 2012. Net unrealized (loss) gain included in other comprehensive income on the Company's available for sale securities was negligible for the nine months ended September 30, 2013 and 2012.

On May 1, 2010, the Company acquired substantially all of the assets of five Medicare-certified hospice companies and four Medicare-certified home health companies located in Arizona, Idaho, Montana and Nevada (which is sometimes referred to herein as the "Hospice/Home Health Acquisition"). As part of the purchase agreement, the purchase consideration included cash, promissory notes, contingent consideration, and deferred cash payments. The contingent consideration arrangement requires the Company to pay contingent payments should the acquired operations achieve certain financial targets based on

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SKILLED HEALTHCARE GROUP, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(UNAUDITED)

EBITDA of the acquired businesses, as defined in the acquisition agreement, which was filed as Exhibit 2.1 to the Company’s Report on Form 10-Q filed with the SEC on May 4, 2010. The contingent consideration is up to $7.0 million over a period of 5 years following the closing. The fair value of the contingent consideration was estimated using a probability-weighted discounted cash flow model. This fair value measurement is based on significant inputs not observable in the market and thus represents a Level 3 measurement. The contingent consideration was recorded at the date of acquisition in the amount of $4.9 million. As of December 31, 2012 and September 30, 2013, the contingent consideration had a fair value of $3.9 million and $1.6 million, respectively. The change from December 31, 2012 represents a reduction in fair value due to a decrease in projected EBITDA for the acquired business over the remainder of the earn-out period. This is included in the Company’s other long-term liabilities on the balance sheet. The change in fair value related to the contingent consideration is included in the Company's depreciation and amortization on the statements of operations. There has been no change in the valuation technique of the contingent consideration from December 31, 2012 to September 30, 2013.

On July 1, 2011, a wholly-owned subsidiary of the Company acquired Altura Homecare & Rehab ("Altura"). The acquisition includes contingent earn-out consideration which can be earned based on the acquired business's achievement of an EBITDA threshold. The contingent consideration is up to $1.5 million over a period of 3 years following the closing. The fair value of the contingent consideration was estimated using a probability-weighted discounted cash flow model. This fair value measurement is based on significant inputs not observable in the market and thus represents a Level 3 measurement. The fair value of the earn-out at December 31, 2012 was $0.9 million and at September 30, 2013 was $0.5 million which reflects payments of $0.5 million to the seller and fair value adjustments of $0.1 million.

On October 24, 2011, wholly-owned subsidiaries of the Company acquired substantially all of the assets of Cornerstone Hospice, Inc. ("Cornerstone"). The acquisition includes contingent earn-out consideration which can be earned based on the acquired business's achievement of an EBITDA threshold. The contingent consideration is up to $1.5 million over a period of 5 years following the closing. The fair value of the contingent consideration was estimated using a probability-weighted discounted cash flow model. This fair value measurement is based on significant inputs not observable in the market and thus represents a Level 3 measurement. The fair value of the earn-out at December 31, 2012 was $1.4 million and at September 30, 2013 was $1.1 million which reflects a $0.3 million payments to the seller and fair value adjustments of $0.2 million.

On May 13, 2012, a wholly-owned subsidiary of the Company acquired substantially all of the assets of A Better Care Home Health, Inc. ("ABC"). The acquisition includes contingent earn-out consideration which can be earned based on the acquired operations' achievement of an EBITDA threshold. The contingent consideration spans 3 years following the closing. The fair value of the contingent consideration was estimated using a probability-weighted discounted cash flow model. This fair value measurement is based on significant inputs not observable in the market and thus represents a Level 3 measurement. The fair value of the earn-out at the acquisition date and at September 30, 2013 was $0.1 million.

As discussed above, EBITDA is the basis for calculating the contingent consideration. The unobservable inputs to the determination of the fair value of the contingent consideration include assumptions as to the ability of the acquired businesses to meet their EBITDA targets and discount rates used in the calculation. Should the actual EBITDA generated by the acquired businesses increase or decrease as compared to our assumptions, the fair value of the contingent consideration obligations would increase or decrease, up to the contracted limit, as applicable. As the timing of contingent payments go further into the future, discount rate assumptions increase due to the increased uncertainty of the EBITDA that may be generated in those periods.

The Company's assumptions range from the acquired businesses achieving none, a portion, or all of the consideration, and discount rates range from 2%- 5%.

Below is a table listing the Level 3 rollforward as of September 30, 2013 (in thousands):



Level 3 Rollforward
Value at January 1, 2013	$	6,238
Change in fair value	(2,082		)
Payout	(800		)
Value at September 30, 2013	$	3,356

Long Term Debt

At September 30, 2013 and December 31, 2012, the fair value of the Company's term loan, due in 2016 and the revolving credit facility, due in 2015, using the Level 2 inputs, was approximately $435.4 million and $447.4 million, respectively. The carrying value of the debt at September 30, 2013 and December 31, 2012 was $437.1 million and $443.6 million, respectively.

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SKILLED HEALTHCARE GROUP, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(UNAUDITED)

Fair value was estimated based on current yield rates plus the Company's estimated credit spread available for loan products with similar terms and maturities.

10. Debt

The Company’s long-term debt is summarized as follows (dollars in thousands):



	As of September 30, 2013			As of December 31, 2012
Revolving Credit Facility due 2015, interest rate comprised of LIBOR plus 4.25%, or 4.50% at September 30, 2013	$	—		$	25,000
Revolving Credit Facility due 2015, interest rate comprised of the Prime rate of 3.25% plus 3.50%, or 6.75% at September 30, 2013	1,500			10,000
Term Loan, due 2016, interest rate based on LIBOR (subject to a 1.50% floor) plus 5.25%, or 6.75% at September 30, 2013; collateralized by substantially all assets of the Company	349,077			411,600
Term Loan original issue discount	(2,303		)	(3,013		)
HUD insured loans due in 2043 and 2048, with a weighted average interest rate of 4.24% at September 30, 2013	79,806			—
Note payable due December 2018, interest rate fixed at 6.50%, payable in monthly installments, collateralized by a first priority deed of trust	1,000			1,118
Hospice/Home Health Acquisition note, interest rate fixed at 6.00%	—			1,483
Insurance premiums financed	5,123			2,119
Other	606			660
Total long-term debt	434,809			448,967
Less amounts due within one year	(17,446		)	(13,338		)
Long-term debt, less current portion	$	417,363		$	435,629

Term Loan and Revolving Loan

On April 9, 2010, the Company entered into an up to $360.0 million senior secured term loan and a $100.0 million revolving credit facility (the "Prior Credit Agreement") that amended and restated the senior secured term loan and revolving credit facility that were set to mature in June 2012. On April 12, 2012, the Company entered into an Amendment and Restatement and Additional Term Loan Assumption Agreement (“Restated Credit Agreement”) that amended and restated the Prior Credit Agreement and pursuant to which, among other things, the size of the Company's existing senior secured term loan was increased by $100.0 million (hereinafter referred to as the incremental senior secured term loan). On June 6, 2013, the Company entered into an amendment to the Restated Credit Agreement that increased the maximum leverage ratio by 0.50 throughout the life of the Restated Credit Agreement. The amendment additionally permits the Company to make future offers to the lenders under the revolving loan facility to extend the maturity date of all or a portion of the revolving loans. The credit arrangements provided under the Restated Credit Agreement are collectively referred to herein as the Company's senior secured credit facility.

The Company expensed fees paid in connection with the refinancing of the Prior Credit Agreement in the amount of $2.0 million in conjunction with the amended senior secured credit facility. In connection with the June 6, 2013 modification, the Company paid fees totaling $2.5 million, of which $1.1 million were recorded as debt modification costs in the consolidated statement of operations, and $1.4 million were recorded as other assets in the consolidated balance sheet. Substantially all of the Company's assets are pledged as collateral under the senior secured credit facility. Amounts borrowed under the senior secured term loan may be prepaid at any time without penalty, except for LIBOR breakage costs. Commitments under the revolving credit facility terminate on April 9, 2015. The senior secured term loan matures on April 9, 2016.

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SKILLED HEALTHCARE GROUP, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(UNAUDITED)

Credit Agreement) to be applied to term debt reductions increased to 75% from 50%, subject to stepdowns to 50% and 25% based on consolidated leverage. The Company also increased its ability to refinance a portion of its credit facility with U.S. Department of Housing and Urban Development ("HUD") insured debt up to $250 million, subject to certain credit facility covenants. Any HUD insured borrowings beyond $250 million would necessitate either refinancing the senior secured credit facility in full or otherwise seeking a waiver or amendment from the senior secured lenders.

The Company has the right to increase its borrowings under the revolving credit facility up to an aggregate amount of $150 million provided that the Company is in compliance with the Restated Credit Agreement, that the additional debt would not cause any covenant violation of the Restated Credit Agreement, and that existing or new lenders within the Restated Credit Agreement agree to increase their commitments. To reduce the risk related to interest rate fluctuations, the Prior Credit Agreement required the Company to enter into, and the Restated Credit Agreement required us to continue to maintain, an interest rate swap, cap or similar agreement to effectively fix or cap the interest rate on 40% of its funded long-term debt for a three year period within three months of the April 2010 commencement of the senior secured credit facility. The Company entered into two interest rate hedge transactions, as described in Note 9 - "Fair Value Measurements," in order to comply with this requirement.

Under the senior secured credit facility, the Company must maintain compliance with specified financial covenants measured on a quarterly basis. The senior secured credit facility also includes certain additional affirmative and negative covenants, including limitations on the incurrence of additional indebtedness, liens, investments in other businesses and capital expenditures. Also under the senior secured credit facility, subject to certain exceptions and minimum thresholds, the Company is required to apply all of the proceeds from any issuance of debt, as much as half of the proceeds from any issuance of equity, as much as 75% of the Company's annual Consolidated Excess Cash Flow (as defined in the Restated Credit Agreement), and amounts received in connection with any sale of the Company's assets to repay the outstanding amounts under the Restated Credit Agreement. The Company believes that it is in compliance with its debt covenants as of September 30, 2013. As of September 30, 2013, the fixed charge coverage ratio was 2.2, which compares to a minimum requirement of 1.75 and the leverage ratio was 4.7, as compared to an allowed maximum of 5.25.

Senior Subordinated Notes

On May 12, 2012, the Company redeemed the entire $130.0 million outstanding principal amount plus all accrued but unpaid interest of the 2014 Notes. The proceeds from the incremental senior secured term loan (as well as a draw on the revolving portion of the senior secured credit facility) were used to fund the redemption of the outstanding 2014 Notes at par plus accrued interest. In addition, the Company expensed unamortized deferred financing fees and original issue discount ("OID") in the amount of $1.9 million in conjunction with the redemption of the 2014 Notes.

The 2014 Notes were issued in December 2005 in the aggregate principal amount of $200.0 million, with an interest rate of 11.0% and a discount of $1.3 million. Interest was payable semiannually in January and July of each year. The 2014 Notes were to mature on January 15, 2014. The 2014 Notes were unsecured senior subordinated obligations and ranked junior to all of the Company's existing and future senior indebtedness, including indebtedness under the senior secured credit facility. The 2014 Notes were guaranteed on a senior subordinated basis by certain of the Company's subsidiaries.

HUD Insured Loans

As of September 30, 2013, the Company has nine mortgages insured by HUD, which are each secured by a skilled nursing facility. These mortgages have an average remaining term of 33 years with fixed interest rates ranging from 3.3% to 4.5% and a weighted average interest rate of 4.24%. Depending on the mortgage agreement, prepayments are generally allowed only after 12 months or from the inception of the mortgage. Prepayments are subject to a penalty of 10% of the remaining principal balances in the first year and the prepayment penalty decreases each subsequent year by 1% until no penalty is required. As all $79.8 million of the HUD insured mortgage loans were originated in September 2013, none of the loans could be prepaid at September 30, 2013. The Company anticipates closing one additional HUD insured loan by the end of the year. Any further HUD insured mortgages will require additional HUD approval.

All HUD-insured mortgages are non-recourse loans to the Company. All mortgages are subject to HUD regulatory agreements that require escrow reserve funds to be deposited with the loan servicer for mortgage insurance premiums, property taxes, insurance and for capital replacement expenditures. As of September 30, 2013, the Company has escrow reserve funds of $1.0 million with the loan servicer that are reported within other current assets, and replacement reserve funds of $1.6 million in other assets. The net proceeds of the HUD insured loans are required to be used to pay down term debt under the Restated Credit Agreement. As of September 30, 2013, $54.7 million of HUD insured loan proceeds were used to pay down term debt. The remaining HUD insured loan proceeds of $20.4 million were used to reduce borrowings on the revolving credit line as of September 30, and subsequently used to permanently pay down term debt on October 3, 2013.

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SKILLED HEALTHCARE GROUP, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

(UNAUDITED)

Other Debt

The Company issued $10.0 million of promissory notes as part of the purchase consideration for the Hospice/Home Health Acquisition. The notes bear interest at 6.0% with $2.0 million of principal due annually beginning November 1, 2010. During 2012, the notes were substantially paid down leaving a remaining balance of $1.5 million at December 31, 2012. The promissory notes are payable to the selling entities, of which the Senior Vice President of Signature Hospice & Home Health, LLC is a significant shareholder. Signature Hospice & Home Health, LLC is a consolidated subsidiary of Skilled holding 100% interests in the operating companies for the Hospice/Home Health Acquisition. The promissory notes were paid in full in April 2013.

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Item 2. Management’s Discussion and Analysis of Financial Condition and Results of Operations

This Management’s Discussion and Analysis of Financial Condition and Results of Operations is intended to assist in understanding and assessing the trends and significant changes in our results of operations and financial condition as of the dates and for the periods presented. Historical results may not indicate future performance. Our forward-looking statements, which reflect our current views about future events, are based on assumptions and are subject to known and unknown risks and uncertainties that could cause actual results to differ materially from those contemplated by these statements. Factors that may cause differences between actual results and those contemplated by forward-looking statements include, but are not limited to, those discussed in our Annual Report on Form 10-K for the year ended December 31, 2012 and our subsequent reports on Form 10-Q and Form 8-K filed with the Securities and Exchange Commission (the “SEC”). As used in this Management’s Discussion and Analysis of Financial Condition and Results of Operations, the words, “we,” “our,” and “us” refer to Skilled Healthcare Group, Inc. and its wholly-owned subsidiaries. This Management’s Discussion and Analysis of Financial Condition and Results of Operations should be read in conjunction with our condensed consolidated financial statements and related notes included in this report.

Business Overview

Skilled Healthcare Group, Inc. ("Skilled") is a holding company that owns subsidiary companies that in turn own and operate skilled nursing facilities, assisted living facilities, hospices, home health providers and a rehabilitation therapy business. As used in this report, the terms "we," "us," "our" and the "Company," and similar terms, refer collectively to Skilled and its consolidated wholly-owned subsidiaries, unless the context requires otherwise. We have an administrative service company that provides a full complement of administrative and consultative services that allows our affiliated operators and third-party operators with whom we contract to better focus on delivery of healthcare services. We currently also have one such service agreement with an unaffiliated skilled nursing facility operator. All of our subsidiaries focus on providing high-quality care to the people we serve, and our skilled nursing facility subsidiaries, which comprise the largest portion of our consolidated business, have a strong commitment to treating patients who require a high level of skilled nursing care and extensive rehabilitation therapy, whom we refer to as high-acuity patients. As of September 30, 2013, we owned or leased 74 skilled nursing facilities and 22 assisted living facilities, together comprising 10,405 licensed beds. We also lease five skilled nursing facilities in California to an unaffiliated third party operator. Our skilled nursing and assisted living facilities are located in California, Texas, Iowa, Kansas, Missouri, Nebraska, Nevada and New Mexico, and are generally clustered in large urban or suburban markets. We owned 77% of these facilities as of September 30, 2013. As of September 30, 2013 we provided hospice and home health services in Arizona, California, Idaho, Montana, Nevada, and New Mexico. We also provided private duty care services in Idaho, Montana, and Nevada. For the nine months ended September 30, 2013, we generated approximately 73% of our revenue from our skilled nursing facilities, including our integrated rehabilitation therapy services at these facilities. The remainder of our revenue is generated from our assisted living services, rehabilitation therapy services provided to third-party facilities, hospice care and home health services.

Industry Trends

Medicare and Medicaid Reimbursement

Rising healthcare costs due to a variety of factors, including an aging population and increasing life expectancies, has in recent years increased demand for post-acute healthcare services, such as skilled nursing, assisted living, home health care, hospice care and rehabilitation therapy. In an effort to mitigate the cost of providing healthcare benefits, third party payors including Medicare, Medicaid, managed care providers, insurance companies and others have increasingly encouraged the treatment of patients in lower-cost care settings. As a result, in recent years skilled nursing facilities, which typically have significantly lower cost structures than acute care hospitals and certain other post-acute care settings, have generally been serving larger populations of higher-acuity patients than in the past. Despite this growth in demand, uncertainty over Medicare and Medicaid reimbursement rates persists as rates have often been reduced or been increased in lesser amounts than expected. Medicare and Medicaid reimbursement rates are subject to change from time to time and, because revenue derived directly or indirectly from Medicare and Medicaid reimbursement has historically comprised the most significant portion of our consolidated revenue, a reduction or slow growth in rates could materially and adversely impact our revenue, particularly in times of increased regulation and related expenses.

On July 31, 2013, CMS issued its final rule providing for, among other things, a net increase of 1.3% in PPS payments to skilled nursing facilities for CMS's fiscal year 2014 (which began October 1, 2013) as compared to the PPS payments in CMS's fiscal year 2013 (which ended September 30, 2013). The 1.3% increase is on a net basis, after the application of a 2.3% market basket increase reduced by a 0.5% forecast error correction and further reduced by 0.5% multi-factor productivity adjustment required by the Patient Protection and Affordable Care Act of 2010 ("PPACA").

On June 27, 2013, CMS proposed a decrease of 1.5% in PPS payments to home health agencies for CMS's fiscal year 2014 as compared to the PPS payments in CMS's fiscal year 2013. The proposed 1.5% decrease is on a net basis, after the application of a 3.5% rebasing decrease and other reductions, partially offset by a 2.4% market basket increase.

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The American Taxpayer Relief Act of 2012 (the “ATRA”) was enacted on January 2, 2013. As noted above, the ATRA delayed by two months the automatic budget sequestration cuts established by the Budget Control Act of 2011. The ATRA also extended the therapy cap exception process for one year. The ATRA also made additional changes to the Multiple Procedure Payment Reduction ("MPPR") previously implemented in 2010. The existing discount to multiple therapy procedures performed in an outpatient environment during a single day was 25%. Effective April 1, 2013, ATRA increased the discount by an additional 25% to 50%. The new rules related to MPPR reduced our revenue by $0.6 million for the six month period from April 1, 2013 through September 30, 2013.

Should future changes in PPS include further reduced rates or increased standards for reaching certain reimbursement levels (including as a result of automatic cuts tied to federal deficit cut efforts or otherwise), our Medicare revenues derived from our skilled nursing facilities (including rehabilitation therapy services provided at our skilled nursing facilities) could be reduced, with a corresponding adverse impact on our financial condition and results of operation. Our rehabilitation therapy, hospice and home health care businesses are also to a large degree directly or indirectly dependent on (and therefore affected by changes in) Medicare and Medicaid reimbursement rates. For example, our rehabilitation therapy business may have difficulty increasing or maintaining the rates it has negotiated with third party nursing facilities in light of reduced PPS reimbursement rates as discussed above or future reductions in reimbursement rates.

We also derive a substantial portion of our consolidated revenue from Medicaid reimbursement, primarily through our skilled nursing business. Medicaid programs are administered by the applicable states and financed by both state and federal funds. Medicaid spending nationally has increased substantially in recent years, becoming an increasingly significant component of state budgets. This, combined with slower state revenue growth and other state budget demands, has led both the federal government and many states, including California and other states in which we operate, to institute measures aimed at controlling the growth of Medicaid spending (and in some instances reducing it).

Historically, adjustments to reimbursement under Medicare and Medicaid have had a significant effect on our revenue and results of operations. Recently enacted, pending and proposed legislation and administrative rulemaking at the federal and state levels could have similar effects on our business. Efforts to impose reduced reimbursement rates, greater discounts and more stringent cost controls by government and other payors are expected to continue for the foreseeable future and could adversely affect our business, financial condition and results of operations. Additionally, any delay or default by the federal or state governments in making Medicare and/or Medicaid reimbursement payments could materially and adversely affect our business, financial condition and results of operations.

Federal Health Care Reform

In addition to the matters described above affecting Medicare and Medicaid participating providers, PPACA enacted several reforms with respect to skilled nursing facilities, home health agencies and hospices, including payment measures to realize significant savings of federal and state funds by deterring and prosecuting fraud and abuse in both the Medicare and Medicaid programs. While many of the provisions of PPACA will not take effect for several years or are subject to further refinement through the promulgation of regulations, some key provisions of PPACA are presently effective.

•

Enhanced CMPs and Escrow Provisions. PPACA includes expanded civil monetary penalty ("CMP") and related provisions applicable to all Medicare and Medicaid providers. CMS rules adopted to implement applicable provisions of PPACA also provide that assessed CMPs may be collected and placed in whole or in part into an escrow pending final disposition of the applicable administrative and judicial appeals processes. To the extent our businesses are assessed large CMPs that are collected and placed into an escrow account pending lengthy appeals, such actions could adversely affect our liquidity and results of operations.

•

Nursing Home Transparency Requirements. In addition to expanded CMP provisions, PPACA imposes new transparency requirements for Medicare-participating nursing facilities. In addition to previously required disclosures regarding a facility's owners, management and secured creditors, PPACA expanded the required disclosures to include information regarding the facility's organizational structure, additional information on officers, directors, trustees and "managing employees" of the facility (including their names, titles, and start dates of services), and information regarding certain parties affiliated with the facility. The transparency provisions could result in the potential for greater government scrutiny and oversight of the ownership and investment structure for skilled nursing facilities, as well as more extensive disclosure of entities and individuals that comprise part of skilled nursing facilities' ownership and management structure.

