Emergency Procedures

The Friendship Village Health & Rehab Center has emergency procedures for fire, tornado, power failure, and other various types of emergencies. The staff has been trained in the emergency procedures to make sure the safety of the residents is maintained, even in everyday activity. To help review our procedures, fire and tornado drills are implemented Welcome to Friendship Village’s throughout the year. These drills are designed to assure that the procedures set are adequate to ensure the safety of Health and Rehab Center! our residents. Emergency procedure manuals are available at the nurses stations. Safety Procedures Pictures, Knickknacks, Misc. While it is important to We wish to make your family member’s stay the resident that their here as pleasant, dignified and safe as stay in the Health Center possible. be as comfortable as possible, there are guidelines that need to be followed: In cooperation with the department  Pictures can be hung on the wall, directors, administration, and Safety but we ask that the Maintenance Health & Rehab Center Committee, this brochure is designed to Department be contacted to do 1400 North Drake Rd. answer some questions that you may have this. This will insure that Kalamazoo, MI 49006 regarding your loved ones safety. Theses placement and weight will not be policies are in effect immediately. a factor. Phone  Knick-knacks, stuffed animals, etc. (269) 381-0515 After reviewing this brochure, please don't are special items to many hesitate to ask any questions you may have. residents, but too many can Fax Please contact the Health and Rehab impede the safety of the residents (269) 488-4827 Center’s Social Worker with any questions and employees. Please be or concerns. courteous of other’s space. Updated 10/02/2015 Furniture Holiday Decorations Electronic Items Each resident’s area has a bed, The holidays are a festive Residents may wish to have nightstand and chair. Because of time in the Health Center. a radio, tape player, razor, the size of the rooms, we ask Parties, treats and decorations etc. While the Health that no other furniture be brought into the are everyday activities. Center will accommodate room. However, the following the need, certain guidelines guidelines need to be followed: must be followed as well: If the resident would like his or her own chair  No glass vases  All items must re-checked and labeled brought in, then the Health Center’s chair  No dried flowers or live Christmas trees. for safety by the Maintenance would be removed. To help maintain a clean  No decorations that contain flammable Department. environment, cloth covered chairs may not materials.  No extension cords. Power strips may be brought into the room. be used as long as they have a circuit  Any electrical item needs to be approved by the breaker. In addition, should the resident’s furniture be maintenance department.  The position of the items brought in, it must be of similar size as that cannot cause other hazards provided by Friendship Village. or impede with the residents care. Too much “clutter” in the room can make it Lighting difficult for proper care from their nursing Occasionally, residents would like their own Safety Checks staff. Personal items cannot interfere with floor lamp or table lamp. These must be Safety is an important part of everyday life Housekeeping and Janitorial maintaining a kept to a minimum. In addition, the here at Friendship Village. clean atmosphere for the resident and family. following applies: It is up to various  No Halogen light departments to maintain Closets  Extension cords, power strips, and any the guidelines set by The room closets are outlet adapter may not be used Friendship Village, local, designed for resident clothes  Lamp positioning cannot cause other state, federal and OSHA requirements. and minimal storage. A red hazards or impede the resident’s care. line is marked in all closets  The over-the-bed light fixture is not to There are daily and weekly checks of the denoting the maximum be used as a shelf. Any items placed on building and individual rooms. Anything that height for storage due to the these lights will be is noted as “unsafe” will be taken care of in a sprinkler heads. We ask that family members removed. timely matter. help maintain these closets by removing clothes that are not worn, seasonal, etc. Certain issues may require a consultation with the resident’s family. The Health and Rehab Center

Resident Handbook Welcome to Friendship Village Health and Rehab Center

We hope that your stay here is pleasant. If at any time you have questions, please feel free to ask the staff for assistance.

The Health Center is dedicated to EXCELLENCE! Our goal is to rehabilitate and/or maintain each resident at his or her maximum capacity. Each resident is considered to be an individual who will be encouraged to exercise his or her rights and responsibilities, and who will be given an opportunity to share in the decisions that affect their Quality of Life. Each resident will be treated with respect, compassion and understanding.

The following is a list of employees here at The Health and Rehab Center and a brief description of the services they offer:

Kathy Harmon, NHA – Administrator is responsible for the general oversight of the Health & Rehab Centers. She supervises clinical and administrative affairs in accordance with established policies and federal and state guidelines. Kathy is available at (269) 381- 8837 to answer questions and to assist with any problems you may have.

Kristen White, RN - Director of Nursing/Chief Complaint Officer is responsible for the day to day operations at The Health Center/Rehab. Kristen develops and implements patient care services. Any concerns regarding Nursing or Physician services may be addressed with Kristen. To schedule an appointment with Kristen or a physician, please call (269) 381-0515 x.455.

2 Updated 10/02/2015 Crystal Nelson, RN – Infection Control / Staff Development Coordinator is responsible for implementing policies, procedures and assuring resident and staff safety throughout the continuum of care by reducing the risk of infection. Crystal also develops and teaches programs designed to enhance the skills of workers, relevant to their positions within the Health and Rehab Centers. To reach Crystal, please call (269) 381-0515 x.472.

Jan Kehl, RN – Nurse Navigator works closely with the care team and physicians in various specialty areas and coordinates a patient’s care plan and discharge. She also provides patient education related to their illness and planned treatment. To reach Jan please call (269) 381- 0515 x.406.

Christy Salisbury, BSW - Social Worker is responsible for Resident Services. She will assist you with your personal and emotional needs. Christy is available to set up appointments with our Hearing, Dental, Vision or Beautician Services. She is also available for counseling or any other issues you may need. Please call (269) 381-0515 x.313 for Christy’s assistance.

Molly Bloomfield, RN – Rehab Unit Manager manages care by directing both nurses and CNA’s in resident needs in the Rehab Center. She is also a liaison between family, resident’s therapy and physicians. If you have questions regarding nursing care, please contact Molly at (269) 381-0515 x. 309.

Trinda Purkey, LPN – Health Center Resident Care Coordinator manages care by directing both nurses and CNA’s in resident needs in the Health Center. She is also a liaison between family, residents and physicians. If you have questions regarding nursing care, please contact Trinda at (269) 381-0515 x. 456.

Therese Holdeman, CDM - Food & Beverage Manager is the Certified Dietary Manager at the Health and Rehab Center. Therese will accommodate your meal preferences in accordance with your diet ordered by your Physician. Please call Therese at (269) 381-0515 x.426 if you have any Dietary concerns.

3 Updated 10/02/2015 Shannon Schaab – Admissions and Marketing Coordinator is responsible for managing Health Center and Rehab Center admissions. Shannon works with hospitals, hospices, senior living centers and similar places to synchronize a resident’s move to and from Friendship Village. Contact Shannon at (269) 381-0515 x 526 for a tour or to answer questions about admission planning.

Kellie Nugteren, CTRS – Activity Director is a Certified Therapeutic Recreation Specialist (CTRS) who schedules many different types of activities to meet our resident’s physical, social, mental, emotional, and spiritual needs. The purpose of the Activity Program is not only to provide entertainment but to improve the quality of life of our residents. Activities featured on the monthly Calendar include, but are not limited to, exercise classes, bingo, spiritual events, educational programs, craft activities, musical programs, outdoor activities, and special entertainment. All the activities and special events are posted on the monthly activity calendar located in every resident room and also in the common areas. Activities are offered multiple times per day, 7 days a week, 365 days a year. In addition to the Director and Activity Assistants, the Activity Program also utilizes volunteers. If you would like to become a volunteer or if you have any questions or suggestions regarding the activity program, please contact Kellie at (269) 381-0515 x.321.

TBD, RN – MDS Assessments & Restorative Nursing Coordinator is responsible for resident assessments and the restorative nursing program at The Health Center. If you have questions for the coordinator, you can reach her at (269) 381-0515 x. 242.

Ashley Bechtel – Medical Records is our medical records coordinator for the Health and Rehab Center. She is also in charge of completing admission paperwork. She can assist you with copies of medical records as well as answer any general questions. You can reach Ashley at (269) 381-0515 x. 311.

Unit Clerks - Transportation Services are available to set up transportation or medical appointments for you. We have an agreement with Life Ambulance EMS to provide roundtrip transportation at a nominal cost. An escort may be provided as needed. You may prefer to ride with a family member to your appointment, however, due to liability reasons; we do not allow our staff to escort residents in private vehicles. If you set up your own medical appointment, please contact out unit clerk so we can assure 4 Updated 10/02/2015 that you have all of the necessary paperwork to accompany you. To set up transportation or medical appointments please call (269) 381-0515.

Shannon Johnson, PTA – Rehab Clinical Lead is responsible for coordinating all of your Physical, Occupational and/or Speech Therapy services. If you need assistance or have questions regarding your therapy services, you may reach Shannon at (269) 381-0515 x424.

Ann Bensinger – Assistant Accounting Director is responsible for the billing for Friendship Village Rehab and Health Center. Please feel free to contact Ann at (269) 381-0560 ext. 306 if you have any questions or concerns about your bill.

TBD – Housekeeping & Laundry Supervisor is our Housekeeping and Laundry Supervisor. If you have any concerns or questions regarding these services, please call (269) 381-0560 x. 476.

Tim Harvey – Maintenance & Security is responsible for our maintenance, grounds, environmental services and security departments. If you have any questions, Tim can be reached at (269) 3810-0560 x 534.

5 Updated 10/02/2015 A Few of Our Guidelines

Food: Each Resident receives their meals based on a diet ordered by their attending Physician. Dining Services, under the direction of a Registered Dietician, provides three meals each day and other nourishments. It is important that we know the food intake of each Resident to ensure that the doctor’s orders are being followed. Inform the Charge Nurse of any food that is brought in to be sure it’s in keeping with dietary restrictions and so that nutrition intake is properly charted.

When food is brought into The Health Center, we ask that only as much as can be eaten at one sitting is left with the Resident in their room. Any food items left in a resident’s room must be in an enclosed container. All foods stored must be labeled with the resident name and the date it is stored. Any perishable food items stored in the refrigerator not used within 3 days will be discarded according to regulation.

Guest meals are available from Food and Beverage and may be ordered in advance. Residents that are totally independent in eating and are not a therapeutic or mechanically altered diet or liquids may eat in the Friendship Village Café if accompanied by a family member. The charge for the guest meal can be paid in the Business Office, Café, or may be added to the resident monthly bill.

Meal times in the Health Center are as follows:

Breakfast 8:00 am Lunch 12:30 pm Dinner 6:00 pm

Personal Clothing and Possessions: We encourage our Residents to dress in his or her own clothing each day. Our Residents are up and about, participating in a variety of activities. Clothing that is washable and does not require ironing is best. Each Resident has an area where he/she can keep clothing. Family members and friends can be of assistance in keeping the resident supplied with clothing and keeping closets rotated with seasonal items. Friendship Village will launder the personal clothing of the resident or if a family member would prefer to do the laundry for a resident we can leave the soiled clothes in the room to be picked up. Please see the Social Worker for assistance.

Radios, pictures, a special bedspread or pillow are all welcomed to make each residents room more home-like. We ask that anything brought into The Health Center that will remain with the resident be labeled with the resident’s name and recorded on an inventory record, which is a part of the resident’s chart. Please check the items in at the nurse’s station.

6 Updated 10/02/2015 Personal furniture is welcome to personalize your room. Please see the social worker if you would like to bring in your own furniture. At times, we may not allow upholstered chairs if there is any problem with incontinence. Our maintenance department to adhere to fire and safety regulations must approve Holiday decorations.

Visiting: Visitors are welcome in The Health Center at any time. We do recommend that you visit between the hours of 11:00 am and 8:00 pm. This allows the staff to assist the residents with their baths and clean up before their visitors arrive. If you are unable to visit between the suggested hours we ask that you let the charge nurse know of the time of your proposed visit to be sure that the resident is ready.

Children are welcome as visitors. We do expect them to be accompanied and supervised by an adult. This is our residence home; please do not allow children to run up and down halls and in and out of other resident rooms.

We ask that if you have a sign of a cold or the flu you refrain from visiting until you are well. Many of our residents are frail and can easily become quite ill from exposure to a cold.

Many people do not know what to do when they come for a visit to a nursing home. Usually the residents are happy to have company and just conversations about the goings on of the family or their friends are very welcome. Some residents would like to have help in writing letters to other friends; others might like to be read to. Assisting a female resident with grooming, such as trying a new hairstyle or giving a manicure is a pleasant way to pass the time. Frequent, short visits are usually enjoyed more than long formal visits that may occur rarely.

It is quite acceptable for the resident to go out of The Health Center for an outing. A ride in the car or a trip to visit the family at home can be a special event for our residents. If the resident is to be gone for a lengthy period of time we would like to be informed in advance so that we can be sure the resident is dressed properly, cancel the meal, and prepare any necessary medications to be sent along with the resident. When the resident leaves the building he or she must be signed out at the nurses station so that we know he or she has gone and when to expect him or her back.

Telephone:

You may have a telephone installed in your room by making arrangements; the telephone company will bill you directly. Please see the Social Worker if you need assistance.

A portable telephone is also available for use. You’re Charge Nurse or Nurse Aide will be happy to assist you. We also have areas available within the community for private phone conversation. Please see the Social Worker for assistance.

7 Updated 10/02/2015

Mail:

Mail is received Monday through Saturday and is delivered to the residents, unopened, on the day it is received. Outgoing mail may be brought to the Front Office to be mailed. Assistance is given when required. Our mailing address is:

The Health Center at Friendship Village 1400 North Drake Road Kalamazoo, Michigan 49006

Money and Valuables:

We suggest that money and valuables not be left in the residents’ rooms. We have a Resident Trust Fund available whereby residents may deposit and withdraw money, as they need it. Additional information on the trust fund is available from the Business Office or Social Worker. We cannot be responsible for any items of value that are left in the resident’s room. Every effort will be made to insure their safekeeping, but The Health Center will not be liable for any losses.

Roommates and Room Assignments:

Every attempt will be made to make room assignments that are acceptable to all. Any requests for room changes should be made to the Social Worker.

Grievances and Problems:

A grievance procedure is available to all residents and their families in the event of a problem. We request that you use this procedure and we will make every effort to resolve your concern. The grievance procedure is posted on the public bulletin board near the nurse’s station. An unanswered question or a problem that is bothering you deserves assistance. There will absolutely be no harassment of the resident if he/she brings a problem to the attention of Administration. We want to help! Please see the Social Worker or the nurse’s station for assistance.

Safety:

The Health Center is equipped with certain devices to help ensure the safety of our residents. Side rails on the beds (as ordered), rails in the bathrooms and handrails in the hallways all help to protect the residents.

We encourage a restraint free community! If at any time a resident’s safety is a concern, our Safety Director will contact you and/or your family to discuss recommendations.

8 Updated 10/02/2015 Rights and Responsibilities:

On admission you were given a copy of The Bill of Rights. In addition to the rights of the residents, are certain responsibilities that must be adhered to. In order to live together in The Health Center, the rights of other residents must also be respected.

Once again, thank you for choosing the Friendship Village Health Center; we look forward to serving you!

9 Updated 10/02/2015

Friendship Village

Health and Rehab Center Disclosure Statement

Updated 12/2016 Table of Contents

1) Resident Rules & Regulations ...... 2

2) Health and Rehab Center Policies and Procedures a) Statement of Authority & Responsibility ...... 4 b) Conflict of Interest ...... 4-5 c) Philosophy Statement ...... 6 d) Disclosure of Care Policies ...... 6 e) Smoking Policy ...... 7 f) Access to Services of Physical Facilities ...... 7 g) Nondiscriminatory Policy ...... 7 h) Medical Director Policy ...... 8 i) Pharmaceutical Services Policy ...... 8 j) Physicians Services Policy ...... 9 k) Private Duty Nurse Policy...... 10 l) Personal Property Policy ...... 11 m) Discharge Policy ...... 12 n) Grievance Procedure ...... 13 o) Complaint Procedure ...... 14 p) Business Office Procedure ...... 15

3) Medicare Information ...... 16-17

4) Ancillary Charges ...... 18-19

1 Updated 12/2016 Resident Rules and Regulations

Policy Statement

At Friendship Village we believe in creating and sustaining a community that sustains a sense of peace and well being for all who live, work, or visit the community. The following rules were established to support that belief, and to provide the safest environment possible for all.

1. Residents will not intentionally disrespect the privacy of others, including but not limited to rooms, personal items, and communications.

2. Residents will not physically, verbally, mentally, or sexually abuse other residents, the staff, or visitors. This includes sexual or other types of harassment.

3. Residents will observe the Friendship Village smoking policy.

4. Residents will not possess any materials that are illegal or pose a threat to other residents, staff, or visitors, including, but not limited to, illicit drugs, firearms, combustible materials, or weapons.