•

Face-to-Face Encounter Requirements. PPACA imposes new patient face-to-face encounter requirements on home health agencies and hospices to establish a patient's ongoing eligibility for Medicare home health services or hospice services, as applicable. A certifying physician or other designated health care professional must conduct the face-to-face encounters within specified timeframes, and failure of the face-to-face encounter to occur and be properly documented during the applicable timeframes could render the patient's care ineligible for reimbursement under Medicare.

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Suspension of Payments During Pending Fraud Investigations. PPACA provides the federal government with expanded authority to suspend Medicare and Medicaid payments if a provider is investigated for allegations or issues of fraud. This suspension authority creates a new mechanism for the federal government to suspend both Medicare and Medicaid payments for allegations of fraud, independent of whether a state exercises its authority to suspend Medicaid payments pending a fraud investigation. To the extent the suspension of payments provision is applied to one of our businesses for allegations of fraud, such a suspension could adversely affect our liquidity and results of operations.

•

Overpayment Reporting and Repayment; Expanded False Claims Act Liability. PPACA enacted several important changes that expand potential liability under the federal False Claims Act. Overpayments related to services provided to both Medicare and Medicaid beneficiaries must be reported and returned to the applicable payor within specified deadlines, or else they are considered obligations of the provider for purposes of the federal False Claims Act. This new provision substantially tightens the repayment and reporting requirements generally associated with operations of health care providers to avoid False Claims Act exposure.

•

Home and Community Based Services. PPACA provides that states can provide home and community-based attendant services and supports through the Community First Choice State plan option. States choosing to provide home and community based services under this option must make them available to assist with activities of daily living, instrumental activities of daily living and health related tasks under a plan of care agreed upon by the individual and his/her representative. For states that elect to make coverage of home and community-based services available through the Community First Choice State plan option, the percentage of the state's Medicaid expenses paid by the federal government will increase by 6 percentage points. PPACA also includes additional measures related to the expansion of community and home based services and authorizes states to expand coverage of community and home-based services to individuals who would not otherwise be eligible for them. The expansion of home-and-community based services could reduce the demand for the facility based services that we provide.

•

Health Care-Acquired Conditions. PPACA provides that the Secretary of Health and Human Services must prohibit payments to states for any amounts expended for providing medical assistance for certain medical conditions acquired during the patient's receipt of health care services. The CMS regulation implementing this provision of PPACA prohibits states from making payments to providers under the Medicaid program for conditions that are deemed to be reasonably preventable. It uses Medicare's list of preventable conditions in inpatient hospital settings as the base (adjusted for the differences in the Medicare and Medicaid populations) and provides states the flexibility to identify additional preventable conditions and settings for which Medicaid payment will be denied.

•

Value-Based Purchasing. PPACA requires the Secretary of Health and Human Services to develop a plan to implement a value-based purchasing (“VBP”) program for payments under the Medicare program for skilled nursing facilities and to submit a report containing the plan to Congress. The intent of the provision is to potentially reconfigure how Medicare pays for health care services, moving the program towards rewarding better value, outcomes, and innovations, instead of volume. According to the plan submitted to Congress in June 2012, the funding for the VBP program could come from payment withholds from poor-performing skilled nursing facilities or by holding back a portion of the base payment rate or the annual update for all skilled nursing facilities. If a VBP program is ultimately implemented, it is uncertain what effect it would have upon skilled nursing facilities, but its funding or other provisions could negatively affect skilled nursing facilities.

•

Anti-Kickback Statute Amendments. PPACA amended the Anti-Kickback Statute so that (i) a claim that includes items or services violating the Anti-Kickback Statute also would constitute a false or fraudulent claim under the federal False Claims Act and (ii) the intent required to violate the Anti-Kickback Statute is lowered such that a person need not have actual knowledge or specific intent to violate the Anti-Kickback Statute in order for a violation to be deemed to have occurred. These modifications of the Anti-Kickback Statute could expose us to greater risk of inadvertent violations of the statute and to related liability under the federal False Claims Act.

The provisions of PPACA discussed above are examples of recently enacted federal health reform provisions that we believe may have a material impact on the long-term care profession generally and on our business. However, the foregoing discussion is not intended to constitute, nor does it constitute, an exhaustive review and discussion of PPACA. It is possible that other provisions of PPACA may be interpreted, clarified, or applied to our businesses in a way that could have a material adverse impact on our business, financial condition and results of operations. Similar federal and/or state legislation that may be adopted in the future could have similar effects.

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Revenue

Revenue by Service Offering

We operate our business in three reportable operating segments: (i) long-term care services, which includes the operation of skilled nursing and assisted living facilities and is the most significant portion of our business; (ii) our rehabilitation therapy services business; and (iii) our hospice and home health businesses. Our reporting segments are business units that offer different services, and that are managed separately due to the nature of services provided.

In our long-term care services segment, we derive the majority of our revenue by providing skilled nursing care and integrated rehabilitation therapy services to residents in our affiliated skilled nursing facilities. The remainder of our long-term care segment revenue is generated by our assisted living facilities, by our administration of an unaffiliated third party skilled nursing facility, and from our leasing of five skilled nursing facilities to an unaffiliated third party operator. In our therapy services segment, we derive revenue by providing rehabilitation therapy services to third-party facilities. In our hospice and home health services segment, we provide hospice and home health services.

The following table shows the revenue and percentage of our total revenue generated by each of these segments for the periods presented (dollars in thousands):



	Three Months Ended September 30,
	2013				2012
	Revenue Dollars		Revenue Percentage		Revenue Dollars		Revenue Percentage		Increase/(Decrease)
	Revenue Dollars		Revenue Percentage		Revenue Dollars		Revenue Percentage		Dollars			Percentage
Long-term care services:
Skilled nursing facilities	$	154,088	72.5	%	$	156,550	72.2	%	$	(2,462	)	(1.6	)%
Assisted living facilities	6,982		3.3		7,133		3.3		(151		)	(2.1	)
Administration of third party facility	137		0.1		132		0.1		5			3.8
Facility lease revenue	787		0.4		769		0.4		18			2.3
Total long-term care services	161,994		76.3		164,584		76.0		(2,590		)	(1.6	)
Therapy services:
Third-party rehabilitation therapy services	25,313		11.9		26,161		12.1		(848		)	(3.2	)
Total therapy services	25,313		11.9		26,161		12.1		(848		)	(3.2	)
Hospice & home health services:
Hospice	18,181		8.5		19,303		8.9		(1,122		)	(5.8	)
Home health	6,957		3.3		6,575		3.0		382			5.8
Total hospice & home health services	25,138		11.8		25,878		11.9		(740		)	(2.9	)
Total	$	212,445	100.0	%	$	216,623	100.0	%	$	(4,178	)	(1.9	)%

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	Nine Months Ended September 30,
	2013				2012
	Revenue Dollars		Revenue Percentage		Revenue Dollars		Revenue Percentage		Increase/(Decrease)
	Revenue Dollars		Revenue Percentage		Revenue Dollars		Revenue Percentage		Dollars			Percentage
Long-term care services:
Skilled nursing facilities	$	465,592	72.2	%	$	471,800	72.2	%	$	(6,208	)	(1.3	)%
Assisted living facilities	21,091		3.3		20,942		3.2		149			0.7
Administration of third party facility	449		0.1		698		0.1		(249		)	(35.7	)
Facility lease revenue	2,335		0.3		2,291		0.3		44			1.9
Total long-term care services	489,467		75.9		495,731		75.8		(6,264		)	(1.3	)
Therapy services:
Third-party rehabilitation therapy services	79,057		12.3		78,661		12.1		396			0.5
Total therapy services	79,057		12.3		78,661		12.1		396			0.5
Hospice & home health services:
Hospice	55,551		8.6		59,634		9.1		(4,083		)	(6.8	)
Home health	20,937		3.2		19,385		3.0		1,552			8.0
Total hospice & home health services	76,488		11.8		79,019		12.1		(2,531		)	(3.2	)
Total	$	645,012	100.0	%	$	653,411	100.0	%	$	(8,399	)	(1.3	)%

Sources of Revenue

The following table sets forth revenue consolidated by state in dollars and as a percentage of total revenue for the periods presented (dollars in thousands):



	Three Months Ended September 30,
	2013				2012
	Revenue Dollars		Percentage of Revenue		Revenue Dollars		Percentage of Revenue
California	$	86,238	40.5	%	$	86,488	39.9	%
Texas	42,400		20.0		45,259		20.9
New Mexico	24,974		11.8		25,457		11.8
Kansas	15,034		7.1		14,980		6.9
Nevada	15,521		7.3		14,832		6.8
Missouri	14,341		6.8		14,677		6.8
Arizona	3,424		1.6		3,381		1.6
Montana	3,521		1.7		4,130		1.9
Idaho	2,580		1.2		2,654		1.2
Iowa	2,401		1.1		2,412		1.1
Nebraska	1,577		0.7		1,178		0.5
Other	434		0.2		1,175		0.5
Total	$	212,445	100.0	%	$	216,623	100.0	%

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	Nine months ended September 30,
	2013				2012
	Revenue Dollars		Percentage of Revenue		Revenue Dollars		Percentage of Revenue
California	$	263,170	40.9	%	$	263,410	40.3	%
Texas	130,371		20.2		135,053		20.7
New Mexico	73,447		11.4		74,357		11.4
Kansas	45,377		7.0		46,373		7.1
Nevada	45,348		7.0		46,389		7.1
Missouri	43,943		6.8		44,083		6.7
Arizona	11,605		1.8		10,423		1.6
Montana	10,608		1.6		11,767		1.8
Idaho	8,103		1.3		7,552		1.2
Iowa	7,167		1.1		8,078		1.2
Nebraska	4,519		0.7		3,121		0.5
Other	1,354		0.2		2,805		0.4
Total	$	645,012	100.0	%	$	653,411	100.0	%

Long-Term Care Services Segment

Skilled Nursing Facilities. Within our skilled nursing facilities, we generate our revenue from Medicare, Medicaid, managed care providers, insurers, private pay and other sources. We believe that our skilled mix, which we define as the number of Medicare and non-Medicaid managed care patient days at our skilled nursing facilities divided by the total number of patient days at our skilled nursing facilities for any given period, is an important indicator of our success in attracting high-acuity patients because it represents the percentage of our patients who are reimbursed by Medicare and managed care payors, for whom we receive higher reimbursement rates. Most of our skilled nursing facilities include our Express Recovery^TM program. This program uses a dedicated unit within a skilled nursing facility to deliver a comprehensive rehabilitation and recovery regimen in accommodations specifically designed to serve high-acuity patients.

Assisted Living Facilities. Within our assisted living facilities, which are mostly in Kansas, we generate our revenue primarily from private pay sources, with a small portion earned from Medicaid or other state-specific programs.

Leased Facility Revenue. We lease five skilled nursing facilities in California to an unaffiliated third party operator. For additional information on the lease arrangement, see Note 5 - "Property and Equipment" to the interim financial statements.

Therapy Services Segment

As of September 30, 2013, we provided rehabilitation therapy services to a total of 189 healthcare facilities, including 64 of our facilities, as compared to 199 facilities, including 64 of our facilities, as of September 30, 2012. In addition, we have contracts to manage the rehabilitation therapy services for our 10 healthcare facilities in New Mexico. The net decrease of 10 facilities serviced was comprised of 10 new facilities serviced, net of 20 cancellations. Rehabilitation therapy revenue derived from servicing our own facilities is included in our revenue from skilled nursing facilities. Our rehabilitation therapy business receives payment for services from the third-party facilities that it serves based on negotiated patient per diem rates or a negotiated fee schedule based on the type of service rendered. As of September 30, 2013, we provided rehabilitation therapy services to facilities in California, Nevada, New Mexico, Texas, Missouri, Nebraska, Iowa, and Indiana.

Hospice and Home Health Services Segment

Hospice. As of September 30, 2013, we provided hospice care in Arizona, California, Idaho, Montana, Nevada and New Mexico. We derive substantially all of the revenue from our hospice business from Medicare and managed care reimbursement.

Federal law imposes a Medicare payment cap on hospice service programs. We monitor the impact of the Medicare cap on our hospice business by attempting to address our average length-of-stay on an agency-by-agency basis. A key component of this strategy is to analyze each hospice agency's mix of patients and referral sources to achieve a desirable mix of the types of patients and referral sources that we serve in each of our agencies. To the extent that actual lengths of stay exceed our estimates, our recorded reserves could prove insufficient.

Home Health. We provided home health care in Arizona, Idaho, Montana, Nevada and New Mexico as of September 30, 2013. We derive the majority of the revenue from our home health business from Medicare. Net service revenue is recorded

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under the Medicare payment program based on a 60-day episodic payment rate that is subject to downward adjustment based on certain variables.

Regulatory and Other Governmental Actions Affecting Revenue

We derive a substantial portion of our revenue from government Medicare and Medicaid programs. In addition, our rehabilitation therapy services, for which we receive payment from private payors, is significantly dependent on Medicare and Medicaid funding, as those private payors are primarily funded or reimbursed by these programs. The following table summarizes the amount of revenue that we received from each of our payor classes by segment in the periods presented (dollars in thousands):



	Three Months Ended September 30,
	2013										2012
	Long-Term Care Services		Therapy Services		Hospice & Home Health Services		Total Revenue		Revenue Percentage		Long-Term Care Services		Therapy Services		Hospice & Home Health Services		Total Revenue		Revenue Percentage
Medicare Part A	$	38,921	$	—	$	21,412	$	60,333	28.4	%	$	43,306	$	—	$	22,145	$	65,451	30.2	%
Medicare Part B	3,908		—		—		3,908		1.8		5,821		—		—		5,821		2.7
Medicaid	67,757		—		879		68,636		32.3		66,805		—		782		67,587		31.2
Subtotal Medicare and Medicaid	110,586		—		22,291		132,877		62.5		115,932		—		22,927		138,859		64.1
Managed Care Part A	25,646		—		1,546		27,192		12.8		22,755		—		1,317		24,072		11.1
Managed Care Part B	522		—		—		522		0.2		452		—		—		452		0.2
Private pay and other	25,240		25,313		1,301		51,854		24.5		25,445		26,161		1,634		53,240		24.6
Total	$	161,994	$	25,313	$	25,138	$	212,445	100.0	%	$	164,584	$	26,161	$	25,878	$	216,623	100.0	%

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	Nine Months Ended September 30,
	2013										2012
	Long-Term Care Services		Therapy Services		Hospice & Home Health Services		Total Revenue		Revenue Percentage		Long-Term Care Services		Therapy Services		Hospice & Home Health Services		Total Revenue		Revenue Percentage
Medicare Part A	$	124,405	$	—	$	65,733	$	190,138	29.5	%	$	139,335	$	—	$	68,686	$	208,021	31.8	%
Medicare Part B	11,670		—		—		11,670		1.8		13,530		—		—		13,530		2.1
Medicaid	198,793		—		2,263		201,056		31.2		195,808		—		1,840		197,648		30.3
Subtotal Medicare and Medicaid	334,868		—		67,996		402,864		62.5		348,673		—		70,526		419,199		64.2
Managed Care Part A	76,567		—		4,326		80,893		12.5		68,897		—		3,575		72,472		11.1
Managed Care Part B	1,677		—		—		1,677		0.3		1,528		—		—		1,528		0.2
Private pay and other	76,355		79,057		4,166		159,578		24.7		76,633		78,661		4,918		160,212		24.5
Total	$	489,467	$	79,057	$	76,488	$	645,012	100.0	%	$	495,731	$	78,661	$	79,019	$	653,411	100.0	%

Medicare. Medicare is a federal program that provides certain healthcare benefits to beneficiaries who are 65 years of age or older, blind, disabled or qualify for Medicare’s End Stage Renal Disease program. Medicare provides health insurance benefits in two primary parts for services that we provide:

•

Part A. Medicare Part A is hospital insurance, which provides reimbursement for inpatient services for hospitals, skilled nursing facilities, hospices, home health and certain other healthcare providers and patients requiring daily professional skilled nursing and other rehabilitative care. Coverage in a skilled nursing facility is limited for a period of up to 100 days, if medically necessary, after the individual has qualified for Medicare coverage as a result of a three-day or longer hospital stay. Medicare pays for the first 20 days of stay in a skilled nursing facility in full and the next 80 days, to the extent above a daily coinsurance amount. Covered services include supervised nursing care, room and board, social services, pharmaceuticals and supplies as well as physical, speech and occupational therapies and other necessary services provided by nursing facilities. Medicare Part A also covers hospice care and some home health care. Skilled nursing facilities are paid under Medicare Part A on the basis of a prospective payment system, or PPS. The PPS payment rates are adjusted for case mix and geographic variation in wages and cover all costs of furnishing covered skilled nursing facilities services (routine, ancillary, and capital-related costs). The amount to be paid is determined by classifying each patient into a resource utilization group ("RUG"), category, which is based upon the patient's acuity level. CMS generally evaluates and adjusts payment rates on an annual basis.


•	Part B. Medicare Part B is supplemental medical insurance, which requires the beneficiary to pay monthly premiums, covers physician services, limited drug coverage and other outpatient services, such as physical, occupational and speech therapy services, enteral nutrition, certain medical items and X-ray services received outside of a Part A covered inpatient stay.

Medicaid. Medicaid is a state-administered medical assistance program for the indigent, operated by the individual states with the financial participation of the federal government. Each state has relatively broad discretion in establishing its Medicaid reimbursement formulas and coverage of service, which must be approved by the federal government in accordance with federal guidelines. All states in which we operate cover long-term care services for individuals who are Medicaid eligible and qualify for institutional care. Providers must accept the Medicaid reimbursement level as payment in full for services rendered. Medicaid programs generally make payments directly to providers, except in cases where the state has implemented a Medicaid managed care program, under which providers receive Medicaid payments from managed care organizations ("MCOs") that have subcontracted with the Medicaid program. PPACA provides for increased financial participation by the federal government in a state's Medicaid program if the state chooses to expand its Medicaid program as contemplated by PPACA. However, states are not required to expand their Medicaid programs and it is uncertain as to which states, including states in which we operate, will ultimately expand their programs.

Managed Care. Our managed care patients consist of individuals who are insured by a third-party entity, typically called a senior Health Maintenance Organization ("HMO") plan, or are Medicare beneficiaries who assign their Medicare benefits to a senior HMO plan.

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Private Pay and Other. Private pay and other sources consist primarily of individuals or parties who directly pay for their services or are beneficiaries of the Department of Veterans Affairs. In addition, the revenue related to the five leased properties is also included as part of the other payor sources.

Critical Accounting Estimates

Goodwill and Other Long-Lived Assets

Goodwill is accounted for under the Financial Accounting Standards Board (“FASB”) Accounting Standards Codification (“ASC”) Topic 805, Business Combinations, and represents the excess of the purchase price over the fair value of identifiable net assets acquired in business combinations accounted for as purchases. In accordance with FASB ASC Topic 350, Intangibles - Goodwill and Other, goodwill is subject to periodic testing for impairment. Goodwill of a reporting unit is tested for impairment on an annual basis, or, if an event occurs or circumstances change that would reduce the fair value of a reporting unit below its carrying amount, between annual testing. We have selected October 1 as the date to test goodwill for impairment on an annual basis. As a result of the proposed home health reimbursement reductions by CMS that are effective January 1, 2014, an interim goodwill impairment analysis was conducted as of September 30, 2013.

We periodically evaluate the carrying value of our long-lived assets other than goodwill, primarily consisting of our investments in real estate, for impairment indicators. If indicators of impairment are present, we evaluate the carrying value of the related real estate investments in relation to the future undiscounted cash flows of the underlying operations to assess recoverability of the assets. Measurement of the amount of the impairment, if any, may be based on independent appraisals, established market values of comparable assets or estimates of future cash flows expected. The estimates of these future cash flows are based on assumptions and projections believed by management to be reasonable and supportable. They require management's subjective judgments and take into account assumptions about revenue and expense growth rates. These assumptions may vary by type of long-lived asset.

Goodwill Impairment Testing

We compare the fair value of each reporting unit to its carrying amount on an annual basis to determine whether there is potential goodwill impairment. If the fair value of the reporting unit is less than its carrying value, an impairment loss is recorded to the extent the fair value of goodwill is less than its carrying value.

As of September 30, 2013, after the calculated fair value was compared to the carrying value of each reporting entity, we concluded that the carrying value of the home health services reporting unit exceeded its fair value and step two of the analysis was performed. The fair value of the long-term care, therapy services and hospice services reporting units exceeded their carrying value.

We assessed the fair value of the home health services reporting units for goodwill impairment based upon a combination of the discounted cash flow (income approach) and guideline public company method (market approach). The income and market approaches were given equal weighting.

The discounted cash flow and market approach methodologies utilized in estimating the fair value of our reporting units for purposes of goodwill impairment testing requires various judgmental assumptions about revenues, EBITDA and operating margins, growth rates, and working capital requirements. In determining those judgmental assumptions, we make a number of judgments regarding a variety of data, including-for each reporting unit, the annual budget for the upcoming year, the longer-term business plan, economic projections, anticipated future cash flows, market data, and historical cash flow growth rates. As we have not yet prepared our budget for the year ended December 31, 2014, our current forecast was utilized for the September 30, 2013 impairment analysis.

Therapy Unit Testing

Below are the key assumptions used to estimate the fair value for our therapy reporting unit at the time of our September 30, 2013 goodwill impairment test using the income approach:

• 2.0% long−term growth rate; and

• a 11.0% discount rate

Our therapy services reporting unit experienced an average annual compounded growth rate in external revenue from 2008 to 2012 of 3.8%. We selected a long term growth rate of 2.0% for the discounted cash flow analysis conducted as part of the impairment analysis as the 2.0% long-term growth rate is our expected long−term growth rate from a combination of growth in external contracts, rate increases as well as occupancy and skilled mix increases at our third party customers, as well as the reimbursement changes discussed in Part I - Item 1 - Business - Industry Trends earlier in the document. This growth rate was also assumed to be 2.0% in the prior year analysis.