5. Residents will observe the Friendship Village Health Center pet policy.

6. Residents will not engage in any illegal activity while on Friendship Village property.

7. Residents will notify the staff when they are leaving the community.

8. Residents will not intentionally destroy the property of others or Friendship Village.

9. Residents will treat other residents, staff, or visitors with courtesy and general respect at all times.

10. Residents will observe the contents of the written and signed contract at all times.

11. Residents will be able to use their motorized scooter or wheelchair once they have a physician’s approval and pass a therapy screen.

12. Residents will observe the general Friendship Village community rules at all times.

2 Updated 10/02/2015 Health and Rehab Center

Policies and Procedures

3 Updated 10/02/2015 Statement of Authority and Responsibility of the Governing Body

The governing body of this facility being the Board of Directors, has full legal authority and responsibility for the operation of the facility.

The governing body adopts and enforces rules and regulations relative to the health and safety of residents to the protection of their personal and property rights, and to the general operation of the facility.

The governing body adopts effective resident care policies and also ensures that they are operational and reviews and revises them as necessary.

The governing body shall appoint a qualified executive director, licensed by this state as specified in the rules of the state board.

The governing body approves an annual operation budget with itemized assumptions and a capital expenditure plan for at least a three-year period including the year of the current operating budget.

The governing body shall implement personnel policies and procedures including staff development plans for all personnel.

The governing body shall ensure the employment of qualified professionals or shall make arrangements to provide services by outside resources for service to residents or for consultation to the facility.

The governing body shall establish written resident rights and responsibilities.

Conflict Of Interest Policy

Resolution WHEREAS, it is desirable that the Board of Directors adopt a policy dealing with potential conflicts of interest:

NOW, THEREFORE, BE IT RESOLVED, that the following statement of policy by and the same hereby adopted.

4 Updated 01/01/2017

Policy It shall be the policy that no member of the Board of Directors shall have any undisclosed conflict of interest. A conflict of interest exists when self-interest or regard for one duty tends to lead to disregard of another. For the purpose of this policy, a conflict of interest shall include, but is not limited to, situations in which the facility is dealing with any Director or any member of the immediate family of any Director or the Director is an officer or director of or has a material financial interest in any entity with which the facility is proposing to enter into or has entered into a contract or other transaction. As used in this paragraph, “immediate family” shall mean spouse of a Director, those within two degrees of kinship of a Director, and within two degrees of kinship of the spouse of a Director and spouse of such persons. A Director who may have a conflict of interest shall give notice describing the nature of the conflict. Whenever a conflict of interest may exist, the fairness of the transaction to the facility shall be reviewed only by the Directors who have no conflict of interest in the transaction.

5 Updated 01/01/2017

Health Center Philosophy Statement

It is the intent of this facility to maintain positive public relations with residents, staff, families and the community at large.

The ultimate aim of the Health Center is to foster resident behavior that maximizes his/her individual independence.

1. In conjunction with the stated philosophy, the facility will endeavor to provide as pleasant an environment as is feasible.

2. Residents will be encouraged to develop self-care skills leading toward independence.

3. Utilization of community resources for training, awareness and socialization will be encouraged.

4. Visitation by family members or friends will be encouraged.

5. Rehabilitation nursing skills, including self-care and socialization will be utilized.

6. Partaking of meals in the Health Center dining room will be encouraged.

Disclosure of Administrative and Resident Care Policies Policy 1. It is the policy of this facility to have available for observation or study, its policy statements.

2. These policy statements will be available for review by admitting physicians, sponsoring agencies, residents, employees, and the public.

Procedures 1. These policy statements will be available in the Director of Nursing and Executive Director’s offices for review.

2. In the event access to these policies is desired at a time when the administrative offices are normally closed, access by appointment will be arranged.

Responsibility The fulfillment of such procedures shall be the responsibility of the Executive Director. 6 Updated 01/01/2017

Smoking In the Health Center

Policy It is the policy of this facility that smoking be prohibited in the Health Care Center and all other common spaces.

Responsibility It shall be the responsibility of all staff members to see that the above policy is carried out at all times. Access to Services and Physical Facilities

In compliance with Title VI of the Civil Rights Act of 1964, the facility has adopted the following policies regarding access to services and physical facilities provided by the facility:

1. Residents privileges and care services such as medical and dental care, nursing, laboratory services, pharmacy, physical, occupational and recreational therapies, and social services are provided on a non-discriminatory basis.

2. Physical facilities including lavatories, lounges, dining facilities, and beauty and barbershops are provided and used without discrimination.

3. Rules of courtesy are uniformly applied without regard to race, color, religion, ancestry, creed, sex, national origin, veteran status, sexual orientation, marital status, handicapping condition, age, or arrest and court records in all situations including face- to-face contact and written records and communications.

4. Assignment of staff to residents is not governed by the race, color, religion, ancestry, creed, sex, national origin, veteran status, sexual orientation, marital status, handicapping condition, age, or arrest and court records of either resident or staff.

Administrative Policies Nondiscrimination Policy

The facility had adopted, and where appropriate, provided its residents, employees, attending physicians and others providing services to residents, with copies of written statements which set forth the Health Care Center’s nondiscrimination policies and practices. These policies are included in any publication of staff regulations or public information brochures, kept current and periodically reviewed with employees.

The nondiscriminatory policy and the nature and extent of services available are conveyed to the community, to hospitals and to other referral sources. 7 Updated 01/01/2017

Medical Director Policy

A physician licensed under State law to practice medicine or osteopathy in the State will serve as Medical Director for the facility.

The Medical Director is designated by the Executive Director with the approval of the Board of Directors.

The Medical Director shall be responsible for the overall coordination of the medical care provided to residents. S/he is specifically responsible to ensure the adequacy and appropriateness of the medical services provided to the residents and to maintain surveillance of the health standards of the facility employees.

The Medical Director serves a minimum of eight hours per month in providing consultation to the facility staff and medical care to facility residents.

The Medical Director is responsible for assisting in the development, execution, and maintenance of resident care practices and general medical policies, including standing orders.

Coordination of medical care is to include liaison with attending physicians to ensure there are written orders promptly upon admission of a resident and periodic evaluation of the adequacy and appropriateness of the professional and supportive staff service.

Incidents and accidents that occur within the facility are to be reviewed by the Medical Director to identify hazards to residents and employees health and safety.

A copy of the Medical Director contract is maintained in the contract book.

Pharmaceutical Services Policy Pharmaceutical Services Policy The facility is responsible for: administering such drugs and non-prescription medications for its residents as are prescribed by the attending physician; ensuring the safe and accurate ordering, storage, distribution, administration review of pharmaceuticals, and complying with principles and appropriate federal, state, and local laws.

Responsibilities Pharmaceutical services must operate under the supervision of a consultant pharmacist who devotes a sufficient number of hours to accomplish the facility’s responsibilities. The consultant is responsible for and accountable for coordination of all pharmaceutical services. 8 Updated 01/01/2017

Physician’s Services Policy

Objective To provide consistency in the quality of medical care provided the resident during his/her stay in the facility.

Admission of Residents • Certification for admission must occur prior to or at the time of admission. • A resident may be admitted to the facility only be a licensed, State physician’s order. • There must be assurance that there will be an attending physician for the resident. This may be the resident’s previous personal physician, a physician to whom the resident is referred, or an assigned physician (who will be responsible for the total care of the resident). • Arrangements must be made for care of the resident if the attending physician is not available. • Arrangements are made for emergency care. • Resident information is made available to the facility prior to or at the time of admission (including current medical findings, diagnosis and orders from a physician for immediate care of the resident). • Information about the rehabilitation potential of the resident and a summary of prior treatment is made available to the facility at the time of admission or within 48 hours thereafter. • A recorded physical examination is done within 48-72 hours of admission unless such examination was performed within five days prior to admission. An updated history and physical is acceptable. • There is prescribed a planned regimen of total resident care. • The physician will indicate in the medical record of admission that the resident has been informed of rights, responsibilities, and diagnosis, or if not, the reason why shall be documented by the physician.

9 Updated 01/01/2017

Private Duty Nurse Policy

Policy The facility retains the right to approve and permit private duty personnel employed by individual residents to work in the skilled nursing facility. Residents’ families, who desire private duty care for residents in the nursing facility, must have any person they wish to employ approved by the Director of Nursing.

Procedure The following procedures are to be utilized by all private duty personnel desiring to provide services on a private duty basis.

1. The initial and ongoing contact of the private duty person with the facility must include:

A. Completion of the attached information form. (This form will be reviewed by the Director of Nursing and/or staff development if applicable, and acceptance of the individual will be acknowledged in writing.) B. Signing of the private duty registry – including completion of all information requested each tour of duty. C. A copy of professional licensure must be provided (if applicable). D. It Is the policy of the nursing facility to only accept: 1) Private duty personnel from an approved agency that has provided us with proof of insurability. A certificate of insurance must be mailed from the insurance company which insures the agency. Both liability and workers compensation are required. 2) Personnel from a professional nurses’ register if the professional nurse can document proof of insurance. 2. The private duty personnel will report to and receive instruction from the charge nurse on duty.

A. The private duty personnel may do ordered treatments, reporting and charting, accordingly, if approved by the charge nurse on duty. B. The resident’s chart must remain at the nurses’ station. C. Should the private duty personnel desire to contact the resident’s physician, they must inform the charge nurse on duty who will make and receive all calls from the physician pertaining to the resident. All private duty personnel must abide by and adhere to all policies and procedures of the facility.

The facility assumes no responsibility for malfeasance nor malpractice due to private duty personnel’s negligent actions.

10 Updated 01/01/2017

Personal Property Policy

Policy It is the policy of this facility to inform each resident, guardian, or responsible party that the facility does not provide a vault for safekeeping. The Charge Nurse is responsible for informing each resident, guardian, or responsible party that it is the facility’s policy to require that all valuables be removed from the facility and kept at some place not subject to the control of the facility. Each resident, guardian, or responsible party acknowledges receipt of this information by signing of the admission agreement.

Procedure At the time of admission, all personal belongings are listed on the resident’s clothing list. This list is signed by the resident, guardian, or responsible party and the staff member preparing the inventory. It is the responsibility of the guardian or responsible party to notify the nursing station when personal belongings are removed from the facility or additional items are brought into the facility in order to update the clothing list.

All clothing is marked with resident’s name; personal items are also marked for identification. In event of discharge, all belongings are taken with the resident or responsible party. If the resident is transferred to a hospital, all belongings are bagged and placed in a storage area, and the family is notified for pick-up. If the resident expires, all belongings are bagged and placed in the storage room until family can collect them. At this time family will sign on the back of the inventory sheet from the resident’s chart that they have received all belongings.

Property, which the resident placed in hands of the facility for safekeeping and facility, has acknowledged receipt in writing is held in trust by the facility.

11 Updated 01/01/2017

Discharge Policy and Procedures Policy

1. It shall be the policy of this facility to discharge a resident only on the written order of a legally licensed physician. The family or responsible party shall be notified, in writing, at the time of resident’s discharge order including reason for discharge.

2. A resident may be involuntarily transferred or discharged only for medical reasons, or for his/her welfare, or that of other residents, or for nonpayment of his/her stay (except as prohibited by titles XVIII or XIX of the Social Security Act) and is given five (5) days notice to ensure orderly transfer or discharge, and such actions are documented in the medical record.

Procedures

1. Prior to discharge, the Director of Nursing/social worker or his/her appointed representative shall confer with the legally responsible party regarding discharge plans to ensure that resident’s needs will continue to be met and that the reason for discharge is understood.

2. In the event of a discharge against medical advice, the family shall be advised of physician’s refusal to discharge resident. A “release of responsibility” for resident’s welfare must be signed by resident (if responsible) or responsible party involved. Notation should be made in nursing notes regarding discharge.

3. All personal belongings, valuables, and money shall be given to resident or responsible party and their signature obtained noting change in custody.

4. A discharge notation shall be made on progress including current status and care. Final diagnosis and prognosis and summary of stay is completed.

Responsibilities It shall be the responsibility of the Director of Nursing for adherence to these policies and procedures.

12 Updated 01/01/2017

Resident Grievance Procedure Policy It is the desire of Friendship Village to proactively handle any and all grievances. There is contact person available twenty-four hours a day, seven days a week to address grievances.

Procedure 1. Each resident and/or resident representative is provided with a complaint form at admission or upon request along with an Explanation of Rights. 2. There is a Complaint Contact Person on duty 24 hours per day, 7 days a week. This person is listed at the nursing station. 3. When the facility receives a verbal complaint, the Contact Person will assist complainant to reduce oral complaint to writing utilizing the forms available in the complaint book located at the nurses’ station. 4. The name, title, location and telephone number of the nursing home Chief Complaint Officer is posted on the public bulletin board. 5. When the Nursing Home Chief Complaint Officer receives complaint from a resident it will be investigated: • Abuse, neglect and misappropriation immediately • Harm within 5 days • All others within 15 days • Report findings within 30 days 6. If the complainant is not satisfied with results of investigation, they may file an appeal with the Administrator. 7. When the Administrator receives an appeal, the complaint will be resolved, or a response will be provided if complaint cannot be resolved. 8. The facility will maintain a complaint file and investigation report for three years. 9. Complaint files will be available to the Department of Consumer & Industry Services upon request.

13 Updated 01/01/2017

Complaint Procedure – Exhibit C

Any person who has a complaint concerning resident abuse, neglect, or misappropriation of resident property, or who believes Friendship Village has violated either federal or state laws or rules applicable to nursing care facilities may make a written or oral complaint against Friendship Village. If such complaint is made to the Director of Nursing or other employees, the Director of Nursing will complete an investigation and if found to be true will also notify the Michigan Department of Consumer and Industry Services.

The Written Or Oral Complaint Should Be Directed To: Michigan Department of Consumer & Industry Services Bureau of Health Systems, Complaint Intake Unit

Po Box 30664 Lansing, MI 48909 Phone: 1-800-882-6006 Fax: 1-517 241-0093 Website: http://www.cis.state.mi.us/bbs

The department shall assist the person making oral complaint to reduce the complainant to writing within seven days after the oral complaint is made. Friendship Village understands that the basis of a complaint will not be provided to Friendship Village before on-site inspection by the Health Department personnel. The complaint will not be identified in the record of the complaint unless the complainant or the resident named in the complaint consents in writing to the disclosure or when the investigation results in an administrative hearing or unless disclosure is considered essential to the investigation. In this instance, the complainant shall be given the opportunity to withdraw the complaint before disclosure.

All complaint investigations shall commence within 15 days after receipt of the written complaint by the Department. Within 30 days after the receipt of the complaint, the Department shall provide the complainant with a copy of the written determination, the correction notice, the warning notice and the violation as listed. If the investigation is not completed within 30 days, the Department shall provide the complainant with a status report.

A complainant who is dissatisfied with the determination may request a hearing in the matter. The request for hearing shall be submitted in writing to the Director within 30 days after mailing the Department’s findings. Notice of the time and place of the hearing shall be sent to the complainant and the nursing care facility.

14 Updated 01/01/2017

Business Office Procedures

Business Office Hours The accounting personnel can generally be found in the office between the hours of 9:00 a.m. and 4:00 p.m., Monday through Friday. Persons making a special trip to Friendship Village in order to consult about an account are encouraged to call for an appointment with accounting personnel.

Residents Statements Statements of charges will be mailed to residents (or resident representatives) by the 15th calendar day of the month.

Payment of Resident Charges Residents (or their resident representatives) are required to pay room and board charges by the last business day of the following month. This includes private pay residents and residents pay amounts. Each private pay resident is notified at least 30 days in advance and LifeCare residents 60 days in advance of any rate change, etc., and, since we charge on a daily basis, the daily rate multiplied by the number of days in a given month will be the amount due from private pay and LifeCare residents. All ancillary services which include physician, hospital, pharmacy, diagnostic x-ray, ambulance, etc. will be billed directly to the resident and/or resident representative. These bills are to be paid directly to the provider of the services. Residents with insurance coverage for their pharmacy bills are required to notify the pharmacy of the details of the coverage as well as to provide them with a copy of the insurance card or necessary information for the policy. Any special services charged to the resident by Friendship Village will be billed at the end of each month.

Residents with Limited Assets Friendship Village does not participate in the Medicaid or SSI programs. Private pay residents who deplete their assets will be required to seek admission to another nursing home which participates in one of these programs. Lifecare residents finding their assets are becoming depleted should contact the Administrator of Friendship Village to determine the level of financial assistance necessary to protect further asset erosion as provided in the policy determined by the Board of Directors of Friendship Village. 15 Updated 01/01/2017

Medicare Information

16 Updated 01/01/2017

Medicare Part A Benefits Explanation

Because of the complexity of applying for Medicare benefits, there are many misconceptions about Medicare in nursing homes. The following paragraphs will attempt to briefly review the benefits and limitations of Medicare coverage in a nursing facility.

Length of Benefits Not all residents will receive Medicare Part A benefits upon admission to a nursing home. Eligibility depends on many things. Where benefits do apply, the maximum number of days of coverage is 100. Benefits may be terminated prior to 100 days due to various circumstances. This number is only a limit, not a guaranteed number. Payment Medicare will pay in full the first 20 days of coverage, and then the remaining 80 days will be paid by Medicare and secondary insurance, respectively. If a resident does not have secondary insurance, they will be financially responsible for this amount. Medicare Part A Criteria While it is widely assumed that a hospital patient transferred to a nursing home will continue to be covered by Medicare, this often is not the case. Certain conditions must exist for coverage in a skilled nursing home. “Daily skilled inpatient treatment” and a prior hospital stay of 3 days must occur in order for the resident to be covered under Medicare. The resident must be transferred to the nursing facility within 30 days of discharge from the hospital and must be treated for the same illness or injury for which he/she was treated in the hospital, otherwise, Medicare will deny benefits for a resident. Termination Because conditions may change daily, it is not always possible to predict the length of coverage one will receive. Termination may come from, 1) further coverage, 2) the Quality Review Committee for the same reason, or 3) the exhaustion of eligible days. In all cases, you will receive a letter indicating termination of coverage and the effective date of termination. Please sign the attached Medicare form when such a letter is received, keep 1 copy and return the other to the facility in the self-addressed, stamped envelope. Information Medicare information is available for you to take home and can be found outside the office of the social services coordinator. If you need to speak with someone, please contact the accounting office at (269) 381-0560. 17 Updated 01/01/2017

Ancillary Charges

18 Updated 01/01/2017

Basic Charges List

The service to be provided by the nursing facility and the amount to be paid by the resident (per Diem rate and advance deposit may not apply to the residents with a full LifeCare contract through Friendship Village of Kalamazoo).

The following services are available at Friendship Village of Kalamazoo and are included in the basic private-pay per Diem rate of $301.00 a day for a semi-private room or a $335.00 a day for a private room:

• A semi-private or private room

• Nursing services provided by licensed and non-licensed personnel on a twenty-four (24) hour per day basis. The organized nursing services will be provided by qualified nursing personnel sufficient in number to meet the total nursing needs of all residents and to meet staffing requirements as set forth by State and Federal health agencies

• Dietetic services which include at least three (3) meals or their equivalent served daily with a substantial bedtime snack

• Planned and organized activities appropriate to the needs and interest of each resident

• Administration of medication by licensed personnel

• Availability of chaplain services

• Social services

• Television

• Availability of wheelchairs

• Linens

19 Updated 01/01/2017

Friendship Village Notice of Privacy Practices November 2015

This notice describes how health information about you may be used and disclosed and how you may obtain access to this information. Please review it carefully.

Your privacy is a high priority for us and it will be treated with the highest degree of confidentiality. This Notice applies to all information and records related to your care that we have received or created This Notice informs you about the possible uses and disclosures of your protected health information. It also describes your rights and obligations regarding your protected health information. In order for us to be able to provide you with the best service and care, we need to receive protected health information from you. However, we want to emphasize that we are committed to maintaining the privacy of this information in accordance with state and federal laws. We are required by law to:  Maintain the privacy of your protected health information;  Provide to you this detailed Notice of our legal duties and privacy practices relating to your protected health information; and  Abide by the terms of the Notice that is currently in effect. We reserve the right to change the terms of this Notice and make the new Notice provisions effective for all protected health information that the Community maintains. Protected Health Information While receiving care from the Community, information regarding your healthcare history, treatment, and payment for your health care may be originated and/or received by us. State and federal laws protect information that can be used to identify you and which relates to your health care or your payment for health care. This is your protected health information.

1 Updated 11/2015 Collecting Information We collect protected information about you to help us provide the best service, assistance and care, provide billing services and to fulfill legal and regulatory requirements. The type of information the Community may receive from you varies according to the assistance and care that you may need. If we become aware that an item of your protected health information may be materially inaccurate, we will make a reasonable effort to re‐verify its accuracy and correct any error as appropriate.

Security Standards We continue to assess new technology to evaluate our ability to provide additional protection for your protected health information. We maintain physical, electronic and procedural safeguards that comply with state and federal standards to guard your protected health information.

Using and Disclosing Your Protected Health Information for Treatment, Payment or Health Care Operations We have described the uses and disclosures below and provide examples of the types of uses and disclosures we may make in each of these categories. For Treatment We will use and disclose your protected health information in providing you with treatment and services. We may disclose your protected health information to Community and non‐Community personnel who also may be involved in your care, including, but not limited to, physicians, nurses, nurse aides, and physical therapists. Our workforce has access to such information on a need to know basis. For example, a nurse caring for you will report any change in your condition to your physician. Your physician may need to know the medications you are taking before prescribing additional medications. It may be necessary for the physician to inform the nurses or staff of the medications you are taking so they can administer the medications and monitor any possible side effects. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health‐related benefits and services which may be of interest to you. We may also disclose protected health information to individuals who will be involved in your care after you leave the Community. Anyone who has access to protected health information is required to protect it and keep it confidential. For Payment We may use and disclose your protected health information so that we can bill and receive payment for the treatment and services you receive at the Community. Bills requesting payment will usually include information which identifies you, your diagnosis and any procedures performed or supplies used. For billing and payment purposes, we may disclose your protected health information to your legal representative, an insurance company, Medicare, Medicaid or another third party payer. For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for a proposed treatment or service.

2 Updated 11/2015 For Health Care Operations We may use and disclose your protected health information for Community operations. These uses and disclosures are necessary to monitor the health status of residents, manage the Community and monitor the quality of our care. For example, we may use protected health information to evaluate our Community’s services, including the performance of our staff. In addition, we may release your protected health information to another individual or covered entity for quality assessment and improvement activities or for review of or evaluation of health care professionals. Health Care Operations may also include the use of information for quality assurance, training, accreditation, medical review, auditing and business planning.

Using and Disclosing Protected Health Information for Other Specific Purposes Community Directory The Community maintains a directory of resident names and their location within the Community. Unless you object, we will include certain limited information about you in our Community directory. This information may include (i) your name, (ii) your location in the Community, and (iii) your religious affiliation. Our directory does not include health information about you. We may release information in our directory, except for your religious affiliation, to people who ask for you by name. We may provide the directory information, including your religious affiliation, to any member of the clergy. You are not obligated, however, to consent to the inclusion of your information in the Community directory. You may restrict or prohibit these uses and disclosures by notifying the Community in writing of your restriction or prohibition.

Community Culture The culture of our Community includes informing residents and staff of changes in your health status to maintain our sense of “community.” You may restrict or prohibit these uses and disclosures by notifying the Community in writing.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose your protected health information to a family member, a close personal friend, your legal representative and any clergy, who are involved in your care to the extent necessary for them to participate in your care. You may restrict or prohibit these uses and disclosures by notifying the Community in writing of your restriction or prohibition.

Emergencies In the event of an emergency or your incapacity, we will do what is consistent with your known preference (if any), and what we determine to be in your best interest. We will inform you of uses or disclosures of protected health information under such circumstances and give you an opportunity to object as soon as practicable.

Disaster Relief We may disclose your protected health information to an organization assisting in a disaster relief effort.

As Required By Law We will disclose your protected health information when required by law to do so.

3 Updated 11/2015 Public Health Activities We may disclose your protected health information for public health activities. These activities may include, for example:  reporting for preventing or controlling disease, injury or disability;  reporting deaths;  reporting abuse or neglect of a dependent adult;  reporting reactions to medications or problems with products;  notifying a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; or  Disclosing for certain purposes involving workplace illness or injuries. Reporting Victims of Abuse, Neglect or Domestic Violence We may use or disclose protected health information to protective services or social services agency or other similar government authorities, if we reasonably believe you have been the victim of abuse, neglect or domestic violence.

Health Oversight Activities We may disclose your protected health information to a health oversight agency for oversight activities authorized by law. These may include, for example, audits, investigations, inspections and licensure actions, judicial/administrative proceedings to which you are not a party, or other legal proceedings. In most cases, the oversight activity will be for the purpose of overseeing the care rendered by the Community or the Community's compliance with certain laws and regulations. The Community does not control or define what information is needed by the health oversight agencies.

Judicial and Administrative Proceedings We may disclose your personal health information in response to a court or administrative order. We may also disclose information in response to a subpoena, discovery request, or other lawful legal process; efforts will be made to contact you regarding the request or to obtain an order or agreement protecting the information.

Law Enforcement We may also release your protected health information to law enforcement officials for the following purposes:  Pursuant to a court order, warrant, subpoena/summons or administrative request;  Identifying or locating a suspect, fugitive, material witness or missing person;  Regarding a crime victim, but only if the victim consents or the victim is unable to consent due to incapacity and the information is needed to determine if a crime has occurred, non‐disclosure would significantly hinder the investigation, and disclosure is in the victim's best interest;  Regarding a decedent, to alert law enforcement that the individual's death was caused by suspected criminal conduct; or  For reporting suspected criminal activity. Coroner, Healthcare Examiners, Funeral Homes We may release your personal health information to a coroner, medical examiner, and funeral director.

4 Updated 11/2015 Organ Donation We may release information to an organization involved in the donation of organs if you are an organ donor.

Fundraising We may use your protected health information for the purpose of contacting you as part of a Community based fundraising effort. Protected health information that may be used as part of the fundraising effort includes name, address, other contact information, age, gender, date of birth, dates of health care provided, treating physician, outcome information, and health insurance status. Use or disclosure of any other protected health information for fundraising purposes will require your authorization. The Community, an affiliated organization, such as a foundation or a business associate may contact you regarding the Community's fundraising efforts. If you do not wish to be contacted regarding fundraising activities, you may contact Ken Greschak at 269‐381‐7155 or you may send an email to [email protected] and request your name be removed from our fundraising list.

Research Your protected health information may be used for research purposes if it has been de‐identified. In most other instances where your protected health information is used or disclosed for research purposes your authorization will be needed unless the Institutional Review Board or a Privacy Board has stated your authorization is not necessary.

More Stringent Laws Some of your protected health information may be subject to other laws and regulations and provided greater protection than outlined in this Notice. For instance, HIV/AIDS, substance abuse, mental health and genetic information are often given greater protection. In the event your protected health information is afforded greater protection under federal or state law, we will comply with the applicable law.

Your Rights You have the following rights regarding your protected health information at the Community:  The right to receive notice of our policies and procedures used to protect your protected health information;  The right to request that certain uses and disclosures of your protected health information be restricted;  The right to restrict disclosure to a health plan of your information where you have paid the full out of pocket costs for the health care item or services rendered;  The right to access your protected health information;  The right to request that your protected health information be amended;  The right to obtain an accounting of certain disclosures by us of your protected health information for the past six years;  The right to revoke any prior authorizations for use or disclosure of protected health information, except to the extent that the Community has already acted on your authorization;

5 Updated 11/2015  The right to request the method by which your protected health information is communicated; and  The right to receive notification of any breach of your unsecured protected health information.

Our Rights  We have the right not to agree to your requested restrictions on the use or disclosure of your personal health information. If we do agree to accept your requested restrictions, we will comply with your request except as needed to provide you with emergency treatment.  We have the right to deny your request to inspect or receive copies of your protected health information in certain circumstances.  We have the right to deny your request for amendment of protected health information if it was not created by us, if it is not part of your personal health information maintained by us, if it is not part of the information to which you have a right of access, or if it is already accurate and complete, as determined by us.

Authorization Uses and disclosures of your protected health information not allowed by law under our Notice of Privacy Practices will only be made with your written authorization. You can revoke the authorization as described in your written authorization. If you revoke your authorization, we will no longer use or disclose your protected health information for the purposes covered by the authorization, except where we have already relied on the authorization. Below are a couple of examples when authorizations will be required.

Marketing Your protected health information will not be provided to third‐party marketers without an authorization. We will not sell your information to others for use and marketing purposes without your specific authorization. Psychotherapy Notes In the event psychotherapy notes are maintained as part of your protected health information, those notes will not be used or disclosed without your authorization, except in limited circumstances.

6 Updated 11/2015 Complaints If you believe your privacy rights have been violated, you may file a written complaint with our Privacy Official. The Privacy Official will review and respond to you in a timely manner. At any time, you may contact the Office of Civil Rights in the U.S. Department of Health and Human Services.

Region V ‐ Chicago (Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin)

Celeste Davis, Regional Manager Office for Civil Rights U.S. Department of Health and Human Services 233 N. Michigan Ave., Suite 240 Chicago, IL 60601 Voice Phone (800) 368‐1019 FAX (312) 886‐1807 TDD (800) 537‐7697 You will not be retaliated against for filing a complaint.

Change to This Notice We will promptly revise this Notice whenever there is a material change to the permitted uses or disclosures, your individual rights, our legal duties or other privacy practices stated in this Notice. We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all protected health information already received and maintained by the Community as well as for all protected health information we receive in the future. We will post a copy of the current Notice in the Community. In addition, you may obtain a current Notice of Privacy Practices at any time from Administration.

Acknowledgment We request that you sign an Acknowledgment of Receipt of Friendship Village's Notice of Privacy Practices, attached as Exhibit A.

CONTACT INFORMATION If you have any questions about this Notice or would like further information concerning your privacy rights, please contact:

Friendship Village Attn: Ashley Bechtel 1400 North Drake Road Kalamazoo, MI 49006

7 Updated 11/2015

Health Center Inventory Current Charges Reference Description Qty Price Number Vendor MDT219860 OVATION WHITE PILLOW 1/EA $7.60 5801000 850 105 00 MEDLINE NON24776 SAFETY GOGGLES 1/EA $6.00 5801000 850 105 00 MEDLINE GOJ963124 PURELL ALOE HAND SANITIZER 1/EA $3.24 5801000 850 105 00 MEDLINE MSC263820 READY FLUSH WIPES 1/PK $2.54 5801000 850 105 00 MEDLINE MSC263153ALALOE TOUCH WIPES 1/PK $3.52 5801000 850 105 00 MEDLINE 63014000 CATH SUCTION TBG. 1/EA $1.74 5854000 850 105 19 MCKESSON 6004000 CATH SUCTION 14 FR COILED 1/EA $0.66 5854000 850 105 19 MCKESSON 10001700 CAP SHOWER DISP 1/EA $0.18 5854000 850 105 19 MCKESSON 60013000 SKINSLEEVE 1/EA $34.20 5854000 850 105 19 MCKESSON 10103000 PROT. GLENSLEEVE WHITE 1/PR $21.36 5854000 850 105 19 MCKESSON DYNDC8522 BED PAN FRACTURE 1/EA $1.48 5854000 850 105 19 MEDLINE 11402900 LARGE GOLD HVYDTY BED PAN 1/EA $7.24 5854000 850 105 MCKESSON DYNC1810 5 CC CATH, 10 CC SYR. 1/EA $2.20 5854000 850 105 MCKESSON DYND70100H ENEMA BAG SET 1/EA $2.84 5854000 850 105 19 MEDLINE 10971700 EMERY BOARD 6/BG $0.32 5854000 850 105 19 MCKESSON NON4420 ACCU-THERM ICE 1/EA $3.06 5854000 850 105 19 MEDLINE 16152500 SCAPLE 1/EA $1.44 5854000 850 105 19 MCKESSON 60021902 CATH EXT TBG. 1/EA $4.54 5854000 850 105 19 MCKESSON 44501900 14 FR SELF CATH 10/PK $1.90 5854000 850 105 19 MCKESSON 14101900 CATH URETH RR STP 14FR 1/EA $0.78 5854000 850 105 19 MCKESSON 32141900 CATH SIL LTX 14FR 30CC 2W 1/EA $1.94 5854000 850 105 19 MCKESSON 23161900 CATH SIL LTX 16FR 30CC 2W 1/EA $1.94 5854000 850 105 19 MCKESSON 35631918 CATH SIL LTX 20 F 2W 5 CC 1/EA $4.28 5854000 850 105 19 MCKESSON 33201900 CATH SIL COATED 30CC3W 1/EA $5.78 5854000 850 105 MCKESSON 36111920 CATH SIL LTX 20F 2W 30CC 1/EA $4.00 5854000 850 105 19 MCKESSON 52161900 CATH SIL LTX 16FR 5CC 2W 1/EA $1.94 5854000 850 105 19 MCKESSON 35581914 CATH SIL LTX 14F 2W 5 CC 1/EA $6.40 5854000 850 105 19 MCKESSON 35631918 CATH SIL LTX 18F 2W 5CC 1/EA $3.58 5854000 850 105 19 MCKESSON 36071918 CATH LATEX 18 FR 30CC 2W 1/EA $4.00 5854000 850 105 19 MCKESSON 35671922 CATH SIL LTX 22F 2W 5CC 1/EA $4.00 5854000 850 105 19 MCKESSON DYND13614 R.R COUDE CATH 1/EA $6.10 5854000 850 105 19 MCKESSON 20002800 12CC SAFETY SYR. 1/EA $1.38 5854000 850 105 19 MCKESSON 55582800 B.D 5CC SAFETY SYR. 1/EA $0.96 5854000 850 105 19 MCKESSON DYNC1815 TRAY-CATH INSERT 30 CC 1/EA $3.66 5854000 850 105 19 MCKESSON DYND10700 14' URETHERAL CATH. 1/EA $2.64 5854000 850 105 19 MEDLINE SYR110010 10 ML L.L W/OUT NDL 1/EA $0.20 5854000 850 105 19 MEDLINE DYND1820 TRAY URETH CATH-14Fr 1/EA $3.90 5854000 850 105 19 MCKESSON 82153000 DRAIN BAG W/C HOLDER 1/EA $22.98 5854000 850 105 19 MCKESSON 60241900 PREFILLED 60 CC SYR. 1/EA $6.28 5854000 850 105 19 MCKESSON 28411900 LEG BAG 1/EA $2.54 5854000 850 105 19 MCKESSON 20002800 SYR 12 CC SFTY 1/EA $1.38 5854000 850 105 19 MCKESSON PSY8143 POSEY CATH STRAP 1/EA $4.68 5854000 850 105 19 MEDLINE 34111200 KIT SPECIMEN CATH FEM. 8 FR 1/EA $5.26 5854000 850 105 19 MCKESSON NON245277 TISSUE FCL KLNX 1/EA $1.36 5854000 850 105 19 MEDLINE EDS51105 TOOTHPASTE 2 .5OZ 1/EA $3.10 5854000 850 105 19 MEDLINE 81112901 BASIN EMESIS 9" 16OZ ROSE 1/EA $0.22 5854000 850 105 19 MCKESSON 19412000 CLSR SKN FLEX/SKIN CLOSURES 1/EA $0.46 5854000 850 105 19 MCKESSON MDS137015ZZ HAIRBRUSH ADULT 1/EA $0.56 5854000 850 105 19 MEDLINE CUR003501 A& D 2-OZ TUBE 1/EA $2.24 5854000 850 105 19 MEDLINE MSC095024 MEDSPA SHAMPOO 1/EA $3.50 5854000 850 105 19 MEDLINE DYND80342 BASIN WASH 7 .5QT GRAPHITE 1/EA $1.38 5854000 850 105 19 MEDLINE MDS136405Z DENT TAB 18/PK $1.44 5854000 850 105 19 MEDLINE 6001 LEG SKINSLEEVE 1/EA $34.20 5854000 850 105 19 MCKESSON