The operating expenses projected under the discounted cash flow method were based upon our historical expenses as a percentage of therapy revenue adjusted for known efficiencies or additional costs to be incurred. Capital expenditures in the therapy services reporting unit have historically been negligible.

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The discount rate used to present value cash flows under the discounted cash flow method is a significant assumption in the analysis. The discount rate was developed using the capital asset pricing model through which a weighted average cost of capital was derived. The cost of equity was assumed to be 12.8% and the pre-tax cost of debt was assumed to be 8.0%, or about 4.8% after tax. Assuming a capital structure of 25% debt and 75% equity, the average cost of capital was determined to be 11.0%, which was used as the discount rate. A 0.5% decrease in the discount rate would increase the equity value of the therapy reporting unit by approximately $4 million, or 7%, using the income approach. A 0.5% increase in the discount rate would decrease the equity value of the therapy reporting unit by approximately $4 million, or 6%, using the income approach. Increasing the long-term revenue growth rate by 0.5% would increase the equity value by approximately $3 million, or 5%, using the income approach. Decreasing the long-term revenue growth rate by 0.5% would decrease the equity value by approximately $2 million, or 4%, using the income approach.

For the market approach, we compared ourselves to a peer group of other public companies. The metric used was business enterprise value, or BEV, divided by revenue. The average BEV divided by projected 2014 revenue for the peer group, including us, was 6.3 with a minimum of 5.7. For our market valuation a multiple of 6.5 was selected due to the relative size of our operations, along with a control premium of 25%, based upon historical transactions.

As the result of this evaluation indicated that the reporting unit's fair value of equity exceeded the carrying value of equity by $10.3 million, it was determined that there was no impairment to the therapy services reporting unit.

Hospice Unit Testing

Below are the key assumptions used to estimate the fair value for our hospice reporting unit at the time of our September 30, 2013 goodwill impairment test using the income approach:

• 2.0% long−term growth rate; and

• a 11.5% discount rate

We selected a long term growth rate of 2.0% for the discounted cash flow analysis conducted as part of the impairment analysis as the 2.0% long-term growth rate is our expected long−term growth rate from a combination of growth in rate increases as well as census increases. This growth rate was also assumed to be 2.0% in the prior year analysis.

The operating expenses projected under the discounted cash flow method were based upon our historical expenses as a percentage of hospice revenue adjusted for known efficiencies or additional costs to be incurred. Capital expenditures in the hospice services reporting unit have historically been negligible.

The discount rate used to present value cash flows under the discounted cash flow method is a significant assumption in the analysis. The discount rate was developed using the capital asset pricing model through which a weighted average cost of capital was derived. The cost of equity was assumed to be 14.0% and the pre-tax cost of debt was assumed to be 8.0%, or about 4.8% after tax. Assuming a capital structure of 25% debt and 75% equity, the average cost of capital was determined to be 11.5%, which was used as the discount rate. A 0.5% decrease in the discount rate would increase the equity value of the hospice reporting unit by approximately $5 million, or 10%, using the income approach. A 0.5% increase in the discount rate would decrease the equity value of the hospice reporting unit by approximately $5 million, or 10%, using the income approach. Increasing the long-term revenue growth rate by 0.5% would increase the equity value by approximately $4 million, or 7%, using the income approach. Decreasing the long-term revenue growth rate by 0.5% would decrease the equity value by approximately $3 million, or 6%, using the income approach.

For the market approach, we compared ourselves to a peer group of other public companies. The metric used was business enterprise value, or BEV, divided by revenue. The average BEV divided by projected 2014 revenue for the peer group, including us, was 7.8 with a minimum of 6.8. For our market valuation a multiple of 7.0 was selected due to the relative size of our operations, along with a control premium of 25%, based upon historical transactions.

As the result of this evaluation indicated that the reporting unit's fair value of equity exceeded the carrying value of equity by $34.3 million, it was determined that there was no impairment to the hospice reporting unit.

Home Health Unit Testing

Below are the key assumptions used to estimate the fair value for our home health care reporting unit at the time of our September 30, 2013 goodwill impairment test using the income approach:


•	A revenue reduction of 1.0% for the initial 24 month period as a result of the proposed reimbursement reductions effective January 1, 2014;


•	2.0% long-term revenue growth rate beginning in 2017; and


•	a 12.0% discount rate

Our home health care reporting unit experienced an average annual compounded growth rate in external revenue from 2008 to 2013 of 9.8%. However, we selected a long-term growth rate of 2.0% for the discounted cash flow analysis conducted as part of the impairment analysis because the historical growth rate includes acquisitions. The 2.0% long-term growth rate is our expected long-term growth rate from a combination of reimbursement rate changes and increases in episodic treatments.

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The operating expenses projected under the discounted cash flow method were based upon our historical expenses as a percentage of home health care revenue adjusted for known efficiencies or additional costs to be incurred.

The discount rate used to calculate the present value of cash flows under the discounted cash flow method is a significant assumption in the analysis. The discount rate was developed using the capital asset pricing model through which a weighted average cost of capital was derived.

The cost of equity was assumed to be 14.4% and the pre-tax cost of debt was assumed to be 8.0%. Assuming a capital structure of 25% debt and 75% equity, the average cost of capital was determined to be 12.0%, which was used as the discount rate. A 0.5% increase in the discount rate would decrease the equity value of the home health reporting unit by approximately $0.5 million, or 3%, using the income approach.

Increasing the long-term revenue growth rate by 0.5% increases the equity value by approximately $0.3 million, or 2%, using the income approach.

For the market approach, we compared ourselves to a peer group of other public companies. The metric used was business enterprise value, or BEV, divided by revenue. The average BEV divided by projected 2014 revenue for the peer group, including us, was 0.6 with a minimum of 0.4. For our market valuation a multiple of 0.3 was selected due to the relative size of our operations, along with a control premium of 25%, based upon historical transactions.

As the result of this evaluation indicated that the reporting unit's carrying value of equity exceeded the fair value of equity, we performed step two of the goodwill impairment analysis for the home health care reporting unit. In this test, the carrying value of goodwill is adjusted to its fair value. Each asset and liability was ascribed a value based on fair value standards under generally accepted accounting principles. An impairment charge of $0.4 million related to the licenses of our home health reporting unit was recognized at September 30, 2013.

Upon completion of step two, we recorded a goodwill impairment charge of $16.5 million, leaving $5.7 of goodwill at our home health care reporting unit

As of September 30, 2013, goodwill in the amount of $69.1 million was recorded on our consolidated balance sheet, of which $9.7 million related to the rehabilitation therapy unit, $53.7 million related to the hospice reporting unit and $5.7 million related to the home health reporting unit.

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Results of Operations

The following table summarizes some of our key performance indicators, along with other statistics, for each of the periods indicated:



	Three Months Ended September 30,						Nine Months Ended September 30,
	2013			2012			2013			2012
Occupancy statistics (skilled nursing facilities):
Available beds in service at end of period	8,809			8,813			8,809			8,813
Available patient days	810,242			810,303			2,405,099			2,413,572
Actual patient days	661,934			669,531			1,977,861			2,003,210
Occupancy percentage	81.7		%	82.6		%	82.2		%	83.0		%
Average daily number of patients	7,195			7,278			7,245			7,311

Hospice average daily census	1,219			1,433			1,292			1,404
Home health episodic-based admissions	1,996			2,083			6,329			6,167
Home health episodic-based recertifications	479			459			1,445			1,152

Revenue per patient day (skilled nursing facilities prior to intercompany eliminations)
LTC only Medicare (Part A)	$	515		$	510		$	518		$	510
Medicare blended rate (Part A & B)	567			574			567			572
Managed care (Part A)	398			382			389			383
Managed care blended rate (Part A & B)	406			391			398			392
Medicaid	163			160			162			158
Private and other	170			167			172			171
Weighted-average for all	$	234		$	235		$	236		$	237

Patient days by payor (skilled nursing facilities):
Medicare	75,587			85,591			239,950			267,315
Managed care	64,392			59,396			196,672			179,882
Total skilled mix days	139,979			144,987			436,622			447,197
Private pay and other	105,742			108,126			316,012			319,568
Medicaid	416,213			416,418			1,225,227			1,236,445
Total days	661,934			669,531			1,977,861			2,003,210

Patient days as a percentage of total patient days (skilled nursing facilities):
Medicare	11.4		%	12.8		%	12.1		%	13.3		%
Managed care	9.7			8.9			10.0			9.0
Skilled Mix	21.1			21.7			22.1			22.3
Private pay and other	16.0			16.1			16.0			16.0
Medicaid	62.9			62.2			61.9			61.7
Total	100.0		%	100.0		%	100.0		%	100.0		%

Revenue for total company:
Medicare	30.2		%	32.9		%	31.3		%	33.9		%
Managed care, private pay, and other	37.5			35.9			37.5			35.8
Quality mix	67.7			68.8			68.8			69.7
Medicaid	32.3			31.2			31.2			30.3
Total	100.0		%	100.0		%	100.0		%	100.0		%

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The following table sets forth details of our revenue, expenses, and net (loss) income and other items as a percentage of total revenue for the periods indicated:



	Three Months Ended September 30,						Nine Months Ended September 30,
	2013			2012			2013			2012
Revenue	100.0		%	100.0		%	100.0		%	100.0		%
Expenses:
Cost of services (exclusive of rent cost of revenue and depreciation and amortization shown below)	86.9			84.1			87.0			83.5
Rent cost of revenue	2.3			2.1			2.3			2.1
General and administrative	3.1			2.8			3.1			2.8
Change in fair value of contingent consideration	—			—			(0.3		)	0.1
Depreciation and amortization	2.9			2.8			2.9			2.8
Impairment of long-lived assets	8.9			—			2.9			—
	104.2			91.9			97.8			91.3
Other income (expenses):
Interest expense	(4.1		)	(4.1		)	(4.1		)	(4.4		)
Interest income	—			0.1			—			0.1
Other income (expense)	—			—			—			—
Equity in earnings of joint venture	0.2			0.2			0.2			0.2
Loss on disposal of asset	—			—			—			—
Debt modification/retirement costs	(0.2		)	(0.1		)	(0.2		)	(0.6		)
Total other (expenses) income, net	(4.1		)	(3.9		)	(4.1		)	(4.8		)
(Loss) income before provision for income taxes	(8.2		)	4.2			(1.8		)	3.9
(Benefit) provision for income taxes	(2.5		)	1.4			(0.7		)	1.4
Net (loss) income	(5.7		)%	2.8		%	(1.2		)%	2.4		%

Adjusted EBITDA(1)	8.3		%	11.1		%	8.3		%	11.8		%
Adjusted EBITDAR(2)	10.7		%	13.3		%	10.5		%	13.9		%

	Three Months Ended September 30,						Nine Months Ended September 30,
	2013			2012			2013			2012
Reconciliation from net (loss) income to EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR (in thousands):
Net (loss) income	$	(12,075	)	$	6,068		$	(7,482	)	$	15,902
Interest expense, net of interest income	8,681			8,665			25,866			28,474
(Benefit) provision for income taxes	(5,410		)	2,965			(4,360		)	9,356
Depreciation and amortization expense	6,130			6,173			18,396			18,409
EBITDA(1)	(2,674		)	23,871			32,420			72,141
Rent cost of revenue	4,950			4,639			14,590			13,734
EBITDAR(2)	2,276			28,510			47,010			85,875
EBITDA(1)	(2,674		)	23,871			32,420			72,141
Change in fair value of contingent consideration	79			85			(2,082		)	715
Organization restructure costs	457			—			2,006			—
Debt modification/retirement costs	432			168			1,520			4,126
Impairment of long lived assets	19,000			—			19,000
Closure of California home health agency	419			—			419
Adjusted EBITDA(1)	17,713			24,124			53,283			76,982
Rent cost of revenue	4,950			4,639			14,590			13,734
Adjusted EBITDAR(2)	$	22,663		$	28,763		$	67,873		$	90,716

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(1)

We define EBITDA as net income before depreciation, amortization and interest expense (net of interest income) and the provision for income taxes. Adjusted EBITDA is EBITDA adjusted for non-core business items, such as change in fair value of contingent consideration, organization restructuring costs, gains or losses on debt modification/retirement costs, impairment of long lived assets, or the disposal of property and equipment.


(2)	We define EBITDAR as net income before depreciation, amortization, interest expense (net of interest income), the provision for income taxes and rent cost of revenue. Adjusted EBITDAR is EBITDAR adjusted for the non-core business items listed above for the definition of Adjusted EBITDA (each to the extent applicable in the appropriate period.)

We believe that the presentation of EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR provides useful information regarding our operational performance because they enhance the overall understanding of the financial performance and prospects for the future of our core business activities.

Specifically, we believe that a report of EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR provides consistency in our financial reporting and provides a basis for the comparison of results of core business operations between our current, past and future periods. EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR are primary indicators management uses for planning and forecasting in future periods, including trending and analyzing the core operating performance of our business from period-to-period without the effect of expenses, revenues and gains (losses) that we believe are unrelated to the day-to-day performance of our business but are required to be reported in accordance with accounting principles generally accepted in the United States of America ("U.S. GAAP"). We also use EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR to benchmark the performance of our business against expected results, analyzing year-over-year trends as described below and to compare our operating performance to that of our competitors.

Management, including operating company based management, uses EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR to assess the performance of our core business operations, to prepare operating budgets and to measure our performance against those budgets on a consolidated and segment level. Segment management uses these metrics to measure performance on a business unit by business unit basis. We typically use Adjusted EBITDA and Adjusted EBITDAR for these purposes on a consolidated basis as the adjustments to EBITDA and EBITDAR are not generally allocable to any individual business unit and we typically use EBITDA and EBITDAR to compare the operating performance of each skilled nursing facility, assisted living facility, or other business unit as well as to assess the performance of our operating segments. EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR are useful in this regard because they do not include such costs as interest expense (net of interest income), income taxes, depreciation and amortization expense, rent cost of revenue (in the case of EBITDAR and Adjusted EBITDAR) and special charges, which may vary from business unit to business unit and period-to-period depending upon various factors, including the method used to finance the business, the amount of debt that we have determined to incur, whether a facility is owned or leased, the date of acquisition of a facility or business, the original purchase price of a facility or business unit or the tax law of the state in which a business unit operates. We believe these types of charges are dependent on factors unrelated to the underlying business unit performance. As a result, we believe that the use of EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR provides a meaningful and consistent comparison of our underlying business units between periods by eliminating certain items required by U.S. GAAP which have little or no significance to their day-to-day operations.

Finally, we use Adjusted EBITDA to determine compliance with our debt covenants and assess our ability to borrow additional funds and to finance or expand operations. Our senior secured credit facility uses a measure substantially similar to Adjusted EBITDA as the basis for determining compliance with our financial covenants, specifically our minimum interest coverage ratio and our maximum total leverage ratio, and for determining the interest rate of our first lien term loan. For example, the senior secured credit facility includes adjustments to EBITDA for (i) gain or losses on sale of assets, (ii) the write-off of deferred financing costs of extinguished debt, (iii) pro forma adjustments for acquisitions to show a full year of EBITDA and interest expense, (iv) sponsorship fees paid to Onex which totals $0.5 million annually, (v) non-cash stock compensation and (vi) impairment of long-lived assets. Our noncompliance with these financial covenants could lead to acceleration of amounts due under our senior secured credit facility.

Despite the importance of these measures in analyzing our underlying business, maintaining our financial requirements, designing incentive compensation and for our goal setting both on an aggregate and individual business level basis, EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR are non-GAAP financial measures that have no standardized meaning defined by U.S. GAAP. Therefore, our EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR measures have limitations as analytical tools, and they should not be considered in isolation, or as a substitute for analysis of our results as reported under U.S. GAAP. Some of these limitations are:


•	they do not reflect our cash expenditures, or future requirements, for capital expenditures or contractual commitments;


•	they do not reflect changes in, or cash requirements for, our working capital needs;


•	they do not reflect the interest expense, or the cash requirements necessary to service interest or principal payments, on our debt;

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•	they do not reflect any income tax payments we may be required to make;


•	although depreciation and amortization are non-cash charges, the assets being depreciated and amortized will often have to be replaced in the future, and EBITDA and Adjusted EBITDA do not reflect any cash requirements for such replacements;


•	they are not adjusted for all non-cash income or expense items that are reflected in our consolidated statements of cash flows;


•	they do not reflect the impact on earnings of charges resulting from certain matters we consider not to be indicative of our ongoing operations; and


•	other companies in our industry may calculate these measures differently than we do, which may limit their usefulness as comparative measures.

We compensate for these limitations by using EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR only to supplement net income on a basis prepared in conformance with U.S. GAAP in order to provide a more complete understanding of the factors and trends affecting our business. Furthermore, the non-GAAP financial measures that we present may be different from the presentation of similar measures by other companies, so the comparability of the measures among companies may be limited. We strongly encourage investors to consider net income determined under U.S. GAAP as compared to EBITDA, EBITDAR, Adjusted EBITDA and Adjusted EBITDAR, and to perform their own analysis, as appropriate.

Three Months Ended September 30, 2013 Compared to Three Months Ended September 30, 2012

Revenue. Revenue decreased by $4.2 million, or 1.9%, to $212.4 million in the three months ended September 30, 2013 from $216.6 million in the three months ended September 30, 2012.

Long term care services



	Three Months Ended September 30,
	2013				2012				Increase/(Decrease)
	Revenue Dollars		Revenue Percentage		Revenue Dollars		Revenue Percentage		Dollars			Percentage
	(dollars in millions)
Skilled nursing facilities	$	154.1	72.5	%	$	156.6	72.3	%	$	(2.5	)	(1.6	)%
Assisted living facilities	7.0		3.3		7.1		3.3		(0.1		)	(1.4	)
Administration of third party facility	0.1		0.1		0.1		0.1		—			—
Leased facility revenue	0.8		0.4		0.8		0.4		—			—
Total long-term care services	$	162.0	76.3	%	$	164.6	76.1	%	$	(2.6	)	(1.6	)%

The $2.5 million decrease in skilled nursing facilities revenue in the third quarter of 2013 as compared to the third quarter of 2012 was primarily due to a decrease in census, the ongoing shift in payor mix from traditional Medicare to Managed Medicare (Medicare Advantage) and a reduction in Medicare Part B revenue. The shift in census away from Medicare to Managed Medicare resulted in a decline of $2.4 million in revenue due to volume decrease offset by $1.0 million increase in managed care rates due to higher acuity residents. In addition, Medicare Part B revenue decreased by $1.9 million primarily due to the impact of the MMR process that was implemented October 1, 2012. The MAC's are still not able to process the volume of MMR's submitted and providers have decreased Part B treatments of patients due to the risk of not being paid. These reductions were offset by $1.0 million increase in Medicaid revenue and a $0.1 million decrease in private and other revenue. We experienced a decrease in our average daily census ("ADC") in our skilled nursing facilities in the third quarter of 2013 as compared to the third quarter of 2012. A significant contributing factor to the decrease in overall census and the revenue decline was attributable to one facility in New Mexico that experienced a significant Medicare and Medicaid census decline in the first 9 months of 2013 as compared to the prior year period, but has since begun to rebuild its Medicare and Medicaid census and work towards more normalized operational performance. Our average patient per day ("PPD") rate decreased by $1.11 for the third quarter of 2013 as compared to the third quarter of 2012 primarily due to the shift in payor mix and the impact of the 2.0% sequestration.

The decrease of $0.1 million at our assisted living facilities in the third quarter of 2013 as compared to the third quarter of 2012 was due primarily to a decrease in ADC.

Therapy services

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	Three Months Ended September 30,
	2013					2012					Increase/(Decrease)
	Revenue Dollars			Revenue Percentage		Revenue Dollars			Revenue Percentage		Dollars			Percentage
	(dollars in millions)
Rehabilitation therapy services	$	39.2		18.4	%	$	41.6		19.2	%	$	(2.4	)	(5.8	)%
Intersegment elimination of services related to affiliated entities	(13.9		)	(6.5	)	(15.4		)	(7.1	)	1.5			(9.7	)
Third party therapy services	$	25.3		11.9	%	$	26.2		12.1	%	$	(0.9	)	(3.4	)%

Hallmark revenue for third party therapy services decreased by $0.9 million in the third quarter of 2013 as compared to the third quarter of 2012. This decrease was related to a $1.2 million decrease in revenue from the third party facilities that operated for the full three months in both 2013 and 2012 offset by a $0.5 million increase in revenue from new third party facilities. The Medicare Part B MMR process that went into effect on October 1, 2012 reduced revenue from third party therapy customers for the three months ended September 30, 2013 by $2.5 million as compared to the same period a year ago as many of our customers are hesitant to provide therapy treatment to their patients in excess of the $3,700 Medicare Part B threshold. Certain MAC's were still not able to process the volume of MMR's submitted and providers have decreased Part B treatments of patients due to the risk of not being paid. We expect the MMR process to continue to negatively impact our therapy revenue in the future. This was offset by an increase in revenue of $0.5 million due to an increase in treatment of managed care patients and an increase in revenue of $1.0 million due to an increase in treatment of Medicare Part A patients at third party facilities. The MPPR for outpatient therapy included in the ATRA went into effect April 1, 2013 and negatively impacted revenue by $0.3 million.

Hospice & Home Health services



	Three Months Ended September 30,
	2013				2012				Increase/(Decrease)
	Revenue Dollars		Revenue Percentage		Revenue Dollars		Revenue Percentage		Dollars			Percentage
	(dollars in millions)
Hospice	$	18.2	8.5	%	$	19.3	8.9	%	$	(1.1	)	(5.7	)%
Home Health	7.0		3.3		6.6		3.0		0.4			6.1
Total hospice & home health services	$	25.2	11.8	%	$	25.9	11.9	%	$	(0.7	)	(2.7	)%

The $1.1 million decrease in hospice revenue in the third quarter of 2013 as compared to the third quarter of 2012 was a result of a reduction in ADC for the third quarter of 2013 as compared to the third quarter of 2012 offset by lower hospice Medicare cap reserves recorded in the third quarter of 2013. For the quarters ended September 30, 2013 and 2012, we recorded hospice cap adjustments of $0.5 million and $3.0 million, respectively, as adjustments to revenue, which negatively affected the weighted average PPD rates for both periods. Of the $0.5 million hospice cap reserves recorded in the three months ended September 30, 2013 $0.2 was related to the 2012 cap year and $0.3 was related to the 2013 cap year. Of the entire $3.0 million recorded in the three months ended September 30, 2012, $0.9 million was for the 2012 cap year and $2.1 million was related to the 2011 cap year.

The $0.4 million increase in our home health revenue in the third quarter of 2013 as compared to the third quarter of 2012 was the result of $0.6 million increase from an increase in rates offset by $0.2 million decrease in episodes. The increase in rate per episode was primarily due to a 6.1% increase in average Medicare reimbursement per episode and a 12.0% increase in managed care reimbursement per episode.

Cost of Services Expenses. Cost of services expenses increased $2.4 million, or 1.3%, to $184.6 million, or 86.9% of revenue, in the three months ended September 30, 2013, from $182.2 million, or 84.1% of revenue, in the three months ended September 30, 2012.

Long term care services

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	Three Months Ended September 30,
	2013				2012				Increase/(Decrease)
	Cost of Service Dollars (prior to intersegment eliminations)		Percentage of Revenue		Cost of Service Dollars (prior to intersegment eliminations)		Percentage of Revenue

									Dollars			Percentage
	(dollars in millions)
Skilled nursing facilities	$	131.0	85.0	%	$	127.3	81.3	%	$	3.7		2.9	%
Assisted living facilities	5.1		73.1		4.9		68.7		0.2			4.1
Regional operations support	4.7		n/a		5.8		n/a		(1.1		)	(19.0	)
Total long-term care services	$	140.8	86.9	%	$	138.0	83.9	%	$	2.8		2.0	%

Cost of services expenses at our skilled nursing facilities increased $3.7 million in the third quarter of 2013 as compared to the third quarter of 2012. The $3.7 million increase was primarily the result of a $1.0 million increase in benefits expense in the third quarter of 2013 as compared to the third quarter of 2012 due to increases in self insured employee medical expense and self insured workers compensation expense. There was a $1.0 million increase in bad debt expense in the third quarter of 2013 as compared to the third quarter of 2012 due to aging accounts receivables for private co-pay and managed care patients, as well as from the aging of Medicare Part B receivables related to the MMR’s. The increase was also attributable to an increase in general and professional liability insurance of $2.7 million in the third quarter of 2013 as compared to the third quarter of 2012 due to a change in the estimated reserves on the professional liability claims from prior years. Taxes and licenses expense increased by $0.5 million in the third quarter of 2013 as compared to the third quarter of 2012 due to an increase in California quality assurance ("QA") fees. These increases were offset by a decrease in rehab and ancillaries expense of $1.5 million due to the reduction in Medicare Part B revenue.

Cost of services at our assisted living facilities increased $0.2 million in the third quarter of 2013 as compared to the third quarter of 2012. All of this increase was due to an increase in labor and benefits expense in the third quarter of 2013 as compared to the third quarter of 2012.

Cost of services at the regional operations support decreased $1.1 million in the third quarter of 2013 as compared to the third quarter of 2012 primarily due to a reduction in labor expense of $0.5 million as a result of the restructuring and due to a reduction of $0.5 million in professional legal fees for the three months ended September 30, 2013 as compared to the three months ended September 30, 2012.

Therapy services



	Three Months Ended September 30,
	2013						2012						Increase/(Decrease)
	Revenue (prior to intersegment eliminations)		Cost of Service Dollars (prior to intersegment eliminations)		Percentage of Revenue		Revenue (prior to intersegment eliminations)		Cost of Service Dollars (prior to intersegment eliminations)		Percentage of Revenue

													Dollars			Percentage
	(dollars in millions)
Rehabilitation therapy services	$	39.2	$	36.3	92.6	%	$	41.6	$	37.8	90.9	%	$	(1.5	)	(4.0	)%
Total therapy services	$	39.2	$	36.3	92.6	%	$	41.6	$	37.8	90.9	%	$	(1.5	)	(4.0	)%

Rehabilitation therapy costs of services as a percentage of revenue increased by 1.7% for the three months ended September 30, 2013, as compared to the same period in 2012. The increase in the cost of services as a percentage of revenue is due to an increase in the treatment of managed care patients for which we receive a lower revenue rate per minute, the MPPR which went into effect April 1, 2013, and from an increase in administrative work due to the compliance with the review

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process on the MMRs and training involved in G-Code (reporting of the functional status of therapy patients by the therapist) implementation.

Hospice and home health services



	Three Months Ended September 30,
	2013				2012				Increase/(Decrease)
	Cost of Service Dollars		Percentage of Revenue		Cost of Service Dollars		Percentage of Revenue

									Dollars			Percentage
	(dollars in millions)
Hospice	$	15.4	84.7	%	$	16.4	85.2	%	$	(1.0	)	(6.3	)%
Home Health	6.6		94.6		6.2		93.9		0.4			6.5
Total hospice & home health services	$	22.0	87.5	%	$	22.6	87.4	%	$	(0.6	)	(2.7	)%

Cost of services expenses related to our hospice business decreased $1.0 million in the third quarter of 2013 as compared to the third quarter of 2012. The $1.0 million decrease was primarily attributable to decreased labor expense related to the decrease in census, though PPD costs increased from $124.7 to $137.4, an increase of 10.2%.

Cost of services related to our home health business increased $0.4 million in the third quarter of 2013 as compared to the third quarter of 2012. The increase was primarily due to an increase of $0.4 million in salaries and benefits for employees due to the increased number of patients.

Rent Cost of Revenue. Rent cost of revenue increased $0.4 million, or 6.7%, to $5.0 million, or 2.3% of revenue, in the three months ended September 30, 2013 from $4.6 million, or 2.1% of revenue, in the three months ended September 30, 2012. The increase was primarily related to rent increases that went into effect since the third quarter of 2012 at two of our California skilled nursing facilities.

General and Administrative Services Expenses. Our general and administrative services expenses increased $0.5 million, or 7.8%, to $6.5 million, or 3.1% of revenue, in the three months ended September 30, 2013 from $6.0 million, or 2.8% of revenue, in the three months ended September 30, 2012. The increase is primarily due to $0.3 million in consulting expenses related to our CEO search.

Depreciation and Amortization. Depreciation and amortization remained consistent at $6.1 million, or 2.9% of revenue, in the three months ended September 30, 2013 and 2.8% of revenue for the three months ended September 30, 2012.

Impairment of long-lived assets. We recorded a goodwill impairment charge of $16.5 million and a $2.5 million impairment charge related to home health licenses in the three months ended September 30, 2013. There was no comparable charge recorded in the three months ended September 30, 2012. See “Management's Discussion and Analysis of Financial Condition and Results of Operations-Goodwill and Other Long-Lived Assets” for a more detailed discussion of the impairment charges.

Change in fair value of contingent consideration. The change in fair value of contingent consideration remained consistent at $0.1 million, for the three months ended September 30, 2013 and September 30, 2012.

Interest Expense. Interest expense decreased by $0.1 million, or 0.5%, to $8.7 million, or 4.1% of revenue, in the three months ended September 30, 2013 from $8.8 million, or 4.1% of revenue, in the three months ended September 30, 2012. The decrease is related to the reduced average interest rate from 6.70% for the three months ended September 30, 2012 to 6.62% for the three months ended September 30, 2013. Also, the average debt outstanding dropped from $460.3 million for the three months ended September 30, 2012 to $444.5 million for the three months ended September 30, 2013.

Interest Income. Interest income remained consistent at approximately $0.1 million for the three months ended September 30, 2013 and September 30, 2012.

Debt modification/retirement costs. Debt modification/retirement costs increased by $0.2 million to $0.4 million or 0.2% of revenue, in the three months ended September 30, 2013 from $0.2 million or 0.1% of revenue in the three months ended September 30, 2012. The increase was due to deferred financing fees expensed on the extinguishment of term debt that was refinanced with HUD insured loans.

Equity in Earnings of Joint Venture. Equity earnings of our pharmacy joint venture remained consistent at $0.5 million in the three months ended September 30, 2013 and September 30, 2012.

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(Loss) income Before Provision for Income Taxes. (Loss) income before provision for incomes taxes decreased by $26.5 million to a loss of $17.5 million in the three months ended September 30, 2013 from an income of $9.0 million in the three months ended September 30, 2012 primarily as a result of the decrease in revenue and impairment of goodwill long lived assets of $19.0 million.

(Benefit) provision for Income Taxes. We recorded a tax benefit of $5.4 million, or 31.3% of pre-tax losses, for the three months ended September 30, 2013, as compared to a tax expense of $3.0 million, or 33.3% of pre-tax earnings, for the three months ended September 30, 2012. The decrease in the tax expense was a result of loss recorded for the three months ended in September 30, 2013 as compared to the net earnings for the same period in 2012. On July 11, 2013, legislation was enacted in California that will limit the carryover period for unused EZ tax credits to 10 years beginning in 2014. Prior to this legislation, unused EZ tax credits could be carried over indefinitely. This change in carryforward period resulted in the recording of a $2.3 million increase to the state valuation allowance, which was partially offset by the federal benefit resulting from the increase in state valuation allowance of $0.8 million.

Nine Months Ended September 30, 2013 Compared to Nine Months Ended September 30, 2012

Revenue. Revenue decreased by $8.4 million, or 1.3%, to $645.0 million in the nine months ended September 30, 2013 from $653.4 million in the nine months ended September 30, 2012.

Long term care services



	Nine Months Ended September 30,
	2013				2012				Increase/(Decrease)
	Revenue Dollars		Revenue Percentage		Revenue Dollars		Revenue Percentage		Dollars			Percentage
	(dollars in millions)
Skilled nursing facilities	$	465.6	72.2	%	$	471.8	72.2	%	$	(6.2	)	(1.3	)%
Assisted living facilities	21.1		3.3		20.9		3.3		0.2			0.7
Administration of third party facility	0.4		0.1		0.7		0.1		(0.3		)	(42.9	)
Leased facility revenue	2.3		0.3		2.3		0.3		—			—
Total long-term care services	$	489.5	75.9	%	$	495.7	75.9	%	$	(6.3	)	(1.3	)%

The $6.2 million decrease in the skilled nursing facilities revenue in the first nine months of 2013 as compared to the first nine months of 2012 was primarily due a decrease in volume and due to one less business day in the nine months ended September 30, 2013 as compared to the nine months ended September 30, 2012. The volume decrease led to a revenue decrease of $6.0 million. The majority of the decreased volume was in Medicare days, which was partially offset by an increase in Managed Medicare (Medicare Advantage) as more seniors elect Medicare Advantage. We also experienced a decrease in Medicaid days. A significant contributing factor to the decrease in overall census and the revenue decline was one facility in New Mexico that experienced a significant Medicare and Medicaid census decline in the first nine months of 2013 as compared to the prior year period, but has since begun to rebuild its Medicare and Medicaid census and work towards more normalized operational performance.

The increase of $0.2 million at our assisted living facilities in the nine months ended September 30, 2013 as compared to the same period in 2012 was due primarily to the increase in PPD rate by 1.7% to $97 for the nine months ended September 30, 2013 as compared to $95 for the nine months ended September 30, 2012.

Therapy services



	Nine Months Ended September 30,
	2013					2012					Increase/(Decrease)
	Revenue Dollars			Revenue Percentage		Revenue Dollars			Revenue Percentage		Dollars			Percentage
	(dollars in millions)
Rehabilitation therapy services	$	122.1		19.0	%	$	125.9		19.2	%	$	(3.8	)	(3.0	)%
Intersegment elimination of services related to affiliated entities	(43.1		)	(6.7	)	(47.2		)	7.3		4.1			(8.7	)
Third party therapy services	$	79.0		12.3	%	$	78.7		12.1	%	$	0.3		0.4	%

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The $0.3 million increase in our Hallmark third party therapy services revenue in the first nine months of 2013 as compared to first nine months of 2012 was related to an increase in revenue for facilities that operated for the full nine months ended September 30, 2013 and 2012. The intersegment revenue from affiliated facilities decreased by $4.1 million for the nine months ended September 30, 2013 as compared to the same period a year ago due to the reduction in Medicare Part A patient census. The Medicare Part B MMR process that went into effect on October 1, 2012 reduced revenue from our third party customers for the six months ended June 30, 2013 by $4.1 million as compared to the same period a year ago as many of our customers are hesitant to provide therapy treatment to their patients in excess of the $3,700 Medicare Part B threshold. We expect the MMR process to continue to negatively impact our therapy revenue in the future. This was offset by a $2.4 million increase in revenue due an increase in the treatment of managed care residents at the third party facilities and a $2.1 million increase in revenue due an increase in the treatment of Medicare Part A residents at the third party facilities for the nine months ended September 30, 2013 as compared to the same period a year ago. The MPPR for outpatient therapy included in the ATRA went into effect April 1, 2013 and negatively impacted our revenue by $0.6 million.

Hospice & Home Health services



	Nine Months Ended September 30,
	2013				2012				Increase/(Decrease)
	Revenue Dollars		Revenue Percentage		Revenue Dollars		Revenue Percentage		Dollars			Percentage
	(dollars in millions)
Hospice	$	55.6	8.6	%	$	59.6	9.1	%	$	(4.0	)	(6.7	)%
Home Health	20.9		3.2		19.4		3.0		1.5			7.7
Total hospice & home health services	$	76.5	11.8	%	$	79.0	12.1	%	$	(2.5	)	(3.2	)%

The $4.0 million decrease in hospice revenue for the first nine months of 2013 as compared to the first nine months of 2012 was due to a $5.0 million decrease in ADC offset by a $1.0 million increase the rates due to higher Medicare reimbursement. For the nine months ended September 30, 2013 and 2012, we recorded hospice Medicare cap adjustments of $3.4 million and $4.2 million, respectively, as adjustments to revenue, which negatively affected the weighted average PPD rates for both periods and accounted for the remaining decrease in revenue. Of the $3.4 million hospice cap reserves recorded in the nine months ended September 30, 2013, $0.9 million was related to the 2013 cap year, $2.3 million was related to the 2012 cap year and $0.2 million was related to the 2011 cap year. Of the $4.2 million in cap adjustment recorded in the nine months ended September 30, 2012, $2.4 million was related to the 2012 cap year and $1.8 million was related to the 2011 cap year.

Of the $1.5 million increase in our home health revenue in the first nine months of 2013 as compared to the first nine months of 2012, $1.0 million was from home health agencies operated for all of both periods, with a $0.9 million increase from an increase in episodes and a $0.1 million increase due to an increase in rate per episode. The increase in rate per episode was primarily due to the increase in Managed care reimbursement rates offset by decreases in rate by other payor sources. The remaining $0.5 million increase in home health revenue was due to acquisitions.

Cost of Services Expenses. Cost of services expenses increased $15.6 million, or 2.9%, to $561.1 million, or 87.0% of revenue, in the nine months ended September 30, 2013, from $545.6 million, or 83.5% of revenue, in the nine months ended September 30, 2012.

Long term care services

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	Nine Months Ended September 30,
	2013				2012				Increase/(Decrease)
	Cost of Service Dollars (prior to intersegment eliminations)		Percentage of Revenue		Cost of Service Dollars (prior to intersegment eliminations)		Percentage of Revenue

									Dollars			Percentage
	(dollars in millions)
Skilled nursing facilities	$	393.9	84.6	%	$	383.4	81.3	%	$	10.5		2.7	%
Assisted living facilities	15.1		71.7		14.8		70.5		0.3			2.0
Regional operations support	16.0		n/a		16.4		n/a		(0.4		)	(2.4	)
Total long-term care services	$	425.0	86.8	%	$	414.6	83.6	%	$	10.4		2.5	%

Cost of services expenses at our skilled nursing facilities increased $10.5 million in the first nine months of 2013 as compared to the first nine months of 2012. The $10.5 million increase was primarily the result of a $6.4 million increase in self insured general and professional liability expense in the first nine months of 2013 as compared to the first nine months of 2012 due to a change in the estimated reserves on the professional liability claims from prior years. There was a $3.9 million increase in labor and benefit costs for the nine months ended September 30, 2013 as compared to the nine months ended September 30, 2012, primarily due to increases in self insured medical and workers compensation expense. Bad debt expense increased $3.0 million in the nine months ended September 30, 2013 as compared to the year ago period due to the payor mix shift and an increase in the aging of private co-pay receivables, as well as from the aging of Medicare Part B receivables related to the MMR’s. Taxes and licenses expense increased by $1.6 million in the nine months ended September 30, 2013 as compared to the nine months ended September 30, 2012 due to an increase in the California QA fees. These increases were offset by a decrease in rehab and ancillaries expense of $4.1 million due to the reduction in Medicare Part B patients treated.

Cost of services expenses at our assisted living facilities increased $0.3 million in the first nine months of 2013 as compared to the first nine months of 2012 due to an increase of $0.6 million in our facilities that operated for the full nine months in both periods attributable to an $0.4 million increase in labor costs resulting from increases in self insured medical and self insured workers compensation expense. In addition, there was a $0.1 million increase in professional liability reserves on existing claims in the first nine month of 2013 as compared to the first nine months of 2012 and a $1.0 million increase in bad debt expense for the nine months ended September 30, 2013 as compared to the same period a year ago. These increases were offset by a $0.3 million decrease in expenses due to the closure of an assisted living facility in California in April, 2012.

Cost of services at our regional operations support decreased by $0.4 million in the first nine months of 2013 as compared to the first nine months of 2012. The primary reason for the decrease was a decrease in labor costs of $0.8 million due to the reduction of overhead positions in August 2013. These were offset by an increase of $0.4 million in purchased services.

Therapy services



	Nine Months Ended September 30,
	2013						2012						Increase/(Decrease)
	Revenue (prior to intersegment eliminations)		Cost of Service Dollars (prior to intersegment eliminations)		Percentage of Revenue		Revenue (prior to intersegment eliminations)		Cost of Service Dollars (prior to intersegment eliminations)		Percentage of Revenue

													Dollars			Percentage
	(dollars in millions)
Rehabilitation therapy services	$	122.1	$	113.2	92.7	%	$	125.9	$	115.2	91.5	%	$	(2.0	)	(1.7	)%
Total therapy services	$	122.1	$	113.2	92.7	%	$	125.9	$	115.2	91.5	%	$	(2.0	)	(1.7	)%

Rehabilitation therapy costs of services as a percentage of revenue increased 1.2% for the nine months ended September 30, 2013, as compared to the same period in 2012. The increase in the cost of services as a percentage of revenue is

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due to an increase in the treatment of managed care patients for which we receive a lower revenue rate per minute, the MPPR which went into effect April 1, 2013, and from an increase in administrative work preparing documentation for the MMRs and training involved in G-Code implementation.

Hospice and home health services



	Nine Months Ended September 30,
	2013				2012				Increase/(Decrease)
	Cost of Service Dollars		Percentage of Revenue		Cost of Service Dollars		Percentage of Revenue

									Dollars		Percentage
	(dollars in millions)
Hospice	$	47.9	86.2	%	$	47.8	80.2	%	$	0.1	0.1	%
Home Health	19.8		94.8		17.3		89.4		2.5		14.3
Total hospice & home health services	$	67.7	88.5	%	$	65.2	82.5	%	$	2.6	3.9	%

Cost of services expenses related to our hospice business increased $0.1 million in the first nine months of 2013 as compared to the first nine months of 2012. The $0.1 million increase resulted from a decrease in the operating cost of $0.7 million at the facilities that operated for the full nine-month period in 2013 and 2012. This was offset by increase in operating expenses of $0.8 million at the GIP unit at our Las Vegas, Nevada hospice. GIP units require a higher level of patient care and result in increased PPD costs. In addition, salaries and wages increased on a PPD basis as the agencies did not reduce staffing levels commensurate with their decreased census.

Cost of services related to our home health business increased $2.5 million in the first nine months of 2013 as compared to the first nine months of 2012. The increase was primarily due to an increase of $1.7 million of additional expenses at our existing home health agencies, commensurate with the increase in episodes. Of the $1.7 million, salaries, contract, and benefits related expense increased by $1.3 million for these facilities. The remaining balance of $0.8 million in home health cost of services expense was due to acquisitions.

Rent Cost of Revenue. Rent cost of revenue increased $0.9 million, or 6.2%, to $14.6 million, or 2.3% of revenue, in the nine months ended September 30, 2013 from $13.7 million, or 2.1% of revenue, in the nine months ended September 30, 2012. The increase was primarily related to a new lease that went into effect in the fourth quarter of 2012 at a California skilled nursing facility.

General and Administrative Services Expenses. Our general and administrative services expenses increased $1.2 million, or 6.4%, to $19.8 million, or 3.1% of revenue, in the nine months ended September 30, 2013 from $18.5 million, or 2.8% of revenue, in the nine months ended September 30, 2012. The increase is primarily due to $1.7 million in severance costs related to the elimination of positions not related to patient care. There was also an increase of $0.3 million in consulting fees related to our CEO search and a $0.6 million increase in purchased services in 2013 as compared to 2012. These increases were offset by a $1.1 million reduction in stock compensation expense and $0.3 million less of incentive accruals in 2013, as compared to 2012.

Depreciation and Amortization. Depreciation and amortization remained consistent at $18.4 million, or 2.9% of revenue, in the nine months ended September 30, 2013 and September 30, 2012.

Change in fair value of contingent consideration. The change in fair value of contingent consideration decreased by $2.8 million, to a benefit of $2.1 million, or 0.3% of revenue, in the nine months ended September 30, 2013 from an expense of $0.7 million, or 0.1% of revenue, in the nine months ended September 30, 2012. The decrease is related to the change in fair value of the contingent consideration related to the 2010 hospice and home health acquisition due to reductions in forecasted EBITDA, which reduces the likelihood of the businesses achieving their EBITDA target necessary for the earn-out to be paid in future periods.