8/16/2017 8:36 AM Page 1 of 6 J:\Health Center\Resident charge list Health Center Inventory Current Charges Reference Description Qty Price Number Vendor 39082800 SYR 3CC SFTY 1/EA $0.90 5854000 850 105 19 MCKESSON 39432800 EAR SYRINGE 3OZ 1/EA $14.00 5854000 850 105 19 MCKESSON 40141200 SPEC COLL PLSTC HAT 800CC 1/EA $0.90 5854000 850 105 19 MCKESSON DYND80235H SUPREME URINAL 1/EA $1.16 5854000 850 105 19 MEDLINE mec37226 CLIPPER TOENAIL 1/EA $0.50 5854000 850 105 19 MEDLINE 42761700 PICK HAIR BLACK MED 1/EA $0.30 5854000 850 105 19 MCKESSON 43021400 PETRO JELLY VASELINE 1OZ 1/EA $1.32 5854000 850 105 19 MCKESSON DYND702937 DENTURE CUP 1/EA $0.24 5854000 850 105 19 MEDLINE 47362900 GRADUATE OPAQUE TRNGL32OZ 1/EA $0.98 5854000 850 105 19 MCKESSON 48444000 SUCT CANSTR 1200CC DISP 1/EA $10.14 5854000 850 105 19 MCKESSON CRI4000 YELLOW DISP. GOWNS 1/BAG $7.58 5854000 850 105 19 MEDLINE 54252500 KIT SUTURE REMVL W/FORCEP 1/EA $1.58 5854000 850 105 19 MCKESSON MDS136850 TOOTHBRUSH ADULT SOFT 1/EA $0.20 5854000 850 105 19 MEDLINE 56021700 TOOTHETTES FLAVORED SGL 10/PK $1.82 5854000 850 105 19 MCKESSON MDS137000 COLD PACKS 1/EA $1.04 5854000 850 105 19 MEDLINE DYND50132 YANKAUER SUCT W/VENT 1/EA $10.12 5854000 850 105 19 MEDLINE MDS096065 BIOTENE MOUTH WASH 1/EA $2.62 5854000 850 105 19 MEDLINE MDTDBLTREDXXL LARGE GRIP SOCK 1/PK $1.48 5854000 850 105 19 MEDLINE MDTBLTREADL XXL GRIP SOCKS 1/EA $1.58 5854000 850 105 19 MEDLINE MDT211218XLI XL GRIP SOCKS 1/EA $1.10 5854000 850 105 19 MEDLINE 61512400 KIT HEMOCCULT SLIDE 100S 1/EA $1.34 5854000 850 105 19 MCKESSON 57702801 35 ML CATHETER TIP SYRINGE 1/EA $1.96 5854000 850 105 19 MCKESSON MLC22196 HOLDER TOOTHBRUSH LG COLOR 1/EA $0.36 5854000 850 105 19 MEDLINE 62242800 SYR 60 CC REG LEUR LOC 1/EA $1.34 5854000 850 105 19 MCKESSON 68621700 SWAB LEMON GLYCERINE 3/PK $0.26 5854000 850 105 19 MCKESSON NON27122 ISOLATION MASK 1/BX $6.78 5854000 850 105 19 MEDLINE 10501700 RAZOR TWIN BLADE DISP 1/EA $0.14 5854000 850 105 19 MCKESSON DYND80102H GRAY SITZ BATH 1/EA $7.10 5854000 850 105 19 MEDLINE 67162500 STAPLE REMOVER ECONOMY 1/EA $2.24 5854000 850 105 19 MCKESSON 70001700 COMB ECONOMY 7" BLACK 1/EA $0.06 5854000 850 105 19 MCKESSON 27301300 GLOVE LARGE STERILE 1/EA $0.98 5854000 850 105 19 MCKESSON 70161800 SHAMPOO HYDX NR 16OZ 1/EA $4.86 5854000 850 105 19 MCKESSON SWD500777H 35 ML L.L SYR 1/EA $0.98 5854000 850 105 19 MEDLINE MEC37224 FINGER CLIPPER 1/BX $0.50 5854000 850 105 19 MEDLINE 12131700 FIXODENT 1.4 1/EA $11.28 5854000 850 105 19 MCKESSON 73231700 FIXODENT 2.4 OZ 1/EA $16.16 5854000 850 105 19 MCKESSON MSC095010 MEDSPA DEOD. 1/EA $0.96 5854000 850 105 19 MEDLINE 77032300 SWABS PVI 3S 3/PK $0.44 5854000 850 105 19 MEDLINE 79612700 ENEMA PHOSPHATE (BLUE) 1/EA $2.40 5854000 850 105 19 MEDLINE 1263300 ENEMA PHOSPHATE (GREEN) 1/EA $3.74 5854000 850 105 19 MCKESSON 88013000 PROT HEEL/ELBOW M/L 1/PR $13.82 5854000 850 105 19 MEDLINE 11731700 DENT CLN DENTUCREME 3 1/EA $6.78 5854000 850 105 19 MCKESSON 95942800 SYR 3CC 23GX1 SFTY LOK 1/EA $0.46 5854000 850 105 19 MEDLINE 96502800 Syringe 30cc L .L. 1/EA $1.08 5854000 850 105 19 MEDLINE DYND70642 60 CC PISTON SYR 1/EA $0.44 5854000 850 105 19 MEDLINE MSC095362 SOOTH & COOL BODY LOTION 1/BT $1.74 5854000 850 105 19 MEDLINE MSC094424 REMEDY SKIN CREAM, 4 OZ 1/EA $5.48 5854000 850 105 19 MEDLINE MSC094544 REMEDY CALAZINE CREAM 1/EA $6.04 5854000 850 105 19 MEDLINE MSC094604 REMEDY ANTIFUNGAL CREAM, 4OZ 1/EA $6.08 5854000 850 105 19 MEDLINE MSC094603 ANTIFUNGAL POWDER 1/EA $5.22 5854000 850 105 19 MEDLINE MSC095323 FOAMING PERI WASH 1/EA $6.42 5854000 850 105 19 MEDLINE MPH191101 MEDLINE SHAVE CREAM 1/EA $2.00 5854000 850 105 19 MEDLINE 21071300 GLOVE VNL TRFLX MED ST. 1/EA $0.92 5854000 850 105 19 MCKESSON

8/16/2017 8:36 AM Page 2 of 6 J:\Health Center\Resident charge list Health Center Inventory Current Charges Reference Description Qty Price Number Vendor 72281300 STERILE P.F LARFE GLOVES 1/EA $0.50 5854000 850 105 19 MCKESSON CNHBAR01DB SLPR SOCKS-BARI 1/EA $2.00 5854000 850 105 19 MEDLINE MDS195075 GLOVES MEDIUM GREEN ALOE 1/EA $7.46 5854000 850 105 19 MEDLINE MDS195074 GLOVES SMALL GREEN ALOE 1/EA $7.46 5854000 850 105 19 MEDLINE MDS195076 GLOVES LARGE GREEN ALOE 1/EA $7.46 5854000 850 105 19 MEDLINE MDS195077 GLOVES XLARGE GREEN ALOE 1/EA $9.34 5854000 850 105 19 MEDLINE NPKC22370 SALINE WIPES 1/bx $0.56 5854000 850 105 19 MCKESSON 1025c60c20 60 ML SYRINGE REG. TIP, NO NEEDLE 1/EA $1.12 5854000 850 105 19 MCKESSON 60831700 LIP MOISTURIZER 1EA $3.70 5854000 850 105 19 MCKESSON 27172800 3CC SYRINGE 23G 1 1/EA $0.28 5854000 850 105 19 MCKESSON 44801900 CATH URETH RR STP 14FR 1/EA $7.00 5854000 850 105 MCKESSON 42012700 HYDROGEN PEROXIDE 4 OZ 1/EA $1.34 5854000 850 105 19 MCKESSON 30891700 SUNMARK LIP BALM 1/EA $1.22 5854000 850 105 19 MCKESSON DYNC1810 FOLEY TRAY PRE-FILLED SYR. 1/EA $2.16 5854000 850 105 19 MEDLINE 42751700 LIP VASELINE THERAPY 1/EA $2.84 5854000 850 105 19 MCKESSON MSC9341OEPZ SILVASORB 4X10 DRESSING 1/EA $67.00 5854000 850 105 19 MEDLINE 42242000 NON WOVEN SPONGES 2X2 1/EA $0.04 5854000 850 105 19 MCKESSON 91103901 SOL IRRG 1000ML 1/EA $19.92 5854000 850 105 19 MCKESSON MSC5575 F-EXUDERM ODORSHLD HP SACRAL 6 1/ea $57.04 5854000 850 105 19 MEDLINE 16282100 TEGADERM DRSG 6X8 1/EA $9.72 5854000 850 105 19 MCKESSON NON251710Z CURAD NONADH 1/EA $0.84 5854000 850 105 19 MEDLINE 76432000 CURAD ADH 3X4 1/EA $0.84 5854000 850 105 19 MEDLINE CUR253440 CURAD XEROFORM GAUZE 1/EA $2.28 5854000 850 105 19 MEDLINE 22082000 GAUZE 2X2 8PLY PERF NS 50/PK $1.44 5854000 850 105 19 MCKESSON SQU403765H AQUACEL 4X4.47 AG HYDRO 1/EA $92.16 5854000 850 105 19 MEDLINE 42782100 AQUACEL EXTRA AG 6X6 1/EA $179.80 5854000 850 105 19 MCKESSON MSC1200EP OPTIFOAM HEEL PROT. 1/EA $18.60 5854000 850 105 19 MEDLINE 96102000 TELFA NON ADHERENT 2X3 1/EA $0.30 5854000 850 105 19 MCKESSON FER1044Z POLYMEM SILVER 4.25X4.25 NADH 1/EA $31.42 5854000 850 105 19 MCKESSON 23122000 TELFA GAUZE NADH 3X4 ST 1/EA $0.54 5854000 850 105 19 MCKESSON MSC5100 EXUDERM LP 4X4 1/EA $18.94 5854000 850 105 19 MCKESSON 18882100 SACRAL HYDRO. 6X7 1/EA $13.52 5854000 850 105 19 MCKESSON 42652000 SUPER SPONGE 6x6.75 1/EA $0.60 5854000 850 105 19 MCKESSON 46292100 OPSITE GRID DRSG 4X4.75 1/EA $2.76 5854000 850 105 19 MCKESSON 3322000 GAUZE 3x3 ST SPONGE 1/EA $0.08 5854000 850 105 19 MCKESSON CUR253590 XEROFORM DRSG 5X9 ST 1/EA $2.10 5854000 850 105 19 MCKESSON 40082000 GAUZE 4X4 8PLY ST 2S 1/EA $0.10 5854000 850 105 19 MCKESSON 23122701 HYDROGEN PER 3% 16OZ 1/EA $2.08 5854000 850 105 19 MCKESSON CUR253440Z XEROFORM DRSG 4X4 ST CURAD 1/EA $1.14 5854000 850 105 19 MCKESSON CUR253220 XEROFORM CURAD 2X2 1/EA $0.80 5854000 850 105 19 MEDLINE 44122000 GAUZE 4X4 12PLY PERF NS 50/PK $2.64 5854000 850 105 19 MEDLINE 46302100 OPSITE GRID DRSG 4X4 1/EA $2.30 5854000 850 105 19 MCKESSON 3342000 BNDG ELST 4" LF 1/EA $1.76 5854000 850 105 19 MCKESSON 57002100 HYDROGEL 4X4 1/EA $4.92 5854000 850 105 19 MCKESSON 62041900 SOL 9% NACL 100ml SALINE 1/EA $1.02 5854000 850 105 19 MCKESSON 66432100 Allevyn 3x3 dressing ADH 1/EA $7.40 5854000 850 105 19 MCKESSON 66442100 Allevyn 5x5 dressing ADH 1/EA $11.80 5854000 850 105 19 MCKESSON PRM25865 GAUZE--KERLEX 1/EA $1.02 5854000 850 105 19 MEDLINE 88022100 CALCIUM ALG. 2X2 1/EA $2.12 5854000 850 105 19 MCKESSON 35262100 CALCIUM AG 4X4 1/EA $6.66 5854000 850 105 19 MEDLINE MSC9422EPZ MAXORB EXTRA AG 1/EA $5.50 5854000 850 105 19 MEDLINE 62701901 SOL IRRG. .9NACL 250ml SALINE 1/EA $3.56 5854000 850 105 19 MCKESSON 75151100 DRAPE STERILE 18X26 1/EA $0.60 5854000 850 105 19 MCKESSON