Impairment of long lived assets. We recorded a goodwill impairment charge of $16.5 million and a $2.5 million impairment charge related to home health licenses in the nine months ended September 30, 2013. There was no comparable charge recorded in the nine months ended September 30, 2012. See “Management's Discussion and Analysis of Financial Condition and Results of Operations-Goodwill and Other Long-Lived Assets” for a more detailed discussion of the impairment charges.

Interest Expense. Interest expense decreased by $2.7 million, or 9.4%, to $26.2 million, or 4.1% of revenue, in the nine months ended September 30, 2013 from $28.9 million, or 4.4% of revenue, in the nine months ended September 30, 2012. The

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decrease is related to the replacement of higher cost subordinated debt with term debt in the second quarter of 2012 which reduced the interest rate from 6.91% for the nine months ended September 30, 2012 to 6.70% for the nine months ended September 30, 2013. Also, the average debt outstanding dropped from $485.3 million for the period ended September 30, 2012 to $446.2 million for the period ended September 30, 2013.

Interest Income. Interest income decreased by $0.1 million to $0.3 million in the nine months ended September 30, 2013 as compared to $0.4 million or 0.1% of revenue, in the nine months ended September 30, 2012.

Equity in Earnings of Joint Venture. Equity earnings of our pharmacy joint venture remained consistent at $1.5 million in the nine months ended September 30, 2013 and September 30, 2012.

Debt modification/retirement costs. The debt modification/retirement costs decreased by $2.6 million to $1.5 million or 0.2% of revenue, in the nine months ended September 30, 2013 from $4.1 million or 0.6% of revenue in the nine months ended September 30, 2012. Of the $1.5 million expensed for debt modification, $1.1 million related to the June 2013 credit facility amendment, which increased the maximum leverage ratio by 0.5. The remaining $0.4 million was related to deferred financing fees expensed on the extinguishment of term debt that was refinanced with HUD insured loans. Of the $4.1 million expensed in 2012, $1.9 million in costs related unamortized subordinated debt deferred financing fees expensed when the bonds were defeased and $2.1 million related to the June 2012 credit facility amendment.

(Loss) income Before Provision for Income Taxes. (Loss) income before provision for incomes taxes decreased by $37.1 million to a loss of $11.8 million in the nine months ended September 30, 2013 from an income of $25.3 million in the nine months ended September 30, 2012 primarily as a result of the decrease in revenue, impairment of goodwill and long lived assets of $19.0 million and the loss due to closure of the Home Health Care of the West agency of $0.4 million.

(Benefit) provision for Income Taxes. We recorded a tax benefit of $4.4 million, or 36.8% of pre-tax loss, for the nine months ended September 30, 2013, as compared to an expense of $9.4 million, or 37.2% of pre-tax earnings, for the nine months ended September 30, 2012. The lower tax expense for the nine months ended September 30, 2013 was due primarily to the resolution and ultimate disposition of remaining funds related to the 2010 settlement of the Humboldt County Action. See Note 7, "Commitments and Contingencies - Legal Matters," for additional detail. On July 11, 2013, legislation was enacted in California that will limit the carryover period for unused EZ tax credits to 10 years beginning in 2014. Prior to this legislation, unused EZ tax credits could be carried over indefinitely. This change in carryforward period resulted in the recording of a $2.3 million increase to the state valuation allowance, which was partially offset by the federal benefit resulting from the increase in state valuation allowance of $0.8 million.

Liquidity and Capital Resources

The following table presents selected data from our condensed consolidated statements of cash flows (in thousands):



	Nine Months Ended September 30,
	2013			2012
Cash Flows from Continuing Operations
Net cash provided by operating activities	$	36,832		$	30,936
Net cash used in investing activities	(9,977		)	(12,516		)
Net cash used in financing activities	(26,263		)	(31,238		)
Net increase (decrease) in cash and cash equivalents	592			(12,818		)
Cash and cash equivalents at beginning of period	2,003			16,017
Cash and cash equivalents at end of period	$	2,595		$	3,199

Based upon our current level of operations, we believe that cash generated from operations, cash on hand and borrowings available to us will be adequate to meet our anticipated debt service requirements, capital expenditures and working capital needs for at least the next twelve months. One element of our business strategy is to selectively pursue acquisitions and strategic alliances. Any acquisitions or strategic alliances may result in our incurrence or assumption of additional indebtedness. We assess our capital needs on an ongoing basis and may from time to time seek additional financing through a variety of methods, including through an extension of our senior secured credit facility, or by accessing available debt and equity markets, and participation in U.S. Department of Housing and Urban Development ("HUD") or other government insured loan programs, as considered necessary to fund capital expenditures and potential acquisitions, refinance existing debt, or for other purposes. Our future operating performance will be subject to future economic conditions and to financial, business, regulatory and other factors, many of which are beyond our control. For additional discussion, see "Other Factors Affecting Liquidity and Capital Resources" below.

Nine Months Ended September 30, 2013 Compared to Nine Months Ended September 30, 2012

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At September 30, 2013, we had cash and cash equivalents of $2.6 million Our available cash is held in accounts at third-party financial institutions. We have periodically invested in AAA-rated money market funds. To date, we have experienced no loss or lack of access to our invested cash or cash equivalents; however, we can provide no assurances that access to our invested cash or cash equivalents will not be impacted by adverse conditions in the financial markets.

Net cash provided by operating activities in the nine months ended September 30, 2013 was $36.8 million, compared to the $30.9 million in the nine months ended September 30, 2012. The change was primarily the result of a $23.4 million decrease in net income which included an impairment charge of $19.0 million. The decrease included a $12.4 million improvement in operating cash flows from operating activities and changes in operating assets and liabilities for the nine months ended September 30, 2013 as compared to the nine months ended September 30, 2012 of $16.6 million. The $12.4 million improvement was due to increase in accounts payable and accrued liabilities due to the timing of payments of $4.8 million, $7.0 million in increases in insurance liability reserves and a decrease in accounts receivable of $6.4 million offset primarily by change in other assets of $3.1 million and debt retirement costs of $2.6 million.

Net cash used in investing activities in the nine months ended September 30, 2013 was $10.0 million, compared to $12.5 million in the nine months ended September 30, 2012 as the result of capital expenditures in both periods.

Net cash used in financing activities in the nine months ended September 30, 2013 was $26.2 million, compared to the $31.2 million used in the nine months ended September 30, 2012. We continue to pay down debt and have incurred costs related to the June 2013 debt amendment and the origination of the HUD insured loans in the nine months ended September 30, 2013.

Principal Debt Obligations

Our primary sources of liquidity are our cash on hand, our cash flows from operations and borrowing under our senior secured credit facility, which is subject to the satisfaction of certain financial covenants therein. Our primary liquidity requirements are for debt service on our first lien senior secured term loan, capital expenditures and working capital.

We are significantly leveraged. As of September 30, 2013, we had $434.8 million in aggregate indebtedness outstanding, consisting of $346.8 million first lien senior secured term loan (net of the unamortized portion of the original issue discount ("OID") of $2.3 million), $1.5 million principal amount outstanding under our $100.0 million revolving credit facility, HUD insured loans of $79.8 million and other debt of approximately $6.7 million. Furthermore, we had $5.5 million in outstanding letters of credit against our $100.0 million revolving credit facility, leaving approximately $93.0 million of additional borrowing capacity under our senior secured credit facility as of September 30, 2013. Substantially all of our subsidiaries except for the HUD insured loan subsidiaries guarantee the first lien senior secured term loan and our revolving credit facility.

If our remaining ability to borrow under our revolving credit facility is insufficient for our capital requirements, we will be required to seek additional sources of financing, including issuing equity, which may be dilutive to our current stockholders, or incurring additional debt. Our ability to incur additional debt is subject to the restrictions in our senior secured credit facility. We cannot assure you that the restrictions contained in the senior secure credit facility will permit us to borrow the funds that we need to finance our operations, or that additional debt will be available to us on commercially reasonable terms or at all. If we are unable to obtain funds sufficient to finance our capital requirements, we may have to forego opportunities to expand our business, including the acquisition of additional facilities.

Term Loan and Revolving Loan

On April 9, 2010, we entered into an up to $360.0 million senior secured term loan and a $100.0 million revolving credit facility ("Prior Credit Agreement") that amended and restated the senior secured term loan and revolving credit facility that were set to mature in June 2012. On April 12, 2012, we entered into an Amendment and Restatement and Additional Term Loan Assumption Agreement (“Restated Credit Agreement”) that amended and restated the Prior Credit Agreement and pursuant to which, among other things, the size of our existing senior secured term loan was increased by $100.0 million (hereinafter referred to as the incremental senior secured term loan). On June 6, 2013, we entered into an amendment to the Restated Credit Agreement that increased the maximum leverage ratio by 0.50 throughout the life of the Restated Credit Agreement. The amendment additionally permits us to make future offers to the lenders under the revolving loan facility to extend the maturity date of all or a portion of the revolving loans. The credit arrangements provided under the Restated Credit Agreement are collectively referred to herein as the senior secured credit facility.

We expensed fees paid in connection with the refinancing of the Prior Credit Agreement in the amount of $2.0 million in conjunction with the amended senior secured credit facility. In connection with the June 6, 2013 modification, we paid fees totaling $2.5 million, of which $1.1 million were recorded as debt modification costs in the consolidated statement of operations, and $1.4 million were recorded as other assets in the consolidated balance sheet. Substantially all of our assets are pledged as collateral under the senior secured credit facility. Amounts borrowed under the senior secured term loan may be prepaid at any time without penalty, except for LIBOR breakage costs. Commitments under the revolving credit facility terminate on April 9, 2015. The senior secured term loan matures on April 9, 2016.

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The incremental senior secured term loan bears interest, at our option, at the London Interbank Offered Rate ("LIBOR") (subject to a floor of 1.50%) plus a margin of 5.25% or the prime rate (subject to a floor of 2.50%) plus a margin of 4.25%. As part of the refinancing, the interest rate on the existing senior secured term loan was amended to match the interest rate of the incremental senior secured term loan. The interest rate on the existing revolving credit facility was also amended to be, at our option, LIBOR plus a margin of between 4.25% and 4.50% (based upon consolidated senior leverage) or the prime rate plus a margin of between 3.25% and 3.50% (based upon consolidated senior leverage). There is no longer a LIBOR or prime rate floor with respect to the revolving credit facility. Pursuant to the Restated Credit Agreement, the quarterly term loan amortization payments increased to $2.6 million beginning June 30, 2012, compared to $0.9 million previously under the Prior Credit Agreement. Additionally, the maximum portion of the annual Consolidated Excess Cash Flow (as defined in the Restated Credit Agreement) to be applied to term debt reductions increased to 75% from 50%, subject to stepdowns to 50% and 25% based on consolidated leverage. We also increased our ability to refinance a portion of our credit facility with U.S. Department of Housing and Urban Development ("HUD") insured debt up to $250 million, subject to certain credit facility covenants. Any HUD insured borrowings beyond $250 million would necessitate either refinancing the senior secured credit facility in full or otherwise seeking a waiver or amendment from the senior secured lenders.

Substantially all of our assets except for the assets owned by the subsidiaries participating in the HUD insured loans are pledged as collateral under the senior secured credit facility. Amounts borrowed under the senior secured term loan may be prepaid at any time without penalty, except for LIBOR breakage costs. Commitments under the revolving credit facility terminate on April 9, 2015. The senior secured term loan matures on April 9, 2016.

We have the right to increase our borrowings under the revolving credit facility up to an aggregate amount of $150 million provided that the we are in compliance with the Restated Credit Agreement, that the additional debt would not cause any covenant violation of the Restated Credit Agreement, and that existing or new lenders within the Restated Credit Agreement agree to increase their commitments. To reduce the risk related to interest rate fluctuations, the Prior Credit Agreement required us to enter into, and the Restated Credit Agreement requires us to continue to maintain, an interest rate swap, cap or similar agreement to effectively fix or cap the interest rate on 40% of our funded long-term debt within three months of the April 2010 commencement of the senior secured credit facility. See Item 3, Quantitative and Qualitative Disclosures About Market Risk, for information about our interest rate swap agreement.

Under the senior secured credit facility, we must maintain compliance with specified financial covenants measured on a quarterly basis. The senior secured credit facility also includes certain additional affirmative and negative covenants, including limitations on the incurrence of additional indebtedness, liens, investments in other businesses and capital expenditures. Also under the senior secured credit facility, subject to certain exceptions and minimum thresholds, we are required to apply all of the proceeds from any issuance of debt, as much as half of the proceeds from any issuance of equity, as much as 75% of our annual Consolidated Excess Cash Flow (as defined in the Restated Credit Agreement), and amounts received in connection with any sale of our assets to repay the outstanding amounts under the Restated Credit Agreement. We believe that we were in compliance with our debt covenants as of September 30, 2013. As of September 30, 2013, our fixed charge coverage ratio was 2.2, which compares to a minimum requirement of 1.75 and our leverage ratio was 4.7, as compared to an allowed maximum of 5.25.

Senior Subordinated Notes

On May 12, 2012, we redeemed the entire $130.0 million outstanding principal amount plus all accrued but unpaid interest, of the 2014 Notes. The proceeds from the incremental senior secured term loan (as well as a draw on the revolving portion of the senior secured credit facility) were used to fund the redemption of the outstanding 2014 Notes at par plus accrued interest. In addition, we expensed unamortized deferred financing fees and OID in the amount of $1.9 million in conjunction with the redemption.

The 2014 Notes were issued in December 2005 in the aggregate principal amount of $200.0 million, with an interest rate of 11.0% and a discount of $1.3 million. Interest was payable semiannually in January and July of each year. The 2014 Notes were to mature on January 15, 2014. The 2014 Notes were unsecured senior subordinated obligations and ranked junior to all of our existing and future senior indebtedness, including indebtedness under the senior secured credit facility. The 2014 Notes were guaranteed on a senior subordinated basis by certain of our subsidiaries.

On September 20, 2013, the Company received funding of its first loans insured by HUD. The loans have a combined principal balance of $21.6 million and are secured by three skilled nursing facilities. The HUD insured loans have an all in interest rate of approximately 4.5% and amortization term 30 years. The net loan proceeds of $20.4 million were used to pay down outstanding term debt in the Company's senior secured credit facility.

On September 26, 2013, the Company received funding of six additional loans insured by HUD. The loans have a combined principal balance of $58.2 million and are secured by six skilled nursing facilities. The HUD insured loans have an all in interest rate of approximately 5.7% and amortization terms of 30 to 35 years. The net loan proceeds of $54.7 million were used to pay down outstanding term debt in the Company's senior secured credit facility.

HUD Insured Loans

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As of September 30, 2013, we have a total of nine mortgages insured by HUD, which are secured by nine skilled nursing facilities. These mortgages have an average remaining term of 33 years with fixed interest rates ranging from 3.4% to 4.6% and a weighted average interest rate of 4.24%. Depending on the mortgage agreement, prepayments are generally allowed only after 12 months or from the inception of the mortgage. Prepayments are subject to a penalty of 10% of the remaining principal balances in the first year and the prepayment penalty decreases each subsequent year by 1% until no penalty is required. As all $79.8 million of the HUD insured mortgage loans were originated in September 2013, none of the loans could be prepaid at September 30, 2013. We anticipate closing one additional HUD insured loan by the end of the year. Any further HUD insured mortgages will require additional HUD approval.

All HUD-insured mortgages are non-recourse loans to us. All mortgages are subject to HUD regulatory agreements that require escrow reserve funds to be deposited with the loan servicer for mortgage insurance premiums, property taxes, insurance and for capital replacement expenditures. As of September 30, 2013, we have escrow reserve funds of $1.0 million with the loan servicer that are reported within other current assets, and replacement reserve funds of $1.6 million in other assets.

Capital Expenditures

We intend to invest in the maintenance and general upkeep of our facilities on an ongoing basis. We also expect to perform renovations of our existing facilities every five to ten years to remain competitive. Combined, we expect that these activities will amount to approximately $1,500 per bed.

We anticipate that we will have capital expenditures in 2013 of approximately $14.0 million to $17.0 million. We will continue to assess our capital spending plans on an ongoing basis.

Other Factors Affecting Liquidity and Capital Resources

Medical and Professional Malpractice and Workers' Compensation Insurance. Our skilled nursing facilities and other businesses, like physicians, hospitals and other healthcare providers, are subject to a significant number of legal actions alleging malpractice, negligence or related legal theories. Many of these actions involve large claims and significant defense costs. To protect ourselves from the cost of these claims, we maintain professional liability and general liability as well as workers' compensation insurance in amounts and with deductibles that we believe to be sufficient for our operations. Historically, unfavorable pricing and availability trends emerged in the professional liability and workers' compensation insurance market and the insurance market in general that caused the cost of these liability coverages to generally increase dramatically. Many insurance underwriters became more selective in the insurance limits and types of coverage they would provide as a result of rising settlement costs and the significant failures of some nationally known insurance underwriters. As a result, we experienced substantial changes in our professional liability insurance program beginning in 2001. Specifically, we were required to assume substantial self-insured retentions for our professional liability claims. A self-insured retention is a minimum amount of damages and expenses (including legal fees) that we must pay for each claim. We use actuarial methods to estimate the value of the losses that may occur within this self-insured retention level and we are required under our workers' compensation insurance agreements to post a letter of credit or set aside cash in trust funds to securitize the estimated losses that we may incur. Because of the high retention levels, we cannot predict with certainty the actual amount of the losses we will assume and pay.

We estimate our self-insured general and professional liability reserves on a quarterly basis and our self-insured workers' compensation reserve on a semiannual basis, based upon actuarial analyses using the most recent trends of claims, settlements and other relevant data from our own and our industry's loss history. Based upon these analyses, at September 30, 2013, we had reserved $21.8 million net of $1.3 million in insurance recoveries for known or unknown or potential self-insured general and professional liability claims and $19.0 million for self-insured workers' compensation claims. Of these reserves, we estimate that a total of $13.8 million, consisting of approximately $8.3 million for self-insured general and professional liability claims based on historical experience and current claims activity and $5.5 million for self-insured workers' compensation claims, will be payable within 12 months; however, there are no set payment schedules and there can be no assurance that the payment amount in the next 12 months will not be significantly larger or smaller. To the extent that subsequent claims information varies from loss estimates, the liabilities will be adjusted to reflect current loss data. There can be no assurance that in the future general and professional liability or workers' compensation insurance will be available at a reasonable price and that we will not have to further increase our levels of self-insurance. For additional information on our general and professional liability and workers’ compensation reserve, see "Business — Insurance" in Part 1, Item 1 in our Annual Report on Form 10-K filed with the SEC on February 11, 2013.

Inflation. We derive a substantial portion of our revenue from the Medicare program. We also derive revenue from state Medicaid and similar reimbursement programs. Payments under these programs generally provide for reimbursement levels that are adjusted for inflation annually based upon the state's fiscal year for the Medicaid programs and in each October for the Medicare program. However, there can be no assurance that these adjustments will continue in the future and, if received, will reflect the actual increase in our costs for providing healthcare services.

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Labor and supply expenses make up a substantial portion of our operating expenses. Those expenses can be subject to increase in periods of rising inflation and when labor shortages occur in the marketplace. To date, we have generally been able to implement cost control measures or obtain increases in reimbursement sufficient to offset increases in these expenses. We cannot assure you that we will be successful in offsetting future cost increases.

Recent Accounting Standards

The information required by this item is incorporated herein by reference to Note 2, "Summary of Significant Accounting Policies," to the unaudited consolidated financial statements included under Part I, Item 1 of this report.

Off-Balance Sheet Arrangements

We had outstanding letters of credit of $5.5 million under our $100.0 million revolving credit facility as of September 30, 2013.

Item 3. Quantitative and Qualitative Disclosures About Market Risk

In the normal course of business, our operations are exposed to risks associated with fluctuations in interest rates. To the extent these interest rates increase, our interest expense will increase, which will make our interest payments and funding our other fixed costs more expensive, and our available cash flow may be adversely affected. We routinely monitor our risks associated with fluctuations in interest rates and consider the use of derivative financial instruments to hedge these exposures. We do not enter into derivative financial instruments for trading or speculative purposes nor do we enter into energy or commodity contracts.

Interest Rate Exposure—Interest Rate Risk Management

Our first lien credit agreement exposes us to variability in interest payments due to changes in interest rates. We entered into an interest rate swap agreement on June 30, 2010 in order to manage fluctuations in cash flows resulting from interest rate risk. The interest rate swap agreement matured on June 30, 2013 and was for a notional amount of $70.0 million with a LIBOR rate of 2.3% from January 2012 to June 2013.

The table below presents the principal amounts, weighted-average interest rates and fair values by year of expected maturity to evaluate our expected cash flows and sensitivity to interest rate changes (dollars in thousands):



	Twelve Months Ending September 30, ⁽¹⁾
	2014			2015			2016			2017			2018			Thereafter			Total		Fair Value
Fixed-rate debt	$	6,960		$	1,383		$	1,445		$	1,510		$	1,576		$	73,661		$	86,535	$	86,535
Average interest rate	3.3		%	4.4		%	4.4		%	4.4		%	4.4		%	4.2		%
Variable-rate debt ⁽²⁾	$	10,487		$	11,987		$	328,103		$	—		$	—		$	—		$	350,577	$	348,831
Average interest rate⁽¹⁾	6.8		%	6.5		%	6.8		%


(1)	Based on implied forward three-month LIBOR rates in the yield curve as of September 30, 2013.


(2)	Excludes unamortized original issue discount of $2.3 million on our first lien senior secured term loan debt.

Item 4. Controls and Procedures

Disclosure Controls and Procedures

As required by Rules 13a-15(e) and 15d-15(e) under the Securities Exchange Act of 1934, as amended (the "Exchange Act"), management has evaluated, with the participation of our Chief Executive Officer and Chief Financial Officer, the effectiveness of our disclosure controls and procedures as of the end of the period covered by this report.

Disclosure controls and procedures refer to controls and other procedures designed to ensure that information required to be disclosed in the reports we file or submit under the Exchange Act is recorded, processed, summarized and reported, within the time periods specified in the rules and forms of the Securities and Exchange Commission. Disclosure controls and procedures include, without limitation, controls and procedures designed to ensure that information required to be disclosed by us in our reports that we file or submit under the Exchange Act is accumulated and communicated to management, including our chief executive officer and chief financial officer, as appropriate to allow timely decisions regarding our required disclosure. In designing and evaluating our disclosure controls and procedures, management recognizes that any controls and procedures, no matter how well designed and operated, can provide only reasonable assurance of achieving the desired control objectives, and management was required to apply its judgment in evaluating and implementing possible controls and procedures.

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We conducted an evaluation, under the supervision and with the participation of our Chief Executive Officer and Chief Financial Officer, of the effectiveness of the design and operation of our disclosure controls and procedures as of the end of the period covered by this report. Based upon their evaluation and subject to the foregoing, the Chief Executive Officer and Chief Financial Officer have concluded that, as of end of the period covered by this report, the disclosure controls and procedures were effective to provide reasonable assurance that information required to be disclosed in the reports we file and submit under the Exchange Act is recorded, processed, summarized and reported as and when required.

Changes in Internal Control Over Financial Reporting

Management determined that there were no changes in our internal control over financial reporting that occurred during the quarter covered by this report that has materially affected, or is reasonably likely to materially affect, our internal control over financial reporting.

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Part II. Other Information

Item 1. Legal Proceedings

For information regarding certain pending legal proceedings to which we are a party or our property is subject, see Note 7, "Commitments and Contingencies—Legal Matters," to our consolidated financial statements included elsewhere in this report, which is incorporated herein by reference.

Item 1A. Risk Factors

Statements made by us in this report and in other reports and statements released by us that are not historical facts constitute "forward-looking statements" within the meaning of Section 21 of the Exchange Act. Statements that use words such as "believe," "anticipate," "estimate," "intend," "could," "plan," "expect," "project" or the negative of these, as well as similar expressions, are intended to identify forward-looking statements. These forward-looking statements are necessarily estimates and expectations reflecting the best judgment of our senior management based on our current estimates, expectations, forecasts and projections, and include comments that express our current opinions about trends and factors that may impact future operating results. Such statements rely on a number of assumptions concerning future events, many of which are outside of our control, and involve known and unknown risks and uncertainties that could cause our actual results, performance or achievements, or industry results, to differ materially from any future results, performance or achievements, expressed or implied by such forward-looking statements. Any such forward-looking statements, whether made in this report or elsewhere, should be considered in the context of the various disclosures made by us about our business and other matters including, without limitation, the risk factors discussed below. We expressly disclaim any duty to update the forward-looking statements and other information contained in this report, except as required by law.

We operate in a rapidly changing and highly regulated environment that involves a number of risks and uncertainties, some of which are highlighted below and others are discussed elsewhere in this report. These risks and uncertainties could materially and adversely affect our business, financial condition, prospects, operating results or cash flows. The following risk factors are not the only ones facing us. Our business is also subject to the risks that affect many other companies, such as employment relations, natural disasters, general economic conditions and geopolitical events. Further, additional risks not currently known to us or that we currently believe are immaterial may in the future materially and adversely affect our business, operations, liquidity and stock price.

Risks Related to Our Business

Reductions in Medicare reimbursement rates, or changes in the rules governing the Medicare program could have a material adverse effect on our revenue, financial condition and results of operations.

Medicare is our largest source of revenue, accounting for 30.2% of our consolidated revenue during the three months period ended September 30, 2013 and 32.9% in the same period for 2012. For the nine months ended September 30, 2013 and 2012 the Medicare revenue accounted for 31.3% and 33.9% of our consolidated revenue respectively. In addition, many private payors base their reimbursement rates on the published Medicare rates or, in the case of our rehabilitation therapy services customers, are themselves reimbursed by Medicare for the services we provide. Accordingly, if Medicare reimbursement rates are reduced or fail to increase as quickly as our costs, or if there are changes in the rules governing the Medicare program that are disadvantageous to our business or industry, our business and results of operations will be adversely affected.

The Medicare program and its reimbursement rates and rules are subject to frequent change. These include statutory and regulatory changes, rate adjustments (including retroactive adjustments), administrative or executive orders and government funding restrictions, all of which may materially adversely affect the rates at which Medicare reimburses us for our services. For example, CMS implemented a net 11.1% reduction in its reimbursement rates to skilled nursing facilities effective October 1, 2011. Furthermore, due to the federal sequestration, an automatic 2% reduction in Medicare spending took effect beginning in April 2013 and will remain in effect unless Congress takes action to terminate the automatic reduction or authorize spending increases. Budget pressures often lead the federal government to reduce or place limits on reimbursement rates under Medicare. Implementation of these and other types of measures has in the past and could in the future result in substantial reductions in our revenue and operating margins. Prior reductions in governmental reimbursement rates partially contributed to our predecessor's bankruptcy filing under Chapter 11 of the United States Bankruptcy Code in October 2001.

In addition, the federal government often changes the rules governing the Medicare program, including those governing reimbursement. Changes that could adversely affect our business include:


•	administrative or legislative changes to base rates or the bases of payment;


•	limits on the services or types of providers for which Medicare will provide reimbursement;

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•	changes in methodology for patient assessment and/or determination of payment levels;


•	the reduction or elimination of annual rate increases; or


•	an increase in co-payments or deductibles payable by beneficiaries.

Given the history of frequent revisions to the Medicare program and its reimbursement rates and rules, we may not continue to receive reimbursement rates from Medicare that sufficiently compensate us for our services or, in some instances, cover our operating costs. Limits on reimbursement rates or the scope of services being reimbursed could have a material adverse effect on our revenue, financial condition and results of operations. Additionally, any delay or default by the federal or state governments in making Medicare and/or Medicaid reimbursement payments could materially and adversely affect our business, financial condition and results of operations.

We expect the federal and state governments to continue their efforts to contain growth in Medicaid expenditures, which could adversely affect our revenue and profitability.

We receive a significant portion of our revenue from Medicaid, which accounted for 32.3% consolidated revenue for the three months ended September 30, 2013 compared to 31.2% for the same period in 2012. For the nine months ended September 30, 2013 Medicaid accounted for 31.2% compared to 30.3% for the same period in 2012. Medicaid is a state-administered program financed by both state funds and matching federal funds. Medicaid spending has increased rapidly in recent years, becoming a significant component of state budgets. This, combined with slower state revenue growth, has led both the federal government and many states (including California and Texas, where significant portions of our Medicaid-related business is located) to institute measures aimed at controlling the growth of Medicaid spending, and in some instances reducing aggregate Medicaid spending. We expect these state and federal efforts to continue for the foreseeable future. Furthermore, not all of the states in which we operate, most notably Texas, have elected to expand Medicaid as part of federal healthcare reform legislation. If Medicaid reimbursement rates are reduced or fail to increase as quickly as our costs, or if there are changes in the rules governing the Medicaid program that are disadvantageous to our businesses, our business and results of operations could be materially and adversely affected.

Recent federal government proposals could limit the states' use of provider tax programs to generate revenue for their Medicaid expenditures, which could result in a reduction in our reimbursement rates under Medicaid.

To generate funds to pay for the increasing costs of the Medicaid program, many states utilize financial arrangements commonly referred to as "provider taxes." Under provider tax arrangements, states collect taxes from healthcare providers and then use the revenue to pay the providers as a Medicaid expenditure, which allows the states to then claim additional federal matching funds on the additional reimbursements. Current federal law provides for a cap on the maximum allowable provider tax as a percentage of the provider's total revenue. There can be no assurance that federal law will continue to provide matching federal funds on state Medicaid expenditures funded through provider taxes, or that the current caps on provider taxes will not be reduced. Any discontinuance or reduction in federal matching of provider tax-related Medicaid expenditures could have a significant and adverse effect on states' Medicaid expenditures, and as a result could have a material and adverse effect on our financial condition and results of operations.

Revenue we receive from Medicare and Medicaid is subject to potential retroactive reduction or repayment.

Payments we receive from Medicare and Medicaid can be retroactively adjusted after examination during the claims settlement process or as a result of post-payment audits. Payors may disallow our requests for reimbursement, or recoup amounts previously reimbursed, based on determinations by the payors or their third-party audit contractors that certain costs are not reimbursable because either adequate or additional documentation was not provided or because certain services were not covered or deemed to not be medically necessary. Significant adjustments, recoupments or repayments of our Medicare or Medicaid revenue, and the costs associated with complying with investigative audits by regulatory and governmental authorities, could adversely affect our financial condition and results of operations.

Additionally, from time to time we become aware, either based on information provided by third parties and/or the results of internal audits, of payments from payor sources that were either wholly or partially in excess of the amount that we should have been paid for the service provided. Overpayments may result from a variety of factors, including insufficient documentation supporting the services rendered or medical necessity of the services, other failures to document the satisfaction of the necessary conditions of payment, or in some cases for providing services that are deemed to be worthless. We are required by law in most instances to refund the full amount of the overpayment after becoming aware of it, and failure to do so within requisite time limits imposed by the law could lead to significant fines and penalties being imposed on us. Furthermore, our initial billing of and payments for services that are unsupported by the requisite documentation and satisfaction of any other conditions of payment, regardless of our awareness of the failure at the time of the billing or payment, could expose us to significant fines and penalties, including pursuant to the Federal False Claims Act ("FFCA") and the Federal Civil Monetary Penalties Law ("FCMPL"). Violations of the FFCA could lead to any combination of a variety of criminal, civil and administrative fines and penalties. The FFCA provides for civil fines ranging from $5,500 to $11,000 per claim plus treble

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damages. The Civil Monetary Penalties Law similarly provides for civil monetary penalties of up to $10,000 per claim plus up to treble damages. We and/or certain of our operating companies could also be subject to exclusion from participation in the Medicare or Medicaid programs in some circumstances as well, in addition to any monetary or other fines, penalties or sanctions that we may incur under applicable federal and/or state law. Our repayment of any such amounts, as well as any fines, penalties or other sanctions that we may incur, could be significant and could have a material and adverse effect on our results of operations and financial condition.

From time to time we are also involved in various external governmental investigations, audits and reviews. Reviews, audits and investigations of this sort can lead to government actions, which can result in the assessment of damages, civil or criminal fines or penalties, or other sanctions, including restrictions or changes in the way we conduct business, loss of licensure or exclusion from participation in government programs. For example, the Office of the Inspector General (“OIG”) conducts a variety of routine, regular and special investigations, audits and reviews across our industry. Failure to comply with applicable laws, regulations and rules could have a material and adverse effect on our results of operations and financial condition. Furthermore, becoming subject to these governmental investigations, audits and reviews can also require us to incur significant legal and document production expenses as we cooperate with the government authorities, regardless of whether the particular investigation, audit or review leads to the identification of underlying issues.

Our success is dependent upon retaining key personnel.

Our senior management team has extensive experience in the healthcare industry. We believe that they have been instrumental in guiding our businesses, instituting valuable performance and quality monitoring, and driving innovation. Accordingly, our future performance is substantially dependent upon the continued services of our senior management team. The loss of the services of any of these persons could have a material adverse effect upon us.

As previously disclosed, Boyd W. Hendrickson, our Chairman of the Board and Chief Executive Officer, has informed the Board of Directors of his desire to retire from his role as Chief Executive Officer around the end of 2013. If we are unable to find a suitable successor to Mr. Hendrickson, we may not be able to successfully manage our business. During the second quarter of 2013, we also eliminated/consolidated certain management positions in an effort to streamline our leadership and reduce labor costs. We incurred approximately $1.7 million in severance costs as a result of these actions, which we do not anticipate will continue in future periods. However, any additional restructuring efforts could result in significant severance-related costs, and lead to difficulty in retaining and attracting talented management.

Health reform legislation could adversely affect our revenue and financial condition.

In recent years, there have been numerous initiatives on the federal and state levels for comprehensive reforms affecting the payment for, the availability of and reimbursement for, healthcare services in the United States. These initiatives have ranged from proposals to fundamentally change federal and state healthcare reimbursement programs, including the provision of comprehensive healthcare coverage to the public under governmental funded programs, to minor modifications to existing programs. The PPACA was enacted in 2010 and is among the most comprehensive and notable of these legislative efforts. The impact of PPACA remains uncertain to a large degree due to various implementation, timing, cost and regulatory requirements imposed by the legislation. The content or timing of any future health reform legislation, and its impact on us is impossible to predict. However, it is likely that certain provisions in PPACA will impose significant costs on us or that will otherwise negatively affect our operations. For instance, the requirement to offer full time employees “affordable” healthcare insurance that meets specified coverage minimums (or alternatively pay a per-employee penalty to the federal government) will likely significantly increase our annual healthcare costs or could damage employee morale and/or cause other employee-related issues that are harmful to our operations. If significant reforms are made to the U.S. healthcare system, those reforms may have an adverse effect on our financial condition and results of operations.

In addition, we incur considerable administrative costs in monitoring the changes made within the various reimbursement programs in which we participate, determining the appropriate actions to be taken in response to those changes, and implementing the required actions to meet the new requirements and minimize the repercussions of the changes to our organization, reimbursement rates and costs

Annual caps that limit the amounts that can be paid for outpatient therapy services rendered to any Medicare beneficiary may negatively affect our results of operations.

Some of our rehabilitation therapy revenue is paid by the Medicare Part B program under a fee schedule. There are annual caps that limit, subject to certain exceptions, the amounts that can be paid (including deductible and coinsurance amounts) for rehabilitation therapy services rendered to any Medicare beneficiary under Medicare Part B. There is a combined cap for physical therapy and speech-language pathology and a separate cap for occupational therapy that apply subject to certain exceptions. The discontinuation or change in the current cap exception process or future modifications of the Medicare Part B cap structure could have an adverse effect on the revenue that we generate through our rehabilitation therapy business. This could in turn have a negative effect on our financial condition and results of operations. For example, the Medicare Part B

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therapy pre-approval provisions (MMR) and multiple procedure payment reduction ("MPPR") rate reductions that took effect October 1, 2012, have continued to negatively impact our therapy business through the end of 2013.

The MMR requirement generally provides that, on a per beneficiary basis and subject to limited exceptions, services above $3,700 for physical therapy and speech-language pathology services combined and/or $3,700 for occupational therapy services are subject to manual medical review (typically on a pre-payment basis) by the applicable Medicare contractors. Challenges in obtaining a timely response from the applicable contractors and other difficulties with the MMR system have added significant uncertainty as to whether beneficiary will have access to the applicable therapy services that are over the cap amount, and whether the provider will be reimbursed for those services. Under the MPPR policy, when physical therapy, occupational therapy and speech-language pathology services are performed on the same day for the same patient and paid under Medicare Part B, then Medicare effectively makes a full reimbursement payment for only one of the procedures and the reimbursements for the other procedures are at a reduced rate. The application of the MPPR policy has negatively affected our therapy business and will continue to do so as long as the policy is in effect.

We are subject to a Medicare cap amount for our hospice business. Our net patient service revenue and profitability could be adversely affected by limitations on Medicare payments.

Overall payments made by Medicare to us on a per hospice basis are subject to an annual cap amount. Total Medicare payments received for services rendered during the applicable Medicare hospice cap year by each of our Medicare-certified hospice programs during this period are compared to the cap amount for the relevant period. Payments in excess of the cap are subject to recoupment by Medicare.

We monitor the Medicare cap amount and seek to implement corrective measures as necessary. We maintain what we believe are adequate allowances in the event that our individual hospice agencies exceed the Medicare hospice cap in any given fiscal year. However, many of the variables involved in estimating the Medicare hospice cap contractual adjustment are beyond our control, and we cannot assure you that we will not increase or decrease our estimated contractual allowance in the future, or that we will not be required to surrender amounts we received from Medicare that were in excess of the Medicare hospice cap for any particular period(s).

For the nine months ended September 30, 2013 we recorded hospice Medicare cap adjustment of $3.4 million compared to $4.2 million for the nine months ended September 30, 2012. Of the $3.4 million, $0.9 million was related to the 2013 cap year, $2.3 million was related to the 2012 cap year, and $0.2 million was related to the 2011 cap year. Of the $4.2 million recorded in the nine months ended September 30, 2012, $2.4 million was related to the 2012 cap year and $1.8 million was related to the 2011 cap year. This adjustment related primarily to patients staying on service longer than estimated which results in the patients' cap allowances being stretched over multiple cap years. Our ability to comply with the cap limitation depends on a number of factors relating to a given hospice program, including number of admissions, average length of stay, mix in level of care and Medicare patients that transfer into and out of our hospice programs. Our revenue and profitability may be materially reduced if we are unable to comply with this and other Medicare payment limitations. We cannot assure you that our hospice programs will not exceed the cap amount in the future or that our estimate of the Medicare cap contractual adjustment will not differ materially from the actual Medicare cap amount.

We are subject to extensive and complex laws and government regulations. If we are not operating in compliance with these laws and regulations or if these laws and regulations change, we could be required to make significant expenditures or change our operations in order to bring our facilities and operations into compliance.

We, along with other companies in the healthcare industry, are required to comply with extensive and complex laws and regulations at the federal, state and local government levels relating to, among other things:


•	licensure and certification;


•	adequacy and quality of healthcare services;


•	qualifications of healthcare and support personnel;


•	quality of medical equipment;


•	confidentiality, maintenance and security issues associated with medical records and claims processing;


•	relationships with physicians and other referral sources and recipients;


•	constraints on protective contractual provisions with patients and third-party payors;


•	operating policies and procedures;


•	addition of facilities and services; and


•	billing for services.

Many of these laws and regulations are expansive, and we do not always have the benefit of significant regulatory or judicial interpretation of these laws and regulations. In addition, many of these laws and regulations evolve to include additional obligations and restrictions, and sometimes with retroactive effect. Certain other regulatory developments, such as revisions in the building code requirements for assisted living and skilled nursing facilities, mandatory increases in scope and

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quality of care to be offered to residents, revisions in licensing and certification standards, mandatory staffing levels, regulations regarding conditions for payment and regulations restricting those we can hire, could also have a material adverse effect on us. In the future, different interpretations or enforcement of these laws and regulations could subject our current or past practices to allegations of impropriety or illegality or could require us to make changes in our facilities, equipment, personnel, services, capital expenditure programs and operating expenses.

One development potentially restricting those we may hire was a decision on November 3, 2010 by the Physical Therapy Board of California ("PT Board") to rescind a 1990 PT Board resolution which determined that the offering of physical therapy services by a corporation, not organized as a professional corporation, was permitted by the Physical Therapy Practice Act, which is the California statute governing the provision of physical therapy within the state. This rescission purports to prohibit employment of a physical therapist to provide physical therapy services by any professional corporation except those owned by physical therapists and Naturopaths. Lay corporations that hold themselves out as physical therapy corporations would be similarly prohibited. We have a subsidiary that employs physical therapists in California, but is not owned by physical therapists. Our subsidiary contracts with nursing facilities to provide the facilities with personnel who are licensed to provide rehabilitation therapy services, including physical therapy, occupational therapy and/or speech language pathology services. Our therapists then provide rehabilitation therapy services to the nursing facilities' patients under the skilled nursing facilities' licenses that authorize the provision of physical therapy (and other rehabilitation therapy services, if applicable). In this relationship, the nursing facilities retain the patient relationship, remain professionally responsible for the healthcare services including therapy, and bill the patient and/or third party payors for the services rendered to their patients. We are unaware of any enforcement actions by the PT Board to date and it is not clear whether the applicable law would ultimately be interpreted to mean that our rehabilitation therapy subsidiary cannot employ and provide physical therapists to nursing facilities in California as it currently does. Nevertheless, the PT Board could seek an enforcement action against our rehabilitation therapy subsidiary and its physical therapist employees and we may have to significantly restructure our California rehabilitation therapy operations to conform to the PT Board's revised interpretation of the law.

In addition, federal and state government agencies have increased and coordinated civil and criminal enforcement efforts as part of numerous ongoing investigations of healthcare companies, including skilled nursing facilities, home health agencies and hospice agencies. This includes investigations of:


•	fraud and abuse;


•	quality of care;


•	financial relationships with referral sources; and


•	the medical necessity of services provided.

We are unable to predict the future course of federal, state and local regulation or legislation, including Medicare and Medicaid statutes and regulations, the intensity of federal and state enforcement actions or the extent and size of any potential sanctions, fines or penalties. Changes in the regulatory framework, our failure to obtain or renew required regulatory approvals or licenses or to comply with applicable regulatory requirements, the suspension or revocation of our licenses or our disqualification from participation in federal and state reimbursement programs, or the imposition of other enforcement sanctions, fines or penalties could have a material adverse effect upon our results of operations, financial condition and liquidity. Furthermore, should we lose licenses or certifications for a number of our facilities or other businesses as a result of regulatory action, legal proceedings such as those described in Note 7, "Commitments and Contingencies-Legal Matters," or otherwise, we could be deemed to be in default under some of our agreements, including agreements governing outstanding indebtedness and the report of such issues at one of our facilities could harm our reputation for quality care and lead to a reduction in our patient referrals and ultimately our revenue and operating income.

We face reviews, audits and investigations under federal and state government programs and contracts. These audits could have adverse findings that may negatively affect our business.

As a result of our participation in the Medicare and Medicaid programs, we are subject to various governmental inspections, reviews, audits and investigations to verify our compliance with these programs and applicable laws and regulations. Managed care payors may also reserve the right to conduct audits. We also periodically conduct internal audits and reviews of our regulatory compliance. An adverse inspection, review, audit or investigation could result in:


•	refunding amounts we have been paid pursuant to the Medicare or Medicaid programs or from managed care payors;


•	state or federal agencies imposing fines, penalties and other sanctions on us;


•	temporary suspension of payment for new patients to the facility or agency;


•	decertification or exclusion from participation in the Medicare or Medicaid programs or one or more managed care payor networks;


•	self-disclosure of violations to applicable regulatory authorities;


•	damage to our reputation;

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•	the revocation of a facility's or agency's license; and


•	loss of certain rights under, or termination of, our contracts with managed care payors.