8/16/2017 8:36 AM Page 3 of 6 J:\Health Center\Resident charge list Health Center Inventory Current Charges Reference Description Qty Price Number Vendor 75522200 TAPE CURASILK 2"X10YD 1/EA $5.42 5854000 850 105 19 MCKESSON MSC9412EP MAXORB AG ROPE 1/EA $8.86 5854000 850 105 19 MEDLINE 76342100 ALLEVYN 4x4 NADH 1/EA $8.20 5854000 850 105 19 MCKESSON 75782100 ALLEVYN DRSG 4X4 THIN 1/EA $13.02 5854000 850 105 MCKESSON 295200 MEPILEX BORDER 3X3 1/EA $9.22 5854000 850 105 19 MEDLINE 76602100 DUODERM CGF DRSG 4X4 1/EA $15.82 5854000 850 105 19 MCKESSON SGR1027OH FIG DRN LEAF BAG 1/EA $10.36 5854000 850 105 MCKESSON 1626W TEGADERM FILM IV 4X4 1/EA $1.90 5854000 850 105 19 MEDLINE 1624W TEGADERM FILM IV 2X2 1/EA $0.66 5854000 850 105 19 MEDLINE 76422101 ALLEVYN DRSG 2X2 NADH 1/EA $7.58 5854000 850 105 19 MCKESSON MSC3044Z ADH. ISLAND DSG. 4X4 BORDER GAUZE 1/EA $1.84 5854000 850 105 19 MEDLINE 78812200 TAPE CURASILK 1"X10YD 1/EA $2.26 5854000 850 105 19 MCKESSON 79552100 DUODERM DRSG XTHIN 4X4 1/EA $6.74 5854000 850 105 19 MCKESSON 87712000 EYE PAD 1/EA $0.80 5854000 850 105 19 MEDLINE 90912000 ABD PAD 5X9 TNDRSRB ST 1/EA $0.68 5854000 850 105 19 MEDLINE 71982000 ABD PAD 8X10 TNDRSRB ST 1/EA $0.64 5854000 850 105 19 MCKESSON 92302100 CURASORB 2X2 1/EA $6.74 5854000 850 105 19 MCKESSON 92332100 CURASORB 4X4 CALCIUM ALGINATE 1/EA $12.62 5854000 850 105 19 MEDLINE MSC9348EP SILVASORB 4X10 DRESSING 1/EA $35.98 5854000 850 105 19 MCKESSON MDT221200 STOCKINETTE 2X25 1/RL $9.32 5854000 850 105 19 MEDLINE MDT221204 STOCKINETTE 4X25 1/RL $16.76 5854000 850 105 19 MEDLINE 59462100 BARR NSTING WIPE 1EA $0.82 5854000 850 105 19 MEDLINE MSC1266Z OPTIFOAM DRSG NON-ADH, 6X6 1/EA $10.70 5854000 850 105 19 MEDLINE MSC9614Z OPTIFOAM DRSG NON-ADH, 4X4 1/EA $12.02 5854000 850 105 19 MEDLINE 15282200 TAPE MICROFOAM 2X5.5 1/EA $13.24 5854000 850 105 19 MEDLINE 81122000 GAUZE PADS 2X2 ST 1/EA $1.00 5854000 850 105 19 MCKESSON MSC3066 ADH. ISLAND WOUND DSG6X6 1/EA $4.74 5854000 850 105 19 MEDLINE 295400 MEPILEX BORDER DRSG 6X6 1/EA $7.24 5854000 850 105 19 MEDLINE 28712100 MEPILEX AG 4X4 1/EA $23.92 5854000 850 105 19 MCKESSON MSC3222 BORDERGAUZE 2x2 1/EA $0.76 5854000 850 105 19 MEDLINE MSC5544 F-EXUDERM ODORSHIELD 4x4 1/EA $5.18 5854000 850 105 19 MEDLINE MSC9322 SILVASORB 2x2 ANTIMIC 1/EA $10.56 5854000 850 105 19 MEDLINE ALA395390Z MEPILEX DRSG 4X4 -BORDER 1/EA $77.80 5854000 850 105 19 MEDLINE 164154 CONFORMING BANDAGES 1/EA $0.24 5854000 850 105 19 MCKESSON MSC9422EPZ MAXORB XTRA AG 2X2 1/EA $4.46 5854000 850 105 19 MEDLINE PRM256000 AVANT GAUZE DRAIN SPONGES 1/EA $0.16 5854000 850 105 19 MEDLINE OTC OTC92101 ASPIRIN TABS, EC, 325 MG $0.05 5854000 850 105 19 MEDLINE OTC18016 ACETAMINOPHEN "SILIPAP" TYLENOL $0.60 5854000 850 105 19 MEDLINE OTC54225 COUGH DROPS SUGAR FREE CHERRY 1/bg $1.15 5854000 850 105 19 MEDLINE OTC10110 ACETAMINOPHEN TAB 325 MG 1000 CAPS 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC22110 ACETAMINOPHEN CAPS 500 MG 1000 CAPS 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC6031260BX ACETAMINOPHEN SUPP 650 MG 1/BX $1.40 5854000 850 105 19 MEDLINE OTCS0883C2 IBUPROFEN TAB 200 MG 1/BTL $0.05 5854000 850 105 19 MEDLINE OTCS0661C2 CHEWABLE ASPIRIN 81 MG 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC770418 ASPIRIN LOW DOSE 81 MG 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC92101 ASPIRIN TABS 325 MG 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC78101 ALLERGY RELIEF TAB 25 MG 1/BX $0.05 5854000 850 105 19 MEDLINE OTC79316 TUSSIN SYRUP 16 OZ 1/BTL $0.10 5854000 850 105 19 MEDLINE OTC9L75504 TUSSIN DM DAS SYRUP SF 4 OZ 1/BTL $0.20 5854000 850 105 19 MEDLINE OTC66016 TUSSIN DM 1/BTL $1.10 5854000 850 105 19 MEDLINE OTC8646 OMEPRAZOLE 1/BTL $1.27 5854000 850 105 19 MEDLINE OTC536560 ACIDGONE TABS (gaviscon) 1/BTL $0.25 5854000 850 105 19 MEDLINE

8/16/2017 8:36 AM Page 4 of 6 J:\Health Center\Resident charge list Health Center Inventory Current Charges Reference Description Qty Price Number Vendor OTC386575 SALINE NASAL SPRAY 1/BTL $2.26 5854000 850 105 19 MEDLINE OTC502198 SORE THROAT LOZENGES 18 BX 1/BX $0.20 5854000 850 105 19 MEDLINE OTC177121 SORE THROAT SPRAY 6oz 1/BTL $10.86 5854000 850 105 19 MEDLINE OTC0263566 LORATADINE 10 MG (CLARITIN) 1/BX $6.50 5854000 850 105 19 MEDLINE OTCS0673C2 ANTACID TABS W/CALCIUM 1/BTL $1.75 5854000 850 105 19 MEDLINE OTC266117A RANITIDINE TABS 75 MG 1/BX $0.55 5854000 850 105 19 MEDLINE OTC62912 ANTACID LIQUID 12 OZ (MYLANTA) 1/BTL $0.35 5854000 850 105 19 MEDLINE OTC772714 GENATON LIQUID 12 OZ (GAVISCON) 1/BTL $0.35 5854000 850 105 19 MEDLINE OTC64916 MILK OF MAGNESIA PINTS 1/BTL $0.20 5854000 850 105 19 MEDLINE OTC40101 DOCUSATE SODIUM SG 100 MG 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC40916 DOCUSATE SODIUM SYRUP 16 OZ 1/BTL $0.30 5854000 850 105 19 MEDLINE OTC44101 BISACODYL TABS 5 MG 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC10199BX BISACODYL SUPPOSITORIES 10 MG 1/BX $0.15 5854000 850 105 19 MEDLINE OTC45101 SENNA TABLETS 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC049060 SENNA S 1/BTL $0.10 5854000 850 105 19 MEDLINE OTCS1498C2 LAXATIVE POWDER ORANGE 13 OZ 1/BTL $0.80 5854000 850 105 19 MEDLINE OTCS0670C2 FIBER CAPLETS 500 MG 1/BTL $0.10 5854000 850 105 19 MEDLINE CUR001231 TRIPLE ANTIBIOTIC OINTMENT 1/TUBE $4.10 5854000 850 105 19 MEDLINE CUR015431 HYDROCORTIZONE 1 OZ TUBE 1/TUBE $2.60 5854000 850 105 19 MEDLINE OTC50101 MULTI-VITAMINS 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC52101 MULTI-VITAMINS W/IRON 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC53101 MULTI-VITAMINS W/MINERAL 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC51560 SILVERVITE SENIOR VITAMIN 1/BTL $0.10 5854000 850 105 19 MEDLINE OTC83101 VITAMIN C TABLETS 250 MG 1/BTL $0.05 5854000 850 105 19 MEDLINE 0TC60101 THERA 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC70310 FERROUS SULFATE 1/BTL $0.05 5854000 850 105 19 MEDLINE OTC423960 MAGNESIUM OXIDE 500MG 1/BTL $0.05 5854000 850 105 19 MEDLINE OTCS0296C2 ZINC TABS 50 MG 1/BTL $0.10 5854000 850 105 19 MEDLINE OTC532852 CRANBERRY CAPSULE 425 MG 1/BTL $0.10 5854000 850 105 19 MEDLINE OTC091160 GLUCOSAMINE CHONDROITIN 1/BTL $0.25 5854000 850 105 19 MEDLINE OTCS0801CZ ANTI-DIARRHEAL CAPLETS 1/BX $0.25 5854000 850 105 19 MEDLINE OTC0039850 MECLIZINE 12.5 MG 1/BTL $0.10 5854000 850 105 19 MEDLINE OTC17715 LIQUI TEARS 15 ML 1/BTL $3.22 5854000 850 105 19 MEDLINE MSC6102H HYDROGEL 1/EA $2.04 5854000 850 105 19 MEDLINE CUR003501 CURAD A & D OINTMENT 1/EA $2.24 5854000 850 105 19 MEDLINE TRESTORELG BRIEFS LARGE 1/BG $18.30 5852000 850 105 19 MEDLINE TRESTOREMD BRIEFS MEDIUM 1/BG $15.98 5852000 850 105 19 MEDLINE ITRESTOREXL BRIEFS XLARGE 1/BG $22.08 5852000 850 105 19 MEDLINE MSC23600 PROTECTIVE UNDERWEAR X-LARGE 1/BG $15.82 5852000 850 105 19 MEDLINE MSC23505 PROTECTIVE UNDERWEAR LARGE 1/BG $15.82 5852000 850 105 19 MEDLINE MSC23005 PROTECTIVE UNDERWEAR MEDIUM 1/BG $15.82 5852000 850 105 19 MEDLINE TRESTOREXXL BRIEFS XXL 1/BG $27.32 5852000 850 105 19 MEDLINE BCPADE02 PANTY LINER 1/BG $8.12 5852000 850 105 19 MEDLINE QTXAD302600 PT REACHERS 1/EA $29.62 5883000 850 105 19 MEDLINE ADC4053V CPR MASK FILTER 1/EA $5.36 5884000 850 105 19 MEDLINE ADC4053 CPR MASK 1/EA $16.94 5884000 850 105 19 MEDLINE 12 E-TANK 1/EA $20.00 5884000 850 105 19 MEDLINE 10163900 EZ WRAP TBG EAR COVER 1/EA $3.46 5884000 850 105 19 MEDLINE HCS4514 CANNULA 7' 1/PR $2.68 5884000 850 105 19 MEDLINE 86202 MASK 02 1/EA $0.68 5884000 850 105 19 MEDLINE HCS4516B CANNULA 14' 1/EA $1.20 5884000 850 105 19 MEDLINE HCS4514H CANNULA 25' 1/EA $1.96 5884000 850 105 19 MEDLINE 81313900 NON-REBREATHER MASK 1/EA $1.20 5884000 850 105 19 MEDLINE

8/16/2017 8:36 AM Page 5 of 6 J:\Health Center\Resident charge list Health Center Inventory Current Charges Reference Description Qty Price Number Vendor HCS4483 NEB W/T TBG MOUTH PC 1/EA $3.30 5884000 850 105 19 MEDLINE HCS4630 NEB MASK 1/EA $2.70 5884000 850 105 19 MEDLINE ASPIRATOR TUBE & FILTER ASSEMBLY 1/EA $0.12 5884000 850 105 19 MEDLINE BXT001900H SPIROMETER 1/EA $6.84 5884000 850 105 19 MEDLINE 20 15 FT. CANNULA 1/EA $8.74 5801000 850 105 00 MEDLINE 21 WATER TRAP 1/EA $3.70 5884000 850 105 19 MEDLINE 63014000 SUCTION MACHINE TUBING 1/EA $3.30 5884000 850 105 19 MEDLINE HUD1420 O2 OXYGEN TUBING CONNECTOR 1/EA $0.58 5884000 850 105 19 MEDLINE 70274200 O2 CYLINDER HOLDERS 1/EA $34.46 5884000 850 105 19 MEDLINE HCS4525 25' O2 TBG 1.36 5884000 850 105 19 MEDLINE

8/16/2017 8:36 AM Page 6 of 6 J:\Health Center\Resident charge list

Friendship Village Salon

Price List

Haircuts Miscellaneous Ladies—$ 20.00 Comb out—$5.00 & up Gentleman—$ 17.00 Eyebrow Arch—$8.00 Shampoo Beard Trim—$8.00 Shampoo & Set—$20.00 Nail Salon Services Shampoo Only—$5.00 Basic Manicure—$15.00 Shampoo, Dry & Comb—$10.00 Basic Manicure w/ Gel —$18.00 Shampoo, Dry & Curling Iron—$20.00 Basic Pedicure—$30.00 Conditioner Basic Pedicure w/ Gel —$33.00 Conditioner—$2.00 Gelish Nails—$25.00

Color / Rinse A-La-Carte Services

Color & Rinse—$2.00 Gel Polish —$8.00 Hair Tints—$ 40.00 & up Polish Change —$5.00

Permanents

Permanents—$65.00—$75.00

2016-2017 Price List

Channel Gu i d e

2 WTLJ - TCT Network 49 Animal Planet 3 WWMT - CBS 50 Telemundo 4 WOTV - ABC 51 Syfy 5 WLLA - Christian Television 52 TNT 7 WWMT - CW 53 USA Network 8 WOOD - NBC 54 FX 9 QVC 55 Comedy Central 10 WGN America 56 CNBC 11 WXMI - FOX 57 msnbc 12 WGVU - PBS 58 truTV 13 WZZM - ABC 59 CNN 14 WZPX - ION 60 HLN 15 WXSP - My TV 61 The Weather Channel 16 HSN 62 FOX News Channel 18 Univisión 63 BTN 20 FXX 64 E! 21 C-SPAN3 65 AMC 22 C-SPAN2 66 NBC Sports Network 23 C-SPAN 69 TV Land 24 Investigation Discovery 70 VH1 25 Lifetime 71 CMT 26 Disney Channel 72 Spike 27 ABC Family 73 BET 28 Cartoon Network 74 TCM 29 Nickelodeon 75 Esquire Network 31 FOX Business Network 78 Jewelry TV 32 TBS 79 Hallmark Channel 33 FOX Sports Detroit 80 BTN - Extra 1 34 ESPN2 81 BTN - Extra 2 35 ESPN 82 EWTN 36 MTV 83 ShopHQ 37 TBN - Trinity Broadcasting 84 TV Guide Network 38 Golf Channel 88 FOX Sports Detroit Plus 39 TLC 89 Oxygen 40 Discovery Channel 90 FOX Sports 1 41 Bravo 92 Disney XD 42 A&E 93 GSN 43 MTV2 94 MLB Network 44 HISTORY 96 INSP 45 HGTV 138 FOX Business Network 46 National Geographic 153 EWTN 47 Food Network 157 INSP 48 Travel Channel 161 TBN - Trinity Broadcasting 165 Investigation Discovery 728 Disney Channel HD 184 Charter Local Programming 731 ShopHQ HD 185 Charter Main Street 732 The Weather Channel HD 186 Revenue Frontier 733 CNN HD 187 P.E.G. Access 734 FOX News Channel HD 188 P.E.G. Access 735 HLN HD 189 P.E.G. Access 736 CNBC HD 190 P.E.G. Access 737 FOX Business Network HD 191 P.E.G. Access 738 msnbc HD 192 WOTV - Weather 741 FX HD 193 WOOD - Weather 743 truTV HD 194 WLLA - Me TV 744 USA Network HD 195 WGVU - PBS (Simulcast) 745 TBS HD 196 WGVU - PBS Create 746 TNT HD 197 WGVU - MHz Worldview 747 Travel Channel HD 198 WXMI - Antenna TV 749 National Geographic HD 199 WXMI - ThisTV 751 INSP HD 204 ESPN 752 GSN HD 205 ESPN2 753 TV Land HD 210 FOX Sports 1 754 Hallmark Channel HD 212 FOX Sports Detroit 756 Esquire Network HD 219 FOX Sports Detroit Plus 757 E! HD 220 Golf Channel 758 Lifetime HD 229 BTN 759 Oxygen HD 230 BTN - Extra 1 760 Bravo HD 231 BTN - Extra 2 761 TV Guide Network HD 232 NBC Sports Network 764 Food Network HD 300 Univisión 765 HGTV HD 303 Telemundo 770 MLB Network HD 336 Cartoon Network 771 ESPN2 HD 337 Disney XD 773 ESPN HD 707 FOX Sports 1 HD 776 FOX Sports Detroit HD 710 Golf Channel HD 777 FOX Sports Detroit Plus HD 715 C-SPAN HD 778 BTN HD 716 WGN America HD 779 NBC Sports Network HD 717 HSN HD 780 WOTV - ABC (HD) 718 Jewelry TV HD 781 WWMT - CW (HD) 719 C-SPAN2 HD 782 WWMT - CBS (HD) 720 C-SPAN3 HD 783 WZZM - ABC (HD) 721 ABC Family HD 784 WZPX - ION (HD) 722 Nickelodeon HD 785 WGVU - PBS (HD) 725 Cartoon Network HD 786 QVC HD 726 Disney XD HD 787 WXMI - FOX (HD) 788 WOOD - NBC (HD) 789 WXSP - MyTV (HD) 792 Syfy HD 794 A&E HD 795 HISTORY HD 796 TLC HD 797 Discovery Channel HD 799 Animal Planet HD 800 Velocity HD 801 Spike HD 802 Comedy Central HD 803 Investigation Discovery HD 807 FXX HD 811 TCM HD 813 AMC HD 822 MTV HD 823 MTV2 HD 825 VH1 HD 826 CMT HD 828 BET HD 834 Univisión HD 837 TBN - Trinity Broadcasting HD 838 EWTN HD 842 Cartoon Network HD 843 Disney XD HD 996 C-SPAN3 997 C-SPAN2 998 C-SPAN Michigan Department of Licensing and Regulatory Affairs (LARA) Bureau of Community and Health Systems 611 W. Ottawa Street, P. O. Box 30664 Lansing, MI 48909 HEALTH FACILITY COMPLAINT FORM

Please print clearly or type information on all sections of this form. If you need help or have questions about this form, please call 1‐800‐882‐6006.