We have in the past and will likely in the future be required to refund amounts we have been paid and/or pay fines and penalties, as a result of these inspections, reviews, audits and investigations. If adverse inspections, reviews, audits or investigations occur and any of the results noted above occur, it could have a material adverse effect on our business and operating results. Furthermore, the legal, document production and other costs associated with complying with these inspections, reviews, audits or investigations could be significant.

Significant legal actions, which are commonplace in our professions, could subject us to increased operating costs and substantial uninsured liabilities, which would materially and adversely affect our results of operations, liquidity and financial condition.

The long-term care profession has experienced an increasing trend in the number and severity of litigation claims involving punitive damages and settlements. We believe that this trend is endemic to the industry and is a result of a variety of factors, including the number of large judgments, including large punitive damage awards, against long-term care providers in recent years resulting in an increased awareness by plaintiffs' lawyers of potentially large recoveries. While some states have enacted tort reform legislation that limits plaintiffs' recoveries in some respects, should our professional liability and general liability increase significantly in the future, we may not be able to increase our revenue sufficiently to cover the cost increases, our operating income could suffer, and we may not be able to meet our obligations to repay our liabilities. For a discussion of recent litigation claims against us, including the Humboldt County Action, see Note 7, "Commitments and Contingencies-Legal Matters" in the notes to the consolidated financial statements included elsewhere in this report.

We also may be subject to lawsuits under the FFCA and comparable state laws for submitting allegedly fraudulent or otherwise inappropriate bills for services to the Medicare and Medicaid programs. These lawsuits, which may be initiated by regulatory authorities as well as private party whistleblowers, can involve significant monetary damages, fines, attorney fees and the award of bounties to private plaintiffs who successfully bring these suits, as well as to the government programs. In recent years, government oversight and law enforcement have become increasingly active and aggressive in investigating and taking legal action against potential fraud and abuse.

We may incur significant liabilities in conjunction with legal actions against us, including as a result of damages, fines and penalties that may be assessed against us, as well as a result of the sometimes significant commitments of financial and management resources that are often required to defend against such legal actions. The incurrence of such liabilities and related commitments of resources could materially and adversely affect our business, financial condition and results of operations.

We could face significant financial difficulties as a result of one or more of the risks discussed in this report, which could cause us to significantly alter our business and/or seek protection under bankruptcy laws or could cause our creditors or government authorities to have a receiver appointed on our behalf.

We could face significant financial difficulties if Medicare or Medicaid reimbursement rates are reduced, patient demand for our services is reduced or we incur unexpected liabilities or expenses, including in connection with legal actions, sanctions, penalties or fines or the other risks discussed in this report. This financial difficulty could cause us to significantly alter our business and/or seek protection under bankruptcy laws or could cause our creditors or government authorities to have a receiver appointed on our behalf.

A significant portion of our business is concentrated in certain geographical markets, and an economic downturn or changes in the laws affecting our business in those markets could have a material adverse effect on our operating results.

For the nine months ended September 30, 2013, we received approximately 40.9% of our consolidated revenue from operations in California and 20.2% from Texas. We expect to continue to receive significant portions of our consolidated revenue from those states in the future as well. Accordingly, economic conditions and changes in state healthcare spending prevailing in either of these markets or other markets in which we have significant concentrations could affect the ability of our patients and third-party payors to reimburse us for our services, either through a reduction of the tax base used to generate state funding of Medicaid programs, an increase in the number of indigent patients eligible for Medicaid benefits, changes in state funding levels or healthcare programs or other factors. A continued or prolonged economic downturn, significant changes in state healthcare spending, or changes in the laws affecting our business in these markets could have a material adverse effect on our financial position, results of operations and cash flows.

Failure to maintain effective internal control over our financial reporting could have an adverse effect on our ability to report our financial results on a timely and accurate basis.

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We produce our consolidated financial statements in accordance with the requirements of accounting principles generally accepted in the United States of America ("U.S. GAAP"). Effective internal control over financial reporting is necessary for us to provide reliable financial reports, to help mitigate the risk of fraud and to operate successfully. We are required by federal securities laws to document and test our internal control procedures in order to satisfy the requirements of the Sarbanes-Oxley Act of 2002, which requires annual management assessments of the effectiveness of our internal control over financial reporting.

Testing and maintaining our internal control over financial reporting can be expensive and divert our management's attention from other matters that are important to our business. We may not be able to conclude on an ongoing basis that we have effective internal control over financial reporting in accordance with applicable law, or our independent registered public accounting firm may not be able or willing to issue an unqualified attestation report if we conclude that our internal control over financial reporting is not effective. If we fail to maintain effective internal control over financial reporting, or our independent registered public accounting firm is unable to provide us with an unqualified attestation report on our internal control, we could be required to take costly and time-consuming corrective measures, be required to restate the affected historical financial statements, be subjected to investigations and/or sanctions by federal and state securities regulators, and be subjected to civil lawsuits by security holders. Any of the foregoing could also cause investors to lose confidence in our reported financial information and in our company and would likely result in a decline in the market price of our stock and in our ability to raise additional financing if needed in the future.

Changes in the acuity mix of patients as well as payor mix and payment methodologies may significantly reduce our profitability or cause us to incur losses.

Our revenue is affected by our ability to attract a favorable patient acuity mix, and by our mix of payment sources. Changes in the type of patients we attract, as well as our payor mix among private payors, managed care companies, Medicare (both traditional Medicare and "managed" Medicare/Medicare Advantage) and Medicaid, significantly affect our profitability because not all payors reimburse us at the same rates. Particularly, if we fail to maintain our proportion of high-acuity patients or if there is any significant increase in the percentage of our population for which we receive Medicaid reimbursement, our financial position, results of operations and cash flow may be adversely affected. Furthermore, in recent periods we have continued to see a shift from “traditional” fee-for-service Medicare patients to “managed” Medicare (Medicare Advantage) patients. Reimbursement rates are generally lower for services provided to Medicare Advantage patients than they are for the same services provided traditional fee-for-service Medicare patients. This trend may continue in future periods. Our financial results have been negatively affected by this shift to date. Our financial results will continue to be negatively affected if the trend towards Medicare Advantage continues, and particularly if it accelerates.

It can be difficult to attract and retain qualified nurses, therapists, healthcare professionals and other key personnel, which can increase our costs related to these employees

Our employees are our most important asset. We rely on our ability to attract and retain qualified nurses, therapists and other healthcare professionals. The market for these key personnel is highly competitive, and we could experience significant increases in our operating costs due to shortages in their availability. Like other healthcare providers, we have at times experienced difficulties in attracting and retaining qualified personnel, especially facility administrators, nurses, therapists, certified nurses' aides and other important healthcare personnel. We may continue to experience increases in our labor costs, primarily due to higher wages and greater benefits required to attract and retain qualified healthcare personnel, and such increases may adversely affect our profitability. Furthermore, while we attempt to manage overall labor costs in the most efficient way, our efforts to them through wage freezes and similar means may have limited effectiveness and may lead to increased turnover and other challenges

Tight labor markets and high demand for such employees can contribute to high turnover among clinical professional staff. A shortage of qualified personnel at a facility could result in significant increases in labor costs and increased reliance on overtime and expensive temporary staffing agencies, and could otherwise adversely affect operations at the affected facilities. If we are unable to attract and retain qualified professionals, our ability to adequately provide services to our residents and patients may decline and our ability to grow may be constrained.

If we are unable to comply with state minimum staffing requirements at one or more of our facilities, we could be subject to fines or other sanctions.

Increased attention to the quality of care provided in skilled nursing facilities has caused several states to mandate, and other states to consider mandating, staffing laws that require minimum nursing hours of direct care per resident per day. These minimum staffing requirements further increase the gap between demand for and supply of qualified professionals, and lead to higher labor costs.

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We operate a number of facilities in California, which enacted legislation aimed at establishing minimum staffing requirements for facilities operating in that state. This legislation required that the California Department of Public Health ("DPH"), promulgate regulations requiring each skilled nursing facility to provide a minimum of 3.2 nursing hours per patient day. The DPH finalized regulations in 2009 that required three 8-hour shifts for nurse-to-patient staffing, described documentation and notice requirements, and specified procedures for obtaining a waiver from per-shift staffing requirements at skilled nursing facilities. Although DPH finalized the regulations, initial implementation of the statute authorizing the regulations is contingent on an appropriation in the state's annual budged legislation or another statute. Because no appropriation was made and no additional statutes were enacted, the regulations did not become operational. Therefore, DPH will continue its practice of determining a facility's compliance with the 3.2 hour of nursing services per patient day measure in accordance with its internal policy and through on-site reviews conducted during periodic licensing and certification surveys and in response to complaints. If the DPH determines that a facility is out of compliance with this staffing measure, the DPH may issue a notice of deficiency, or a citation, depending on the impact on patient care. A citation carries with it the imposition of significant monetary fines. DPH has issued guidelines, implementing the provisions of newly enacted California laws, for state audits that verify compliance with the 3.2 nursing hours per patient day staffing requirements. If DPH determines under an audit that a facility has failed to meet the minimum staffing requirement for between 5% and 49% of the audited days, a significant administrative monetary penalty will be assessed. If DPH determines that a facility has failed to meet the minimum staffing requirement for more than 49% of the audited days, then a larger administrative monetary penalty will be assessed. The issuance of either a notice of deficiency or a citation requires the facility to prepare and implement an acceptable plan of correction. The Humboldt County Action included allegations that certain of our California skilled nursing facilities failed to meet state-mandated minimum staffing requirements. The Humboldt County Action resulted in a jury verdict against us and certain of our affiliated skilled nursing companies that awarded $677 million in damages. The case was ultimately settled in September 2010, pursuant to which we were required to deposit into escrow a total of $50 million to cover certain settlement costs. For more information regarding the Humboldt County Action and the settlement, as well as a description of our February 2013 settlement with the BMFEA which included a new staffing agreement and an ongoing investigation by the DOJ regarding related staffing considerations, see Note 7, "Commitments and Contingencies-Legal Matters" in the notes to the consolidated financial statements included elsewhere in this report.

Our ability to satisfy any minimum staffing requirements depends upon our ability to attract and retain qualified healthcare professionals, including nurses, certified nurse's assistants and other personnel. Attracting and retaining this personnel is difficult, given a tight labor market for these professionals in many of the markets in which we operate. Furthermore, if states do not appropriate additional funds (through Medicaid program appropriations or otherwise) sufficient to pay for any additional operating costs resulting from minimum staffing requirements, our profitability may be materially adversely affected.

If we fail to attract patients and residents and to compete effectively with other healthcare providers, our revenue and profitability may decline and we may incur losses.

The healthcare services industry is highly competitive. Our skilled nursing facilities compete primarily on a local and regional basis with many long-term care providers, from national and regional chains to smaller providers owning as few as a single nursing center. We also compete under certain circumstances with inpatient rehabilitation facilities and long-term acute care hospitals. Our hospices and home health agencies also compete with local, regional and national companies. We anticipate additional competition in the future from accountable care organizations, as well as HMO's and similar healthcare systems that seek to provide a wider variety of healthcare services to their patients/members. Increased competition could limit our ability to attract and retain patients, maintain or increase rates and occupancy, or to expand our business. Our ability to compete successfully varies from location to location and depends on a number of factors, including the number of competitors in the local market, the types of services available, our local reputation for quality care of patients, achieve or maintain desired census levels, the commitment and expertise of our staff and physicians, our local service offerings and treatment programs, the cost of care in each locality, and the physical appearance, location, age and condition of our facilities. If we are unable to attract patients to our facilities and agencies, particularly high-acuity patients, then our revenue and profitability will be adversely affected. Some of our competitors may have greater recognition and be more established in their respective communities than we are, and may have greater financial and other resources than we have. Competing long-term care companies may also offer newer facilities or different programs or services than we do, which, combined with the foregoing factors, may result in our competitors being more attractive to our current patients, to potential patients and to referral sources. Furthermore, while we budget for routine capital expenditures at our facilities to keep them competitive in their respective markets, to the extent that competitive forces cause those expenditures to increase in the future our financial condition may be negatively affected.

Some of our competitors may accept lower profit margins than we do, which could present significant price competition, particularly for managed care and private pay patients. We believe we utilize a conservative approach in complying with laws prohibiting kickbacks and referral payments to referral sources. However, some of our competitors may use more aggressive methods than we do with this respect to obtaining patient referrals, and as a result competitors may from time to time obtain patient referrals that are not otherwise available to us.

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The primary competitive factors for our assisted living, rehabilitation therapy, hospice and home health care services are similar to those for our skilled nursing businesses and include reputation, the cost of services, the quality of services, responsiveness to patient/resident needs and the ability to provide support in other areas such as third-party reimbursement, information management and patient recordkeeping. Furthermore, given the relatively low barriers to entry and continuing healthcare cost containment pressures, we expect that the markets we service will become increasingly competitive in the future. Increased competition in the future could limit our ability to attract and retain patients and residents, maintain or increase our fees, or expand our business.

Insurance coverage may become increasingly expensive and difficult to obtain for health care companies, and our self-insurance may expose us to significant losses.

It may become more difficult and costly for us to obtain coverage for patient care liabilities and certain other risks, including property and casualty insurance. Insurance carriers may require health care companies to significantly increase their self-insured retention levels and/or pay substantially higher premiums for reduced coverage for most insurance coverages, including workers' compensation, employee healthcare and patient care liability.

We self-insure a significant portion of our potential liabilities for several risks, including certain types of professional and general liability, workers' compensation and employee healthcare benefits. Due to our self-insured retentions under many of our professional and general liability, workers' compensation and employee healthcare benefits programs, including our election to self-insure against workers' compensation claims in Texas, there is no limit on the maximum number of claims or amount for which we can be liable in any policy period. We base our loss estimates and related accruals on actuarial analyses, which determine expected liabilities on an undiscounted basis, including incurred but not reported losses, based upon the available information on a given date. It is possible, however, for the ultimate amount of losses to exceed our estimates and related accruals, as well as our insurance limits as applicable. In the event our actual liability exceeds our estimates for any given period, our results of operations and financial condition could be materially adversely impacted. Additionally, we may from time to time need to increase our accruals as a result of future actuarial reviews and claims that may develop. Such increases could have an adverse impact on our business and results of operations. An adverse determination in legal proceedings, whether currently asserted or arising in the future, could have a material adverse effect on our business and results of operations.

If our referral sources fail to view us as an attractive health care provider, our patient base would likely decrease.

We rely significantly on appropriate referrals from physicians, hospitals and other healthcare providers in the communities in which we deliver our services to attract the kinds of patients we target. Our referral sources are not obligated to refer business to us and generally also refer business to other healthcare providers. We believe many of our referral sources refer business to us as a result of the quality of our patient service and our efforts to establish and build a relationship with them. If we lose, or fail to maintain, existing relationships with our referral resources, fail to develop new relationships or if we are perceived by our referral sources for any reason as not providing high quality patient care, our volume of referrals would likely decrease, the quality of our patient mix could suffer and our revenue and results of operations could be adversely affected.

If we do not achieve or maintain a reputation for providing high quality of care, our business may be negatively affected.

Our ability to achieve and maintain a reputation for providing high quality of care to our patients at each of our skilled nursing and assisted living facilities, or through our rehabilitation therapy, hospice and home health businesses, is important to our ability to attract and retain patients, particularly high-acuity patients. In some instances, our referral sources are affiliated with health care systems that may have affiliated businesses that offer services that compete with ours, and the frequency of this occurring may increase in the future as accountable care organizations are formed in the markets we serve. We believe that the perception of our quality of care by a potential patient or potential patient's family seeking to contract for our services is influenced by a variety of factors, including doctor and other healthcare professional referrals, community information and referral services, newspapers and other print and electronic media, results of patient surveys, recommendations from family and friends, and quality care statistics or rating systems compiled and published by CMS or other industry data. Through our focus on retaining high quality staffing, reviewing feedback and surveys from our patients and referral sources to highlight areas of improvement and integrating our service offerings at each of our facilities, we seek to maintain and improve on the outcomes from each of the factors listed above in order to build and maintain a strong reputation at our facilities. If any of our companies fail to achieve or maintain a reputation for providing high-quality care, or is perceived to provide a lower quality of care than competitors within the same geographic area, our ability to attract and retain patients would be adversely affected. If our businesses fail to maintain a strong reputation in the areas in which we operate, our business, revenue and profitability could be adversely affected.

We may be unable to reduce costs to offset decreases in our patient census levels or other expenses completely.

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We depend on implementing adequate cost management initiatives in response to fluctuations in levels of patient census in our businesses in order to maintain our current cash flow and earnings levels. Fluctuation in our patient census levels may become more common as we continue our emphasis in our skilled nursing facilities on patients with shorter stays but higher acuities. A decline in patient census levels would likely result in decreased revenue. If we are unable to put in place corresponding reductions in costs in response to decreases in our patient census or other revenue shortfalls, our financial condition and operating results could be adversely affected.

We may not be fully reimbursed for all services that our skilled nursing facilities are able to bill through Medicare's consolidated billing requirements.

Skilled nursing facilities are required to bill Medicare on a consolidated basis for certain items and services that they furnish to patients and residents, regardless of the amount or costs of services that the patients and residents actually receive. The consolidated billing requirement essentially confers on the skilled nursing facility itself the Medicare billing responsibility for the entire package of care that its residents receive in these situations. Federal law also requires that post-hospitalization skilled nursing services be “bundled” into the hospital's Diagnostic Related Group ("DRG") payment in certain circumstances. Where this rule applies, the hospital and the skilled nursing facility must, in effect, divide the payment which otherwise would have been paid to the hospital alone for the patient's treatment, and no additional funds are paid by Medicare for skilled nursing care of the patient. This requirement may, in instances where it is applicable, have a negative effect on skilled nursing facility utilization/census and payments, either because hospitals may find it difficult to place patients in skilled nursing facilities which will not be paid as they previously were, or because hospitals are reluctant to discharge patients to skilled nursing facilities and lose a portion of the payment that the hospital would otherwise receive. This bundling requirement could be extended to more DRGs in the future, which could exacerbate the potentially negative impact on skilled nursing facility utilization/census and payments. As a result of the bundling requirements we may not be fully reimbursed for all services that a facility bills through consolidated billing, which could adversely affect our results of operations and financial condition.

Consolidation of managed care organizations and other third-party payors or reductions in reimbursement from these payors may adversely affect our revenue and income or cause us to incur losses.

Managed care organizations and other third-party payors have in many instances consolidated in order to enhance their ability to influence the delivery of healthcare services. Consequently, the healthcare needs of a large percentage of the United States population are increasingly served by a small number of managed care organizations. These organizations generally enter into service agreements with a limited number of providers for needed services. These organizations have become an increasingly important source of revenue and referrals for us. To the extent that such organizations terminate us as a preferred provider or engage our competitors as a preferred or exclusive provider, our business could be materially adversely affected.

In addition, private third-party payors, including managed care payors, are continuing their efforts to control healthcare costs through direct contracts with healthcare providers, increased utilization reviews, or reviews of the propriety of, and charges for, services provided, and greater enrollment in managed care programs and preferred provider organizations. As these private payors increase their purchasing power, they are demanding discounted fee structures and the assumption by healthcare providers of all or a portion of the financial risk associated with the provision of care. Significant reductions in reimbursement from these sources could materially adversely affect our business and financial condition.

Delays in reimbursement may cause liquidity problems.

If we have information systems problems or payment or other issues arise with Medicare, Medicaid or other payors that affect the amount or timeliness of reimbursements, we may encounter delays in our payment cycle. Any significant payment timing delay could cause us to experience working capital shortages. As a result, working capital management, including prompt and diligent billing and collection, is an important factor in our consolidated results of operations and liquidity. Our working capital management procedures may not successfully mitigate the effects of any delays in our receipt of payments or reimbursements. Accordingly, such delays could have an adverse effect on our liquidity and financial condition.

Our rehabilitation and other related healthcare services are also subject to delays in reimbursement, as we act as vendors to other providers who in turn must wait for reimbursement from other third-party payors. Each of these customers is therefore subject to the same potential delays to which our nursing homes are subject, meaning any such delays would further delay the date we would receive payment for the provision of our related healthcare services. To the extent we grow and expand the rehabilitation and other complementary services that we offer to third parties, we may incur increasing delays in payment for these services, and these payment delays could have an adverse effect on our liquidity and financial condition. We may also experience delays in reimbursement related to change of ownership applications for our acquired facilities, as well as changes in fiscal intermediaries.

Future acquisitions may use significant resources, may be unsuccessful and could expose us to unforeseen liabilities.

We intend to selectively pursue acquisitions of skilled nursing facilities, assisted living facilities, home health companies, hospice agencies and other related healthcare operations. Acquisitions may involve significant cash expenditures,

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debt incurrence, operating losses and additional expenses that could have a material adverse effect on our financial position, results of operations and liquidity. Acquisitions involve numerous risks, including:


•	difficulties integrating acquired operations, personnel and accounting and information systems, or in realizing projected efficiencies and cost savings;


•	diversion of management's attention from other business concerns;


•	potential loss of key employees or customers of acquired companies;


•	entry into markets in which we may have limited or no experience;


•	increasing our indebtedness and limiting our ability to access additional capital when needed;


•	assumption of unknown liabilities or regulatory issues of acquired companies, including failure to comply with healthcare regulations or to establish internal financial controls; and


•	straining of our resources, including internal controls relating to information and accounting systems, regulatory compliance, logistics and others.

Furthermore, certain of the foregoing risks could be exacerbated when combined with other growth measures that we may pursue.

Global economic conditions may impact our ability to obtain additional financing on commercially reasonable terms or at all and our ability to expand our business may be harmed.

Recent global market and economic conditions have been very challenging with tight credit conditions and slow or negative economic growth in most major economies generally expected to continue in 2013 and possibly beyond. Ongoing concerns about the systemic impact of potential long-term and widespread economic recession or stagnation, energy costs, geopolitical issues, sovereign debt issues, the availability and cost of credit, and the global real estate and mortgage markets have contributed to increased market volatility, uncertainty and liquidity issues for both borrowers and investors. These conditions, combined with volatile prices for energy, food and other commodities, unstable business and consumer confidence, and significant unemployment, have contributed to pronounced economic volatility.

As a result of these market conditions, the cost and availability of credit has been and may continue to be adversely affected by illiquid credit markets, interest rate fluctuations and wider credit spreads. Concern about the stability of the markets generally and the strength of counterparties specifically has led many lenders and institutional investors to reduce, and in some cases, cease to provide credit to businesses and consumers. These factors have led to a decrease in spending by businesses and consumers alike, and a corresponding decrease in global infrastructure spending. Continued turbulence in the U.S. and international markets and economies and prolonged declines or stagnation in business and consumer spending may adversely affect our liquidity and financial condition, and the liquidity and financial condition of our customers, including our ability to refinance maturing liabilities and access the capital markets to meet liquidity needs. If we are not able to timely retire or refinance our senior secured credit facility on acceptable terms at or before its stated maturity in April 2015 (for the revolving portion) and April 2016 (for the term portion), due to market conditions or otherwise, our liquidity, financial condition, business and operating results could be materially and adversely affected.

If our ability to borrow under our senior secured credit facility is insufficient for our capital requirements, we will be required to seek additional sources of financing, including issuing equity, which may be dilutive to our current stockholders or incurring additional debt. Our ability to incur additional debt is subject to the restrictions in our senior secured credit facility. There can be no assurance that the restrictions contained in our senior secured credit facility will permit us to borrow the funds that we need to finance our operations, or that additional debt will be available to us on commercially reasonable terms or at all. Furthermore, market conditions may impede our ability to secure additional sources of financing, whether through the extension of our existing senior secured credit facility or by accessing the debt and/or equity markets. If we are unable to obtain funds sufficient to finance our capital requirements, we may have to forego opportunities to expand our business, including the acquisition or development of additional or expanded facilities.

Our substantial indebtedness could adversely affect our financial health and prevent us from fulfilling our financial obligations.

We have now and will for the foreseeable future continue to have a significant amount of indebtedness. At September 30, 2013, our total indebtedness was approximately $434.8 million. Our substantial indebtedness could have important consequences. For example, it could:


•	increase our vulnerability to adverse economic and industry conditions;


•	require us to dedicate a substantial portion of our cash flow from operations to payments on our indebtedness, thereby reducing the availability of our cash flow to fund working capital, capital expenditures and other general corporate purposes;


•	limit our flexibility in planning for, or reacting to, changes in our business and the industry in which we operate;


•	place us at a competitive disadvantage compared to our competitors that have less debt;

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•	increase the cost or limit the availability of additional financing, if needed or desired, to fund future working capital, capital expenditures and other general corporate requirements, or to carry out other aspects of our business plan;


•	require us to maintain debt coverage and financial ratios at specified levels, reducing our financial flexibility; and


•	limit our ability to make strategic acquisitions and develop new or expanded facilities.

In addition, if we are unable to generate sufficient cash flow or otherwise obtain funds necessary to make required debt payments, or if we fail to comply with the various covenants and requirements of our senior secured credit facility or other existing or future indebtedness, we would be in default, which could permit the holders of our indebtedness, including our senior secured credit facility, to accelerate the maturity of indebtedness, as the case may be. Any default under our senior secured credit facility, or our other existing or future indebtedness, as well as any of the above-listed factors, could have a material adverse effect on our business, operating results, liquidity and financial condition.

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Despite our substantial indebtedness, we may still be able to incur more debt. This could intensify the risks associated with this indebtedness.

The terms of our senior secured credit facility contain restrictions on our ability to incur additional indebtedness. These restrictions are subject to a number of important qualifications and exceptions, and the indebtedness incurred in compliance with these exceptions could be substantial. Accordingly, we could incur significant additional indebtedness in the future. The more we become leveraged, the more we become exposed to the risks described above under “Our substantial indebtedness could adversely affect our financial health and prevent us from fulfilling our financial obligations.”

Floating rate indebtedness subjects us to interest rate risk, which could cause our debt service obligations to increase.

Borrowings under our senior secured credit facility are subject to floating rates of interest over an interest rate floor of 1.5%. If interest rates increase over the floor, our debt service obligations on our variable rate indebtedness would increase even though the amount borrowed remained the same, and our net income and cash flows would correspondingly decrease. As of April 12, 2012, we increased the size of the term loan by $100.0 million. The incremental term loan bears interest at LIBOR (subject to a floor of 1.50%) plus a margin of 5.25%. As part of the refinancing, the interest rate on the existing term loan was amended to match the interest rate of the incremental term loan. The interest rate on the existing revolving credit facility was also amended to LIBOR plus a margin of 4.50%. There is no longer a LIBOR floor on the revolving credit facility.

Our operations are subject to environmental and occupational health and safety regulations, which could subject us to fines, penalties and increased operational costs.

We are subject to a wide variety of federal, state and local environmental and occupational health and safety laws and regulations. Regulatory requirements faced by healthcare providers such as us include those relating to air emissions, wastewater discharges, air and water quality control, occupational health and safety (such as standards regarding blood-borne pathogens and ergonomics), management and disposal of low-level radioactive medical waste, biohazards and other wastes, management of explosive or combustible gases, such as oxygen, specific regulatory requirements applicable to asbestos, lead-based paints, polychlorinated biphenyls and mold, other occupational hazards associated with our workplaces, and providing notice to employees and members of the public about our use and storage of regulated or hazardous materials and wastes. Failure to comply with these requirements could subject us to fines, penalties and increased operational costs. Moreover, changes in existing requirements or more stringent enforcement of them, as well as discovery of currently unknown conditions at our owned or leased facilities, could result in additional cost and potential liabilities, including liability for conducting cleanup, and there can be no guarantee that such increased expenditures would not be significant.

A portion of our workforce is unionized and our operations may be adversely affected by work stoppages, strikes or other collective actions.

As of September 30, 2013, approximately 570 of our 14,950 active employees were represented by unions and covered by collective bargaining agreements. In addition, certain labor unions have publicly stated that they are concentrating their organizing efforts within the long-term healthcare industry. We cannot predict the effect that continued union representation or future organizational activities will have on our business or future operations. There can be no assurance that we will not experience a material work stoppage in the future.

Disasters and similar events may seriously harm our business.

Natural and man-made disasters and similar events, including terrorist attacks and acts of nature such as hurricanes, tornados, earthquakes, floods and wildfires, may cause damage or disruption to us, our employees and our facilities, which could have an adverse impact on our patients and our business. In order to provide care for our patients, we are dependent on consistent and reliable delivery of food, pharmaceuticals, utilities and other goods to our facilities, and the availability of employees to provide services at our facilities and other locations. If the delivery of goods or the ability of employees to reach our facilities and patients were interrupted in any material respect due to a natural disaster or other reasons, it would have a significant impact on our business. For example, in connection with Hurricane Katrina in New Orleans, several nursing home operators unaffiliated with us were accused of not properly caring for their residents, which resulted in, among other things, criminal charges being filed against the proprietors of those facilities. Furthermore, the impact, or impending threat, of a natural disaster has in the past and may in the future require that we evacuate one or more facilities, which would be costly and would involve risks, including potentially fatal risks, for the patients and employees. The impact of disasters and similar events is inherently uncertain. Such events could harm our patients and employees, severely damage or destroy one or more of our facilities, harm our business, reputation and financial performance, or otherwise cause our business to suffer in ways that we currently cannot predict.

The operation of our business is dependent on effective and secure information systems.

We depend on several information technology systems for the efficient functioning of our business. The software programs supporting these systems are licensed to us by independent software developers. Our inability or the inability of these developers, to continue to maintain and upgrade these information systems and software programs could disrupt or reduce the

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efficiency of our operations. In addition, costs and potential problems and interruptions associated with the implementation of new or upgraded systems and technology or with maintenance or adequate support of existing systems could also disrupt or reduce the efficiency of our operations. Furthermore, while we budget for the changes and upgrades to our information technology systems that we anticipate needing over time, it is possible that we may underestimate the actual costs of those changes and upgrades. Failure to make necessary changes and upgrades due to financial or other concerns could negatively impact the effectiveness of our information technology systems, as well as our operations and financial performance.

Additionally, we maintain information necessary to conduct our business, including confidential and proprietary information as well as personal information regarding our patients, employees and others with whom we do business, in digital form. Data maintained in digital form is subject to the risk of tampering, theft and unauthorized access. We develop and maintain systems to prevent this from occurring, but the development and maintenance of these systems is costly and requires ongoing monitoring and updating as technologies change and efforts to overcome security measures become more sophisticated. Moreover, despite our efforts, the possibility of tampering, theft and other unauthorized access cannot be eliminated entirely, and risks associated with each of these remain. If our information technology systems are compromised and personal or other protected information regarding patients, employees or others with whom we do business is stolen, tampered with or otherwise improperly accessed, our ability to conduct our business and our reputation may be impaired. If personal or other protected information of our patients, employees or others with whom we do business is tampered with, stolen or otherwise improperly accessed, and we may incur significant costs to remediate possible injury to the affected persons, compensate the affected persons, pay any applicable fines, or take other action with respect to judicial or regulatory actions arising out of the incident, including under HIPAA or the HITECH Act, as applicable.

Risks Related to Ownership of Our Class A Common Stock

We are controlled by Onex Corporation, whose interests may conflict with yours.

Our Class A common stock has one vote per share, while our Class B common stock has ten votes per share, on all matters voted on by our stockholders. As of September 30, 2013, Onex Corporation, its affiliates and certain of our directors and members of our senior management who are party to a voting agreement with an affiliate of Onex Corporation owned shares of common stock representing over 75.0% of the combined voting power of our outstanding common stock. Accordingly, Onex Corporation generally has the power to control the outcome of matters on which stockholders are entitled to vote. Such matters include the election and removal of directors, the adoption or amendment of our certificate of incorporation and bylaws, possible mergers, corporate control contests and significant transactions. Through its control of elections to our board of directors, Onex Corporation may also have the ability to appoint or replace our senior management and cause us to issue additional shares of our common stock or repurchase common stock, declare dividends or take other actions. Onex Corporation may make decisions regarding our company and business that are opposed to our other stockholders’ interests or with which they disagree. Onex Corporation may also delay or prevent a change of control of us, even if the change of control would benefit our other stockholders, which could deprive our other stockholders of the opportunity to receive a premium for their Class A common stock. The significant concentration of stock ownership and voting power may also adversely affect the trading price of our Class A common stock due to investors’ perception that conflicts of interest may exist or arise. To the extent that the interests of our public stockholders are harmed by the actions of Onex Corporation, the price of our Class A common stock may be harmed.

Additionally, Onex Corporation is in the business of making investments in companies and currently holds, and may from time to time in the future acquire, controlling interests in businesses engaged in the healthcare industries that complement or directly or indirectly compete with certain portions of our business. Further, if it pursues such acquisitions in the healthcare industry, those acquisition opportunities may not be available to us.

If our stock price is volatile, purchasers of our Class A common stock could incur substantial losses.

Our stock price has been and is likely to continue to be volatile. The stock market in general often experiences substantial volatility that is seemingly unrelated to the operating performance of particular companies. These broad market fluctuations may adversely affect the trading price of our Class A common stock. The price for our Class A common stock may be influenced by many factors, including:


•	the depth and liquidity of the market for our Class A common stock;


•	developments generally affecting the healthcare industry;


•	investor perceptions of us and our business;


•	actions by institutional or other large stockholders;


•	strategic actions, such as acquisitions or restructurings, or the introduction of new services by us or our competitors;


•	new laws or regulations or new interpretations of existing laws or regulations applicable to our business;


•	litigation and governmental investigations;

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•	changes in accounting standards, policies, guidance, interpretations or principles;


•	adverse conditions in the financial markets, state and federal government or general economic conditions, including those resulting from statewide, national or global financial and deficit considerations, overall market conditions, war, incidents of terrorism and responses to such events;


•	sales of Class B common stock by Onex, us or members of our management team;


•	additions or departures of key personnel; and


•	our results of operations, financial performance and future prospects.

These and other factors may cause the market price and demand for our Class A common stock to fluctuate substantially, which may limit or prevent investors from readily selling their shares of Class A common stock and may otherwise negatively affect the liquidity of our Class A common stock. In addition, in the past, when the market price of a stock has been volatile, holders of that stock have sometimes instituted securities class action litigation against the company that issued the stock. If any of our stockholders brought a lawsuit against us, we could incur substantial costs defending or settling the lawsuit. Such a lawsuit could also divert the time and attention of our management from our business.

If securities or industry analysts do not publish research or reports about our business, if they change their recommendations regarding our stock adversely or if our operating results do not meet their expectations, our stock price and trading volume could decline.

The trading market for our Class A common stock is significantly influenced by the research and reports that industry or securities analysts publish about us or our business. If one or more of these analysts cease coverage of our company or fail to publish reports on us regularly, we could lose visibility in the financial markets, which in turn could cause our stock price or trading volume to decline. Moreover, if one or more of the analysts who cover us downgrade our stock or if our operating results do not meet their expectations, our stock price could decline.

We do not intend to pay dividends on our common stock.

We do not anticipate paying any cash dividends on our common stock in the foreseeable future. We currently anticipate that we will retain all of our available cash, if any, for use as working capital and for other general purposes, including to service or repay our debt and to fund the operation and expansion of our business. Any payment of future dividends will be at the discretion of our board of directors and will depend on, among other things, our earnings, financial condition, capital requirements, level of indebtedness, statutory and contractual restrictions applying to the payment of dividends and other considerations that our board of directors deems relevant.

We are a “controlled company” within the meaning of NYSE rules and, as a result, qualify for and rely on exemptions from certain corporate governance requirements.

Onex Corporation and its affiliates control a majority of the voting power of our outstanding common stock. Under the NYSE rules, a company of which more than 50% of the voting power is held by another person or group of persons acting together is a “controlled company” and may elect not to comply with certain NYSE corporate governance requirements, including the requirements that:


•	a majority of the board of directors consist of independent directors;


•	the nominating and corporate governance committee be entirely composed of independent directors with a written charter addressing the committee’s purpose and responsibilities;


•	the compensation committee be entirely composed of independent directors with a written charter addressing the committee’s purpose and responsibilities; and


•	there be an annual performance evaluation of the nominating and corporate governance and compensation committees.

We elect to be treated as a controlled company and thus utilize some of these exemptions. In addition, although we currently have a board composed of a majority of independent directors and have adopted charters for our audit, corporate governance, quality and compliance and compensation committees, and intend to conduct annual performance evaluations for these committees, none of these committees are composed entirely of independent directors, except for our audit committee. Accordingly, you may not have the same protections afforded to stockholders of companies that are subject to all of NYSE corporate governance requirements.

Our amended and restated certificate of incorporation, bylaws and Delaware law contain provisions that could discourage transactions resulting in a change in control, which may negatively affect the market price of our Class A common stock.

In addition to the effect that the concentration of ownership and voting power in our significant stockholders may have, our amended and restated certificate of incorporation and our amended and restated bylaws contain provisions that may enable our management to resist a change in control. These provisions may discourage, delay or prevent a change in the ownership of our company or a change in our management, even if doing so might be beneficial to our stockholders. In addition, these

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provisions could limit the price that investors would be willing to pay in the future for shares of our Class A common stock. The provisions in our amended and restated certificate of incorporation or amended and restated bylaws include:


•	our board of directors is authorized, without prior stockholder approval, to create and issue preferred stock, commonly referred to as “blank check” preferred stock, with rights senior to those of our Class A common stock and Class B common stock;

•

advance notice requirements for stockholders to nominate individuals to serve on our board of directors or to submit proposals that can be acted upon at stockholder meetings; provided, that prior to the date that the total number of outstanding shares of our Class B common stock is less than 10% of the total number of shares of common stock outstanding, which we refer to as the "Transition Date," no such requirement is required for holders of at least 10% of our outstanding Class B common stock;


•	our board of directors is classified so not all of the members of our board of directors are elected at one time, which may make it more difficult for a person who acquires control of a majority of our outstanding voting stock to replace our directors;


•	following the Transition Date, stockholder action by written consent will be prohibited;


•	special meetings of the stockholders are permitted to be called only by the chairman of our board of directors, our chief executive officer or by a majority of our board of directors;


•	stockholders are not permitted to cumulate their votes for the election of directors;


•	newly created directorships resulting from an increase in the authorized number of directors or vacancies on our board of directors will be filled only by majority vote of the remaining directors;


•	our board of directors is expressly authorized to make, alter or repeal our bylaws; and


•	stockholders are permitted to amend our bylaws only upon receiving at least 66 2/3% of the votes entitled to be cast by holders of all outstanding shares then entitled to vote generally in the election of directors, voting together as a single class.

After the Transition Date, we will also be subject to the provisions of Section 203 of the Delaware General Corporation Law, which may prohibit certain business combinations with stockholders owning 15% or more of our outstanding voting stock. These and other provisions in our amended and rested certificate of incorporation, amended and restated bylaws and Delaware law could discourage acquisition proposals and make it more difficult or expensive for stockholders or potential acquirers to obtain control of our board of directors or initiate actions that are opposed by our then-current board of directors, including delaying or impeding a merger, tender offer or proxy contest involving us. Any delay or prevention of a change of control transaction or changes in our board of directors could cause the market price of our Class A common stock to decline.

Item 2. Unregistered Sales of Equity Securities and Use of Proceeds

Purchases of Equity Securities by the Issuer and Affiliated Purchasers

The table below sets forth information with respect to purchases of our Class A common stock made by us or on our behalf during the quarter ended September 30, 2013:



Period	Total Number of Shares Purchased ₍₁₎	Average Price Paid per Share		Total Number of Shares Purchase as Part of Publicly Announced Plans or Programs	Maximum Dollar Value of Shares that May Yet Be Purchased Under the Plans or Programs
July 1 - 31, 2013	5,572	$	5.46	n/a	n/a
August 1 - 31, 2013	1,064	$	5.46	n/a	n/a
September 1 - 30, 2013	—	$	—	n/a	n/a
Total:	6,636	$	5.46	n/a	n/a

(1) Reflects shares forfeited to us upon the vesting of restricted stock granted to participants in our 2007 Incentive Award Plan, to satisfy applicable tax withholding obligations with respect to such vesting. We did not have any publicly announced plans or programs to purchase our Class A common stock in the quarter ended September 30, 2013.

Item 3. Defaults Upon Senior Securities

None.

Item 4. Mine Safety Disclosures

None.

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Item 5. Other Information

None.

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Item 6. Exhibits


(a)	Exhibits.




Number		Description

3.1		Second Amended and Restated Bylaws of Skilled Healthcare Group, Inc. (incorporated by reference to Exhibit 3.1 of the Company's Form 8-K filed with the SEC on August 7, 2013).

10.1		Form of Healthcare Facility Note with respect to HUD-insured loans (incorporated by reference to Exhibit 10.1 of the Company's Form 8-K filed with the SEC on September 24, 2013).

31.1		Certification of Principal Executive Officer pursuant to Section 302 of the Sarbanes-Oxley Act of 2002.

31.2		Certification of Principal Financial Officer pursuant to Section 302 of the Sarbanes-Oxley Act of 2002.

32**		Certifications pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002.

101		The following financial information from our Quarterly Report on Form 10-Q for the quarter ended September 30, 2013 as filed with the SEC on November 4, 2013, formatted in Extensible Business Reporting Language (XBRL): (i) the condensed consolidated balance sheets at September 30, 2013 and December 31, 2012, and (ii) the condensed consolidated statements of operations for the three months ended September 30, 2013 and September 30, 2012, and (iii) the condensed consolidated statements of comprehensive income for the three ended September 30, 2013 and September 30, 2012, and (iv) the condensed consolidated statements of cash flows the nine months ended September 30, 2013 and September 30, 2012, and (v) the Notes to Condensed Consolidated Financial Statements.


**	Furnished herewith and not "filed" for purposes of Section 18 of the Securities Exchange Act of 1934, as amended.

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SIGNATURES

Pursuant to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned thereunto duly authorized.



		SKILLED HEALTHCARE GROUP, INC.

Date:	November 4, 2013	/s/ Christopher N. Felfe
		Christopher N. Felfe
		Acting Chief Financial Officer
		(Principal Financial Officer, Principal Accounting Officer, and Authorized Signatory)

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EXHIBIT INDEX



Number		Description

3.1		Second Amended and Restated Bylaws of Skilled Healthcare Group, Inc. (incorporated by reference to Exhibit 3.1 of the Company's Form 8-K filed with the SEC on August 7, 2013).
10.1		Form of Healthcare Facility Note with respect to HUD-insured loans (incorporated by reference to Exhibit 10.1 of the Company's Form 8-K filed with the SEC on September 24, 2013).
31.1		Certification of Principal Executive Officer pursuant to Section 302 of the Sarbanes-Oxley Act of 2002.
31.2		Certification of Principal Financial Officer pursuant to Section 302 of the Sarbanes-Oxley Act of 2002.
32**		Certifications pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002.
101		The following financial information from our Quarterly Report on Form 10-Q for the quarter ended September 30, 2013 as filed with the SEC on November 4, 2013, formatted in Extensible Business Reporting Language (XBRL): (i) the condensed consolidated balance sheets at September 30, 2013 and December 31, 2012, and (ii) the condensed consolidated statements of operations for the three months ended September 30, 2013 and September 30, 2012, and (iii) the condensed consolidated statements of comprehensive income for the three ended September 30, 2013 and September 30, 2012, and (iv) the condensed consolidated statements of cash flows the nine months ended September 30, 2013 and September 30, 2012, and (v) the Notes to Condensed Consolidated Financial Statements.


**	Furnished herewith and not "filed" for purposes of Section 18 of the Securities Exchange Act of 1934, as amended.