INFORMATION ABOUT PERSON FILING THE COMPLAINT If you wish to remain anonymous, do not complete this section. If anonymous, our office will not be able to contact you to obtain additional information or notify you of the results of the investigation. Your Name Daytime Phone # Evening Phone # ( ) ‐ Work ( ) ‐ Work Street Address City State Zip Code

E‐mail Address (that the department can use to contact you if more information is needed)

RESIDENT/PATIENT INFORMATION Resident/Patient Name Birthdate and/or Age / / Date Admitted/Entered Room # (if applicable) Date Discharge/Left (if applicable) / / / / Guardian or Resident/Patient Representative Daytime Phone # Evening Phone # ( ) ‐ ( ) ‐ FACILITY/AGENCY INFORMATION Nursing home/long term care facility Hospice agency or residence Hospital/Long Term Care Unit Home health agency Hospital (including psychiatric) Other* Surgery center

* Other federally certified providers include dialysis centers, rural health clinics, outpatient physical therapy (OPT) providers, comprehensive outpatient rehab facilities (CORF), portable X‐ray providers, and providers offering laboratory services.

Facility/Agency Name

Facility/Agency Street Address City State Zip Code MI

BHCS‐Complaint Form‐361 (Rev. 7/15) Authority: MCL 333.20176 Completion: Voluntary Page 1 of 3

INFORMATION ABOUT YOUR COMPLAINT Date of Problem/Incident Time / / : AM PM The Department will not disclose the name of a complainant or resident/patient during an investigation without written consent. However, the investigation can proceed quicker if the complaint can be discussed at the time of the investigation.

Do you give permission for the resident/patient’s name to be released? Yes No What is the complaint about? Attach additional sheets if necessary. No. of additional pages attached: ( )

Have you contacted the facility/agency Yes No If yes, name of the person you talked with? about your complaint? Your Signature: Date Signed:

BHCS‐Complaint Form‐361 (Rev. 7/15) Authority: MCL 333.20176 Completion: Voluntary Page 2 of 3

All Health Care Facilities that are state licensed and/or federally certified providers are required to post the name, title, location, and telephone number of staff responsible for receiving complaints. You may wish to contact the provider representative or administrator before filing this complaint.

The Department will send an acknowledgement letter upon receipt of the complaint and will send an additional letter after the investigation is completed to notify the complainant regarding the results of the investigation. You may submit the completed signed form to the Bureau of Community and Health Systems by mail, email or FAX to:

Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems – Health Facility Complaints P.O. Box 30664 Lansing, MI 48909 FAX (517) 241‐0093 BHCS‐Facility‐[email protected] www.michigan.gov/lara

Other agencies that help citizens with complaints are:

For complaints related to a state licensed child care center, adult foster care facility or adult/child camp, please visit our online complaint page for these additional covered providers.

The State Long‐Term Care Ombudsman The ombudsman investigates complaints at licensed long‐term care facilities. Call: 1‐866‐485‐9393 (toll‐free) or find more information at http://www.elderslaw.org

Department of Attorney General (AG) The AG investigates elder abuse and Medicaid fraud. Call: 1‐800‐242‐2873 or find more information at www.michigan.gov/ag

Michigan Protection & Advocacy Service (MPAS) MPAS can help you file a complaint or investigate an abuse/neglect allegation. Call: 1‐800‐288‐5923 or (517) 487‐1755 or find more information at www.mpas.org

Citizens for Better Care (CBC) CBC is an advocacy group for nursing home residents and families. Call: Detroit 1‐800‐833‐9548 or find more information at www.cbcmi.org

Bureau of Professional Licensing (BPL) BPL handles complaints against licensed professionals including physicians, nurses, etc. Find more information at www.michigan.gov/bpl

Michigan Department of Health and Human Services (MDDHS) DHHS handles abuse and neglect complaints. Find more information at www.michigan.gov/mdhhs.

The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc. under the Americans with Disability Act, you may make your needs known to this agency.

BHCS‐Complaint Form‐361 (Rev. 7/15) Authority: MCL 333.20176 Completion: Voluntary Page 3 of 3

Dear Resident / Resident Representative:

Welcome to Friendship Village. I am delighted that you have chosen our facility for your medical care. You will find our exceptional staff very willing and happy to help you with all your needs.

We would like to ensure that all resident’s belongings are labeled and inventoried. Please assist us in this task by completing an inventory list and fill in the resident’s personal items. This includes all clothing, valuables, glasses, dentures, electronics and such. We will be happy to assist if you have any questions or concerns with this process. When the inventory list is completed, please return it to the Social Worker or Activity Director.

Please remember to bring any new items brought into the facility to the front desk to be labeled and added to the resident’s inventory list. If you remove any inventoried items from the facility, as well, please report this to the front desk or Social Worker so the inventory list may be update.

Thank you in advance for your help in this endeavor.

Sincerely,

Kathy Harmon, RN

Administrator

What to Bring

 Power of Attorney, Living Will, Patient Advocate paperwork

 Insurance cards (we will copy and give back)

 List of all medications you take at home

 At least 7 changes of clothing (it is important to mark clothing even if you are doing own laundry. Unit clerk has a marker for you to use)

 Walking shoes with non‐skid bottoms

 Nightclothes

 Robe or Duster

 Slippers – non‐skid

 Miscellaneous Items

 Small familiar objects

Updated 10/02/2015

Friendship Village Health & Rehab Center Financial Responsibility for Residents

Admission as Medicare Part A

1. Resident must have Medicare part A coverage. 2. Resident must have a 3-day qualifying hospital stay. 3. Resident must have days remaining in their 100-day SNF benefit period. 4. Resident must qualify for daily skilled services, up to 100 days.

Medicare will pay 100% of covered services for the first 20 days, in most cases. The remaining 80 days are paid by Medicare and coinsurance. Currently, the coinsurance amount is $164.50 per day. If the resident does not have a secondary insurance coverage, they are responsible for payment of non-covered services, such as beauty or barber shop usage, laundry and certain nursing supplies.

Admission as Private Pay

1. An advance deposit equal to one month’s room and board charges is required. Currently, that amount is $10,185 for a private room and $9,150 for a semi-private room. This amount is refundable and will be applied to the final bill.

2. Private pay residents are charged a per diem rate of $335 for a private room and $301 for a semi-private room. The resident is financially responsible for additional services that aren’t considered “room and board”, such as beauty or barber shop usage, nursing supplies, etc.

Admission as Temporary Lifecare

1. Residents that have a LifeCare contract with Friendship Village will not pay room and board charges while temporarily residing in the Health Center. They will continue to pay for their monthly apartment service fee, which includes one meal per day while in the health center.

2. The resident is financially responsible for additional services that aren’t considered “room and board”, such as beauty or barber shop usage, laundry, nursing supplies, etc.

3. Three meals per day are served to each resident in the health center. A temporary resident will pay for the two additional meals per day. Currently, that per diem amount is $18.50.

Updated 10/2017 Admission as Permanent Lifecare

1. Residents that have a LifeCare contract with Friendship Village and have cleared out their apartment in order to be permanently assigned to the Health Center will pay a monthly service fee for room and board in accordance with their LifeCare contract.

2. The resident is financially responsible for additional services that aren’t considered “room and board”, such as beauty or barber shop usage, laundry, nursing supplies, etc.

3. Three meals per day are served to each resident in the Health Center. One meal per day is included in the monthly service fee. A permanent resident will pay for the two additional meals per day. Currently, that per diem amount is $18.50.

Updated 10/01/2016 Covered and Non‐Covered Services and Charges Under Medicare

Medicare Part A Certified

The room charge includes the following services:

 Room and board (semi‐private room; private room if medically necessary)  Nursing care  Supplies and equipment  Pharmacy  Medical supplies  Laboratory tests  Radiology  Specialty beds and mattresses  Physical, Occupational and Speech therapy  Respiratory therapy  Oxygen  Personal laundry

NON‐Covered Charges

Medicare does not pay for personal needs items or services. These include but are not limited to the following:

 Telephone  Private Duty Nurse  Beauty/barber shop

If the beneficiary meets the qualifying condition, Medicare will, in most cases, pay 100% of the covered daily charges for the first twenty (20) days. The beneficiary is responsible for a portion of the charges for days twenty‐one (21) through day one hundred (100) of each benefit period. That portion is the co‐insurance. The co‐insurance amount is established each year by the federal government. Medicare pays the remaining amount of the expenses. The beneficiary may have supplemental insurance that will pay for the co‐insurance.

Updated 10/02/2015

Friendship Village Kalamazoo Advance Directives Exhibit E

Definition of Advance Directive

An advance directive is “a written instruction, such as a Living Will or Durable Power of Attorney for Health Care, recognized under state law (whether statutory or as recognized by the courts of the state) and relating to the provision of such care when the individual is incapacitated”.

The written document specifies the type of medical care a resident wants in the future should he or she lose the ability to make decisions.

1. A Living Will is a written statement of your wishes regarding the use of any medical treatments and serves as a guide for your patient advocate and physician should you be unable to express your wishes. 2. A Durable Power of Attorney for Health Care, also known as a Health Care Proxy, is a document in which you give another person power to make medical treatment and related personal care decisions for you should you be unable to express your wishes.

An Individual’s Right to Execute an Advance Directive A resident has the right to participate in decisions regarding his or her health care, including the right to refuse medical or surgical treatment and the right to prepare advance directives.

Specific Laws Relating To Resident Rights

1. Public Act 312 Of 1990

A. A person 18 years of age or older who is of sound mind at the time a designation is made may designate in writing a person who is 18 years of age or older to exercise powers concerning car, custody, and medical treatment decisions for the person who made the designation. The person who is named shall be known as a patient advocate and the person who makes the designation shall be known as the patient. B. A designation shall be in writing, signed, and witnessed and shall be executed only when the patient is unable to participate in medical treatment decisions. C. A designation may include a statement of the patient’s desire on care, custody, and medical treatment. D. A patient may designate a successor individual if the first individual named as patient advocate does not accept, is incapacitated, resigns, or is removed. E. The proposed patient advocate shall sign an acceptance to the designation.

Updated 10/02/2015 F. The determination of when a patient is unable to participate in medical treatment decisions shall be made by the patient’s attending physician and another physician or licensed psychologist. G. A Health Care Power of Attorney or Health Care Proxy can be changed or terminated at any time. The patient shall notify the patient advocate, physician, and/or other interested persons, in writing, of the changes.

2. Living Will

Michigan has not yet passed a law making living wills binding; however, based on past court judgments, it is more probable that a patient’s wishes would be honored if those wishes were known by the family, physician, and patient advocate.

3. Patient Self‐Determination Act Of 1990

A. Providers shall provide information to patients regarding individual rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives. B. Providers shall document in the medical record whether or not the individual has executed an Advance Directive. C. Providers shall furnish written information to the resident at the time of admission. D. Providers shall not discriminate against an individual based on whether or not the individual has executed an Advance Directive. E. Providers shall provide for education for staff and the community on issues concerning Advance Directives.

4. Location of Advance Directive Document

A. For residents from the apartments i. Notebook at the nurses’ station ii. Residents home health file B. For residents in the Health & Rehab Center i. Behind the plastic cover in the front of the medical record ii. In the business file in the medical records office 1. If resident chooses “No Resuscitation”, a red NO CPR sticker shall be placed on the front of the chart. 2. In no decision regarding CPR is made, and it becomes necessary, CPR shall be started and an ambulance summoned.

Updated 10/02/2015 Friendship Village Health and Rehab Center Admission Statement Regarding Health Center Resident Trust Fund Accounts

All Health Center residents and their legal guardians or designated representatives should review and understand the following information pertaining to Health Center Resident Trust Fund Accounts.

1. There is no obligation for the Health Center resident to deposit his/her funds with the facility.

2. The Health Center resident’s rights regarding personal funds, include, at a minimum, all of the following: A. The right to receive, retain, and manage his or her personal funds, or to have this done by a legal guardian, if any. B. The right to apply to the Social Security Administration to have a representative payee designated for purposes of federal or state benefits to which he or she may be entitled. C. The right to designate, in writing, another person to act for the purpose of managing his or her personal funds. D. The right to authorize, in writing, Friendship Village to hold, safeguard, and account for the Health Center resident’s personal funds in accordance with state and federal law and Friendship Village’s policy.

3. It is Friendship Village’s policy to provide the service of holding monies in trust for any Health Center resident, regardless of capabilities and who have no guardian or designated representative to provide the service.

4. Friendship Village’s procedure for handling, accounting for and giving access to monies held in trust for Health Center residents is summarized below: A. If requested, Friendship Village will establish a Health Center resident trust fund account for any Health Center resident. B. The total amount deposited in a Health Center resident trust fund account by any one Health Center resident is limited to $5,000.00. C. Proper authorizations must be signed by the Health Center resident, legal guardian or designated representative prior to establishing the account. D. Individual accounts with a balance greater than $50.00 will be placed in an interest bearing account. Quarterly interest earned will be distributed to all Health Center resident trust accounts regardless of balance. The allocation of interest will be based on the percent of each Health Center residents’ balance to the total account balance. E. The Health Center resident trust fund accounts will be maintained in the Accounting Office. These accounts and records will be maintained in accordance with the

Updated 10/02/2015 American Institute of Certified Public Accountants’ generally accepted accounting principles. F. Transactions in the Health Center resident trust fund account may be made during normal business hours Monday through Friday (9:00 a.m. to 4:00 p.m.). G. Statements for each Health Center resident trust fund account will be prepared and distributed on a quarterly basis by the Accounting Office. H. Additional information regarding the Health Center resident trust fund accounts may be obtained by contacting the social worker or Accounting Office.

5. Friendship Village’s procedure for handling Health Center resident trust funds following death.

A. Upon Health Center resident death, Friendship Village will provide the executor or administrator of the Health Center resident’s estate with a written accounting of the Health Center resident’s trust account balance within 10 business days. B. Unless otherwise notified by the executor or administrator of the Health Center resident’s estate, Friendship Village will return any and all outstanding trust account balance, including interest, on the final bill.

6. Friendship Village’s procedure following discharge, transfer, or request to close trust fund.

A. Upon Health Center resident discharge, transfer or request, Friendship Village will return any and all funds to the Health Center resident, legal guardian or designated representative within three business days.

Updated 10/02/2015

29200 Southfield Road | Suite 204 | Southfield, MI | 48076 Office: 248.809.6398 | FAX: 248.809.6518 | www.mobilecaregroup.com

Friendship Village partners with Mobile Care Group to arrange “on‐location” audiology, dentistry, optometry, and podiatry services for their residents in the safety and comfort of the building.

Our physicians and equipment assure the highest quality of care. Examinations, treatment, follow up care, and aids (glasses, dentures, and hearing aids) can be fitted, ordered, engraved, dispensed, and adjusted at the facility.

Residents may be entitled to services through Medicare, Medicaid, private insurance, and private pay. Appropriate insurances will be billed directly and only the expected co‐pays and deductibles are the responsibility of the insured.

Attached you will find coverage information and our fee schedule, along with a consent form. Additional consent will be requested in the event a physician recommends additional treatment.

Please refer to our web site, www.mobilecaregroup.com, for more information or contact our office, 248.809.6398, if you have questions.

Best regards,

Mobile Care Group

James L. Wallace

James L. Wallace Director of Michigan Mobile Healthcare

Enc

29200 Southfield Road | Suite 204 | Southfield, MI | 48076 Office: 888.685.3937 or 248.809.6398 | FAX: 888.882.5008 | www.mobilecaregroup.com

MICHIGAN HEALTH CARE SERVICES FEE SCHEDULE

Audiology Medicare Part B provides for one examination per year (co-pays and/or deductibles are expected) Medicaid covers one examination every two years Mobile Care Group private pay rates: Examination $40 - $130 depending on the scope of the exam Standard Analog BTE or ITE engraved hearing aid $800 Digital BTE or ITE engraved hearing aid $1,200

Dentistry Traditional Medicare does not provide for dental services Medicaid covers: One examination and cleaning every 6 months One set of full dentures every 5 years with prior authorization One partial every 5 years with prior authorization X rays as necessary in connection with issuance of dentures/partials or as needed Extractions and Fillings as needed Mobile Care Group private pay rates: Examination New Patient = $90; Existing Patient = $75 Cleaning $85 Engraved Dentures $1,200 per upper or lower Engraved Particials $1,450 per upper or lower X-Rays As Needed $23 per X-Ray plus $10 per additional X-Ray, or $100 for full mouth Fillings (1 to 5 surfaces of decay) $85 - $175 depending on the scope of the filling Extractions (including molar and root tips) $150 - $200 depending on the scope of the extraction

Optometry Medicare Part B provides for vision and eye care services (co-pays and/or deductibles are expected) Medicaid covers 100% vision and eye care services Medicaid covers one pair of glasses every two years Mobile Care Group private pay rates: Examination $180 - $450 depending on the scope of the exam Glasses $80 - for engraved frames and standard lenses

Podiatry Medicare Part B provides for complete nail care every 61 days (co-pays and/or deductibles are expected) Medicaid covers 100% complete nail care every 61 days Mobile Care Group private pay rates: Complete nail care $60 - $120 depending on the scope of the treatment

Soft tissue procedures $60 - $120 depending on the scope of the treatment

Residential House Calls Mobile Care Group provides residential physician “house calls”. Residential “house calls” have a trip-fee, which is not covered by Medicare, Medicaid, or insurances. Please call our scheduling office for trip-fee rates. Scheduling Office: 888.685.3937 www.mobilecaregroup.com

All “private-pay” require pre-payment conditions. Rates effective 6/2016 VACCINE INFORMATION STATEMENT

Many Vaccine Information Statements are Influenza (Flu) Vaccine available in Spanish and other languages. See www.immunize.org/vis (Inactivated or Recombinant): Hojas de información sobre vacunas están disponibles en español y en muchos otros What you need to know idiomas. Visite www.immunize.org/vis There is no live flu virus in flu shots.They cannot cause 1 Why get vaccinated? the flu. Influenza (“flu”) is a contagious disease that spreads There are many flu viruses, and they are always around the United States every year, usually between changing. Each year a new flu vaccine is made to protect October and May. against three or four viruses that are likely to cause disease in the upcoming flu season. But even when the Flu is caused by influenza viruses, and is spread mainly vaccine doesn’t exactly match these viruses, it may still by coughing, sneezing, and close contact. provide some protection. Anyone can get flu. Flu strikes suddenly and can last Flu vaccine cannot prevent: several days. Symptoms vary by age, but can include: • flu that is caused by a virus not covered by the vaccine, • fever/chills or • sore throat • illnesses that look like flu but are not. • muscle aches • fatigue It takes about 2 weeks for protection to develop after • cough vaccination, and protection lasts through the flu season. • headache • runny or stuffy nose 3 Some people should not get Flu can also lead to pneumonia and blood infections, and this vaccine cause diarrhea and seizures in children. If you have a Tell the person who is giving you the vaccine: medical condition, such as heart or lung disease, flu can • If you have any severe, life-threatening allergies. make it worse. If you ever had a life-threatening allergic reaction Flu is more dangerous for some people. Infants and after a dose of flu vaccine, or have a severe allergy to young children, people 65 years of age and older, any part of this vaccine, you may be advised not to pregnant women, and people with certain health get vaccinated. Most, but not all, types of flu vaccine conditions or a weakened immune system are at contain a small amount of egg protein. greatest risk. • If you ever had Guillain-Barré Syndrome (also Each year thousands of people in the United States die called GBS). from flu, and many more are hospitalized. Some people with a history of GBS should not get this Flu vaccine can: vaccine. This should be discussed with your doctor. • keep you from getting flu, • If you are not feeling well. • make flu less severe if you do get it, and It is usually okay to get flu vaccine when you have • keep you from spreading flu to your family and a mild illness, but you might be asked to come back other people. when you feel better.

Inactivated and recombinant 2 flu vaccines A dose of flu vaccine is recommended every flu season. Children 6 months through 8 years of age may need two doses during the same flu season. Everyone else needs only one dose each flu season. Some inactivated flu vaccines contain a very small amount of a mercury-based preservative called U.S. Department of thimerosal. Studies have not shown thimerosal in Health and Human Services Centers for Disease vaccines to be harmful, but flu vaccines that do not Control and Prevention contain thimerosal are available. 4 Risks of a vaccine reaction What if there is a serious 5 reaction? With any medicine, including vaccines, there is a chance of reactions. These are usually mild and go away on their What should I look for? own, but serious reactions are also possible. • Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or Most people who get a flu shot do not have any problems unusual behavior. with it. Minor problems following a flu shot include: Signs of a severe allergic reaction can include hives, • soreness, redness, or swelling where the shot was swelling of the face and throat, difficulty breathing, given a fast heartbeat, dizziness, and weakness. These • hoarseness would start a few minutes to a few hours after the • sore, red or itchy eyes vaccination. • cough What should I do? • fever • If you think it is a severe allergic reaction or other • aches emergency that can’t wait, call 9-1-1 and get the person • headache to the nearest hospital. Otherwise, call your doctor. • itching • Reactions should be reported to the Vaccine Adverse • fatigue Event Reporting System (VAERS). Your doctor should If these problems occur, they usually begin soon after the file this report, or you can do it yourself through the shot and last 1 or 2 days. VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967. More serious problems following a flu shot can include the following: VAERS does not give medical advice. • There may be a small increased risk of Guillain-Barré Syndrome (GBS) after inactivated flu vaccine. This 6 The National Vaccine Injury risk has been estimated at 1 or 2 additional cases per Compensation Program million people vaccinated. This is much lower than the The National Vaccine Injury Compensation Program risk of severe complications from flu, which can be (VICP) is a federal program that was created to prevented by flu vaccine. compensate people who may have been injured by • Young children who get the flu shot along with certain vaccines. pneumococcal vaccine (PCV13) and/or DTaP vaccine at the same time might be slightly more likely to have Persons who believe they may have been injured by a a seizure caused by fever. Ask your doctor for more vaccine can learn about the program and about filing a information. Tell your doctor if a child who is getting claim by calling 1-800-338-2382 or visiting the VICP flu vaccine has ever had a seizure. website at www.hrsa.gov/vaccinecompensation. There is a time limit to file a claim for compensation. Problems that could happen after any injected vaccine: • People sometimes faint after a medical procedure, 7 How can I learn more? including vaccination. Sitting or lying down for about • Ask your healthcare provider. He or she can give you 15 minutes can help prevent fainting, and injuries the vaccine package insert or suggest other sources of caused by a fall. Tell your doctor if you feel dizzy, or information. have vision changes or ringing in the ears. • Call your local or state health department. • Some people get severe pain in the shoulder and have • Contact the Centers for Disease Control and difficulty moving the arm where a shot was given. This Prevention (CDC): happens very rarely. - Call 1-800-232-4636 (1-800-CDC-INFO) or • Any medication can cause a severe allergic reaction. - Visit CDC’s website at www.cdc.gov/flu Such reactions from a vaccine are very rare, estimated at about 1 in a million doses, and would happen within Vaccine Information Statement a few minutes to a few hours after the vaccination. Inactivated Influenza Vaccine As with any medicine, there is a very remote chance of a Office Use Only vaccine causing a serious injury or death. 08/07/2015 The safety of vaccines is always being monitored. For more information, visit: www.cdc.gov/vaccinesafety/ 42 U.S.C. § 300aa-26 VACCINE INFORMATION STATEMENT

Many Vaccine Information Statements are Pneumococcal Polysaccharide Vaccine available in Spanish and other languages. See www.immunize.org/vis Hojas de información sobre vacunas están What You Need to Know disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis

Most people need only one dose of PPSV. A second dose 1 Why get vaccinated? is recommended for certain high-risk groups. People 65 and older should get a dose even if they have gotten one Vaccination can protect older adults (and some children or more doses of the vaccine before they turned 65. and younger adults) from pneumococcal disease. Your healthcare provider can give you more information Pneumococcal disease is caused by bacteria that can about these recommendations. spread from person to person through close contact. It can cause ear infections, and it can also lead to more Most healthy adults develop protection within 2 to 3 serious infections of the: weeks of getting the shot. • Lungs (pneumonia), Some people should not get • Blood (bacteremia), and 3 this vaccine • Covering of the brain and spinal cord (meningitis). Meningitis can cause deafness and brain damage, and • Anyone who has had a life-threatening allergic it can be fatal. reaction to PPSV should not get another dose. Anyone can get pneumococcal disease, but children • Anyone who has a severe allergy to any component of under 2 years of age, people with certain medical PPSV should not receive it. Tell your provider if you conditions, adults over 65 years of age, and cigarette have any severe allergies. smokers are at the highest risk. • Anyone who is moderately or severely ill when the About 18,000 older adults die each year from shot is scheduled may be asked to wait until they pneumococcal disease in the United States. recover before getting the vaccine. Someone with a mild illness can usually be vaccinated. Treatment of pneumococcal infections with penicillin and other drugs used to be more effective. But some • Children less than 2 years of age should not receive strains of the disease have become resistant to these this vaccine. drugs. This makes prevention of the disease, through • There is no evidence that PPSV is harmful to either vaccination, even more important. a pregnant woman or to her fetus. However, as a precaution, women who need the vaccine should be Pneumococcal polysaccharide vaccinated before becoming pregnant, if possible. 2 vaccine (PPSV23) Pneumococcal polysaccharide vaccine (PPSV23) protects against 23 types of pneumococcal bacteria. It will not prevent all pneumococcal disease. PPSV23 is recommended for: • All adults 65 years of age and older, • Anyone 2 through 64 years of age with certain long- term health problems, • Anyone 2 through 64 years of age with a weakened immune system, • Adults 19 through 64 years of age who smoke cigarettes or have asthma. 4 Risks of a vaccine reaction What if there is a serious 5 reaction? With any medicine, including vaccines, there is a chance of side effects. These are usually mild and go away on What should I look for? their own, but serious reactions are also possible. Look for anything that concerns you, such as signs of About half of people who get PPSV have mild side a severe allergic reaction, very high fever, or unusual effects, such as redness or pain where the shot is given, behavior. which go away within about two days. Signs of a severe allergic reaction can include hives, Less than 1 out of 100 people develop a fever, muscle swelling of the face and throat, difficulty breathing, a aches, or more severe local reactions. fast heartbeat, dizziness, and weakness. These would usually start a few minutes to a few hours after the Problems that could happen after any vaccine: vaccination. • People sometimes faint after a medical procedure, What should I do? including vaccination. Sitting or lying down for about 15 minutes can help prevent fainting, and injuries If you think it is a severe allergic reaction or other caused by a fall. Tell your doctor if you feel dizzy, or emergency that can’t wait, call 9-1-1 or get to the nearest have vision changes or ringing in the ears. hospital. Otherwise, call your doctor. • Some people get severe pain in the shoulder and have Afterward, the reaction should be reported to the Vaccine difficulty moving the arm where a shot was given. This Adverse Event Reporting System (VAERS). Your doctor happens very rarely. might file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by • Any medication can cause a severe allergic reaction. calling 1-800-822-7967. Such reactions from a vaccine are very rare, estimated at about 1 in a million doses, and would happen within VAERS does not give medical advice. a few minutes to a few hours after the vaccination. As with any medicine, there is a very remote chance of a 6 How can I learn more? vaccine causing a serious injury or death. • Ask your doctor. He or she can give you the vaccine The safety of vaccines is always being monitored. For package insert or suggest other sources of information. more information, visit: www.cdc.gov/vaccinesafety/ • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines

Vaccine Information Statement PPSV Vaccine Office Use Only 4/24/2015 VACCINE INFORMATION STATEMENT

Many Vaccine Information Statements are Pneumococcal Conjugate Vaccine (PCV13) available in Spanish and other languages. See www.immunize.org/vis Hojas de información sobre vacunas están What You Need to Know disponibles en español y en muchos otros idiomas. Visite www.immunize.org/vis

1 Why get vaccinated? Some people should not get 3 this vaccine Vaccination can protect both children and adults from pneumococcal disease. Anyone who has ever had a life-threatening allergic reaction to a dose of this vaccine, to an earlier Pneumococcal disease is caused by bacteria that can pneumococcal vaccine called PCV7, or to any vaccine spread from person to person through close contact. It containing diphtheria toxoid (for example, DTaP), can cause ear infections, and it can also lead to more should not get PCV13. serious infections of the: • Lungs (pneumonia), Anyone with a severe allergy to any component of • Blood (bacteremia), and PCV13 should not get the vaccine. Tell your doctor if the • Covering of the brain and spinal cord (meningitis). person being vaccinated has any severe allergies. Pneumococcal pneumonia is most common among If the person scheduled for vaccination is not feeling adults. Pneumococcal meningitis can cause deafness and well, your healthcare provider might decide to brain damage, and it kills about 1 child in 10 who get it. reschedule the shot on another day. Anyone can get pneumococcal disease, but children under 2 years of age and adults 65 years and older, 4 Risks of a vaccine reaction people with certain medical conditions, and cigarette With any medicine, including vaccines, there is a chance smokers are at the highest risk. of reactions. These are usually mild and go away on their Before there was a vaccine, the United States saw: own, but serious reactions are also possible. • more than 700 cases of meningitis, Problems reported following PCV13 varied by age and • about 13,000 blood infections, dose in the series. The most common problems reported • about 5 million ear infections, and among children were: • about 200 deaths • About half became drowsy after the shot, had in children under 5 each year from pneumococcal a temporary loss of appetite, or had redness or disease. Since vaccine became available, severe tenderness where the shot was given. pneumococcal disease in these children has fallen • About 1 out of 3 had swelling where the shot was by 88%. given. About 18,000 older adults die of pneumococcal disease • About 1 out of 3 had a mild fever, and about 1 in 20 each year in the United States. had a fever over 102.2°F. Treatment of pneumococcal infections with penicillin • Up to about 8 out of 10 became fussy or irritable. and other drugs is not as effective as it used to be, Adults have reported pain, redness, and swelling where because some strains of the disease have become the shot was given; also mild fever, fatigue, headache, resistant to these drugs. This makes prevention of the chills, or muscle pain. disease, through vaccination, even more important. Young children who get PCV13 along with inactivated flu vaccine at the same time may be at increased risk 2 PCV13 vaccine for seizures caused by fever. Ask your doctor for more information. Pneumococcal conjugate vaccine (called PCV13) protects against 13 types of pneumococcal bacteria. PCV13 is routinely given to children at 2, 4, 6, and 12–15 months of age. It is also recommended for children and adults 2 to 64 years of age with certain U.S. Department of health conditions, and for all adults 65 years of age and Health and Human Services Centers for Disease older. Your doctor can give you details. Control and Prevention Problems that could happen after any vaccine: The National Vaccine Injury • People sometimes faint after a medical procedure, 6 including vaccination. Sitting or lying down for about Compensation Program 15 minutes can help prevent fainting, and injuries The National Vaccine Injury Compensation Program caused by a fall. Tell your doctor if you feel dizzy, or (VICP) is a federal program that was created to have vision changes or ringing in the ears. compensate people who may have been injured by • Some older children and adults get severe pain in the certain vaccines. shoulder and have difficulty moving the arm where a shot was given. This happens very rarely. Persons who believe they may have been injured by a

• Any medication can cause a severe allergic reaction. vaccine can learn about the program and about filing a Such reactions from a vaccine are very rare, estimated claim by calling 1-800-338-2382 or visiting the VICP at about 1 in a million doses, and would happen within website at www.hrsa.gov/vaccinecompensation. There

a few minutes to a few hours after the vaccination. is a time limit to file a claim for compensation. As with any medicine, there is a very small chance of a vaccine causing a serious injury or death. 7 How can I learn more? The safety of vaccines is always being monitored. For • Ask your healthcare provider. He or she can give you more information, visit: www.cdc.gov/vaccinesafety/ the vaccine package insert or suggest other sources of information. What if there is a serious • Call your local or state health department. 5 • Contact the Centers for Disease Control and reaction? Prevention (CDC): What should I look for? - Call 1-800-232-4636 (1-800-CDC-INFO) or • Look for anything that concerns you, such as signs of - Visit CDC’s website at www.cdc.gov/vaccines a severe allergic reaction, very high fever, or unusual behavior.

Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness—usually within a few minutes to a few hours after the vaccination. What should I do? • If you think it is a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor.

Reactions should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor should file this report, or you can do it yourself through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967.

VAERS does not give medical advice.

Vaccine Information Statement PCV13 Vaccine Office Use Only 11/05/2015 42 U.S.C. § 300aa-26 Face Sheet Friendship Village of Kalamazoo Health and Rehab Center

Admission Date/Time Admission ID:

Resident Name Preferred Name Social Security Number Marital Status

Primary Address Phone Number Birth Date Age

Admit From Hospital/Home Hosp. Admit Date Hosp. Discharge Date Room/Bed #

Medicare Part A or B Number Secondary Insurance Name & Number

Primary Language  M Gender  F Religion

Admitting Diagnosis

Allergies

Home Primary Physician Name: Specialist Name: Health & Rehab Primary Physician Name Address Phone Number  Dr. Schroyer 1521 Gull Rd, Suite 146 E, Kalamazoo, MI 49048 552‐2970

Dentist Name Address Phone Number

Opthamologist Name Address Phone Number

Responsible Parties: Financial Resp., Emergency Contact, Durable POA, Medical POA, Patient Advocate, etc. Name Party Type Address Phone Number Financial Responsibility Name Party Type Address Phone Number

Name Party Type Address Phone Number

Name Party Type Address Phone Number

Hospital Preference: Bronson  Borgess  Ambulance Service Yes  No Name of Service: Pride Life EMS Funeral Home Preference Yes  No  Name of Home: Forward Mail? Yes  No  Address: Veteran? Yes  No  Branch of Service: Admission Payer Source Medicare A  Private  Life Care 

Fax Copy of Face Sheet and Insurance Information to Pharmacy

Updated 10/02/2015

Resident: Completed By:

Date:

DPOA/Guardian Decision Tree

1) Can resident make his/her own decisions?  Yes – No action required.  No or Unsure – Notify social worker. No further paperwork at this time. 2) Do you have DPOA paperwork filled out?  Yes – FVK is requesting a copy on ______, 2017.  No 3) Would you like help with initiating the DPOA paperwork?  Yes – Notify social worker.  No – Notify social worker. ______Resident Initials Witness Initials Social work note: ______Social work signature: ______

Updated: 01/2017

Friendship Village Health & Rehab Center

Authorization for Physicians and Nursing Staff Disclosure of Protected Health Information

Residents Name:______Birthdate:______

Date of Request:______

I hereby authorize Friendship Village of Kalamazoo and Woodside at Friendship Village to discuss my protected health information (PHI) with the following individual(s):

______Name (Relationship) Telephone Number

______Name (Relationship) Telephone Number

______Name (Relationship) Telephone Number

______Name (Relationship) Telephone Number

_____ I understand that this authorization remains in effect until this authorization is revoked in writing and submitted to this facility. I also understand that the information being released will be specific to: ______

_____ I understand that this authorization remains in effect until this authorization is revoked in writing and submitted to this facility. I also understand that the information being released will be for the purpose of coordinating caregiver issues or understanding my treatment plan.

______Resident or Legal Resident Representative Date

______Witness Date

Updated 10/02/2015

Friendship Village Health & Rehab Center ‐ Skilled Nursing Services

For Home Town Pharmacy

Resident Pay Status:  Private  Medicare Part A

Resident Name: ______Resident Birth Date: ______

Resident Room Number: ______Medical Record Number: ______

Resident Social Security #: ______

Physician to follow: ______

Please List Allergies: ______

______

______

______

Please fax copies of insurance cards and face sheet then place in pharmacy tote when done.

Contact for any questions:

Ashley Bechtel, Medical Records Coordinator (269) 381‐0515 Extension: 311

Please leave a message and I will return your call.

Thanks!

Friendship Village Health & Rehab Center Consent Form

Resident Name: ______

Resident Room Number: ______MR #______

Beauty/Barber Service Yes No Beauty/Barber Shop

Weekly Every Other Week Monthly As Needed Yes No How Often

Wash/Dry ______

Wash/Blow Dry ______

Wash/Set/Dry ______

Permanent ______

Hair Cut ______

Manicure ______

Trust Fund Yes No Incontinent Products Yes No Wheelchair Rental Yes No Own Yes No Admission Kit Yes No

______Signature – Resident/Resident Responsible Party Date

Update 01/2017

29200 Southfield Road | Suite 204 | Southfield, MI | 48076 Office: 888.685.3937 or 248.809.6398 | FAX: 888.882.5008 | www.mobilecaregroup.com HEALTH CARE SERVICES CONSENT FORM Upon admissions, please fax face sheet, consent form, medication list, and signed physician orders to 888.882.5008

Resident Name: ______Facility Name: Friendship Village Date: ______

To assure residents receive excellent care, we coordinate additional services that our medical team recommends. Eye care, dental care, hearing care, and foot care assessments and procedures are available conveniently in the facility for all residents. Most residents have one or more health conditions that specifically indicate the need for these services.

Appropriate insurances will be billed when possible with only the expected co-pays and balances remaining that are the responsibility of the insured and/or their representative. “Private-Pay” fee-for-services are available and pre-payment conditions apply.

Additional consent will be obtained for recommendations if there are financial obligations beyond the exam and routine follow-up care.

Prior history of (if known, check those that apply):  Heart Disease  Strokes  Thyroid  Hypertension  Arthritis  Diabetes  Macular Degeneration  Cataracts  Glaucoma  Vision Loss  Glasses/Contacts  Gum Disease  Dentures  Tooth Decay  Dry Mouth  Bulimia  Ear Infections  Hearing Aid  Hearing Loss  Depression  Anxiety  Alzheimer’s Disease  Dementia  Other ______

Audiology / Hearing Services A Hearing Professional will provide a medical examination to determine the degree of hearing loss and other hearing related testing. Hearing aids may be ordered as deemed necessary. Earwax removal services delivered through Michigan Ear Care, PC  Accept  Decline (Please Check One) Dentistry Services A dental team will provide an oral examination, dental cleaning, and x-rays, extractions and filings as needed. Dentures may be ordered as deemed necessary. (Not a Medicare covered service).  Accept  Decline (Please Check One) Optometry / Vision Services An Optometrist will provide medical and visual performance examinations of the eyes. Glasses may be ordered as deemed necessary.  Accept  Decline (Please Check One) Podiatry Services Mobility is a key component to the rehabilitation of the resident. A medical examination is performed to access and treat all related podiatric services. Diabetic Shoes may be ordered if deemed necessary by the resident’s PCP.  Accept  Decline (Please Check One)

I authorize Mobile Care Group and/or their staff to release information regarding our physician services to the family members or friends listed in this resident’s nursing home record. Mobile Care Group is compliant with HIPAA Federal regulations.

Resident, Family, Guardian, or Facility Authorization ______Date: ______(Signature)

Resident, Family, Guardian, or Facility Authorization ______(Printed Name & Relationship to Resident)

 Facility authorized personnel consents for above selected services because resident is not self-responsible, or POA/Family/Guardian are unavailable. July, 2015

Friendship Village Kalamazoo The Health & Rehab Center Personal Property Waiver and Release

I, ______, have been advises by representative of Print Name LifeCare, Inc. that the following item(s) belong to me: ______Personal______Belongings______should be removed to a location not under the control of either the Health & Rehab Center at Friendship Village Kalamazoo or LifeCare, Inc., due to the value of the/these item(s). However, I have refused to do so and am signing this Personal Property Waiver and Release Form as (i) evidence of such refusal and (ii) to release LifeCare, Inc. (and any other party or entity under or affiliated with LifeCare, Inc.) from any and all liability due to theft, loss, and/or damage, in regard to such item(s), as provided herein.

I understand that by signing this Personal Property Waiver and Release Form, I expressly and willingly agree to assume complete responsibility for any rest of theft, loss, and/or damage that may arise from keeping such item(s) at the Health & Rehab Center at Friendship Village Kalamazoo. On behalf of myself, my heirs, assigns and next of kin, I waive any and all claims that I may have otherwise had against LifeCare, Inc. (and any other party or entity under or affiliated with LifeCare, Inc.) relating to theft, loss, and/or damage of the above listed item(s).

I have read and fully agree to the terms of this Personal Property Waiver and Release Form. I understand and confirm that by signing this Personal Property Waiver and Release form, I have given up considerable future legal rights. I have signed this Personal Property Waiver and Release Form freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional Personal Property Waiver and Release Form and to release LifeCare, Inc. (and any other party or entity under or affiliated with LifeCare, Inc.) from any and all liability releasing to the theft, loss, and/or damage of the above listed item(s), to the full extent of the law. I am 18 years of age or older and mentally competent to enter into and grant this Personal Property Waiver and Release Form.

I declare that the foregoing is true and correct. Signed on this ______day of ______, 20___.

Signature of Resident Witness

Signature of Resident’s Legal Representative Witness

Updated 10/02/2015

Acknowledgement of Receipt Friendship Village of Kalamazoo

Notice of Privacy Practices

I, ______, acknowledge that I have received a copy of Friendship Village Notice of Privacy Practices which summarizes the ways my health information may be used and disclosed by Friendship Village and state my rights with respect to my protected health information. I understand Friendship Village has the right to revise these information practices and to amend the Notice of Privacy Practices. I have been informed that in the event Friendship Village changes this current Notice of Privacy Practices at any time the community will promptly post a copy of the Notice in the media center, on bulletin board located in the health center activities area and at the front office at Woodside. In addition, they will provide a copy of the revised Notice to all Residents upon request.

Acknowledgement to the posting of privilege information: (Please check yes or no for consent to the following)

1. Posting of community phone directory to include: name, apartment number and phone number. Yes  No

2. Posting of hospitalization, sending a get‐well card, death notice, name in obituary book and flower “in memory of” or Notification of being in Health Center permanently or temporarily. Yes  No

3. Posting of birthday, certificate of recognition or photo. For example, on social media or in publications. Yes  No

4. Identification plaque outside your room. Yes  No

______Signature of Resident or Legal Representative Date

______Witness Date

1 Updated 11/2015

Friendship Village Health and Rehab Center Bed Hold Policy

As a life care retirement community, Friendship Village has a primary purpose of serving residents who have entered into a Life Care contract. Friendship Village also serves other clients from the Kalamazoo area who are in need of short-term recuperative care as space is available.

Life Care Residents – will not be charged a bed hold fee during an absence from the facility for hospitalization or other therapeutic leave, as long as their normal monthly fee includes necessary nursing facility care. The same room placement will be provided whenever possible.

Other Nursing Facility Residents – (Private Pay or Medicare) Friendship Village has formally adopted the following policy and procedure regarding the holding open of beds in the event of a resident’s temporary absence from the facility. The purpose of the policy is to notify and inform residents of their rights and obligations in the event of a temporary absence.

A. When the resident has a temporary absence from the facility for emergency treatment, the facility will hold the bed open for ten (10) days for that resident in that resident’s absence, if there is a reasonable expectation that the resident will return within that period of time and the facility receives payment for the absent period. A request must be made in writing, or verbally by the resident or resident representative for Friendship Village to reserve the bed with payment of the per diem rate of:

• $301 for a semi-private room • $335 for a private room

B. The facility shall offer the opportunity to pay to hold open a bed during a resident’s temporary absence from the facility for emergency medical treatment or for therapeutic reasons, when such payment is not made by another third-party payor.

In case of a Medicare recipient, Friendship Village is not permitted to charge bed hold fees for the resident, but the bed may be held up to ten (10) days if paid by someone else. If no payment is received, the facility is under no obligations to hold a bed open for the resident, and the resident would be re- admitted when the next appropriate bed became available if the resident requires the services provided by the facility.

C. The facility notes that the Medicare program does not pay for holding beds in the event of a resident’s temporary absence from a nursing home for the purposes of receiving care in a hospital for therapeutic reasons.

The undersigned Resident, Resident’s Representative, Resident’s Legal Guardian, and/or Financially Responsible Party or Guarantor, hereby acknowledge receipt of the Bed Hold policy and procedure regarding holding of beds and further acknowledge that he/she understands the policy and procedure.

Signature Date

Relationship to Resident: 11/2016

Friendship Village Health & Rehab Center Liability of Charges

You have been admitted to Friendship Village Health or Rehab center and meet the medical criteria for Medicare or Managed Care plan coverage.

 Per your Medicare and/or secondary insurance contract, once your deductible has been met: For days 1 – 20 you are responsible for a copayment of ______per day. Beginning day 21, you are responsible for a copayment of______per day.

The current coinsurance amount is $167.50 per day. You will be financially responsible for this amount if you do not have secondary insurance coverage. If you do have secondary insurance, you will be financially responsible for any portion that is not reimbursed to Friendship Village.

 Per your Managed Care contract, once your deductible has been met:

For days 1 – 20 you are responsible for a copayment of ______per day. Beginning day 21, you are responsible for a copayment of ______per day.

If/when all benefit days are exhausted, you will be notified by this facility and you will then be responsible for any further financial costs incurred during your continued stay in the facility.

• The standard rate for a Private Room in the Health or Rehab Center is: $10,185 per month or $335 per day.

• The standard rate for a Semi-Private Room in the Health or Rehab Center is: $9,150 per month or $301 per day.

I, ______, ______have read and understand the above Date statements. I hereby accept responsibility for any financial costs incurred during my stay at ______Friendship Village for which my managed care Beneficiary or Resident Representative plan does not cover. ______

Friendship Village Representative Updated 10/2017

Assignment of Insurance Benefits Authorization Statement to Permit Payment of Medicare Benefits to Provider

______Name of Resident Medicare Number

______Insurance Company

______Contract Number Policy and/or Group Number

I request that payment of authorized benefits be paid to Friendship Village on my behalf for any services furnished to me by Friendship Village Health Center. I authorize any holder of medical information about me to release to Medicare and/or insurance holder and its agents any information needed to determine these benefits or the benefits payable for related services.

______Signature of Resident or Representative Date

Updated 10/02/2015

Medicare Secondary Payer Questionnaire

Resident’s Name: ______Resident # ______

Date of Birth: ______Medicare # ______

Physician’s Full Name: ______

1. Is this illness/injury covered by Worker’s Compensation?  Yes  No If yes, note employer name and address and claim number, if assigned, in # 11.

2. Is the resident receiving Black Lung benefits?  Yes  No If yes, what is the name and address of the HMO? Complete # 11.

3. Does the resident have secondary insurance?  Yes  No If yes, what is the name and address of the insurance company? Complete #11.

4. Is this illness/injury due to an automobile accident?  Yes  No If yes, what is the name of the automobile insurer responsible for coverage? Complete # 11.

5. Does this resident feel that another party is responsible for this illness/injury?  Yes  No Name of responsible party: ______Name of liability insurer/attorney: ______Address of liability insurer/attorney: ______

6. Is this resident covered by an Employer Group Health Plan (EGHP) including  Yes  No Federal Employee Health Benefits?

7. Is this resident 65 years of age or older?  Yes  No If no, move to # 9. If yes, move to # 8.

8. Is this resident or the resident’s spouse actively employed by an employer  Yes  No of 20 or more employees? If yes, enter the EGHP data in # 11. If no, move to Prior Stay Information.

Updated 10/02/2015

9. Is this resident entitled to Medicare coverage solely on the basis of a disability?  Yes  No If no, move to # 10. If yes, is this resident or the resident’s spouse actively employed by an employer of 100 or more employees? If yes, enter the Large Group Health Plan data in # 11. If no, move to Prior Stay Information.

10. A. Is this patient entitled to Medicare coverage solely on basis of End Stage  Yes  No Renal Disease (ESRD)? If no, move to Prior Stay Information. Has this patient completed the ESRD coordination period?  Yes  No If no, enter the EGHP data in # 11. If yes, move to Prior Stay Information.

11. Name of Insurance Company or HMO: ______

Insured’s name and policy number: ______

Employer: ______

Address of Insurance Company or HMO: ______

Prior Stay Information

Has this patient been confined to a hospital or skilled nursing facility within the last 60 days? If yes, complete the following information for each stay:

Hospital or skilled nursing facility: ______

Address: ______

Admission Date: ______Discharge Date: ______‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Hospital or skilled nursing facility: ______

Address: ______

Admission Date: ______Discharge Date: ______

Name of person who supplied information ______Date ______

Updated 10/02/2015 Ambulance Coverage for Medicare Part A Patients

For Medicare beneficiaries in a covered Part A stay in a skilled nursing facility, the facility is responsible for the cost of the ambulance trip to a hospital or doctor’s office only when it is medically necessary due to the following situations:

 Resident is confined to bed, i.e. unable to ambulate and unable to sit in a car, chair, or wheelchair  Requires cardiac EKG monitoring  Unable to sit due to sacral decubitus ulcers  Combative and needs to be restrained  Unconscious or in shock  Needs to remain immobile due to fracture or a suspected fracture  Any other medical necessity requiring the resident to be on a gurney/stretcher

If an ambulance is not medically necessary, other modes of transportation may be used which could include wheelchair transport. The resident will be responsible for the cost.

______Signature of Resident/Responsible Party Date

______Signature of Witness Date

Updated 10/02/2015

Friendship Village 1400 North Drake Rd. Kalamazoo, MI 49006 (269) 381-0515

Skilled Nursing Facility Advance Beneficiary Notice (SNFABN)

Date of Notice:

NOTE: You need to make a choice about receiving these health care items or services.

It is not Medicare's opinion, but our opinion, that Medicare will not pay for the items or services described below. Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason to receive it. Right now, in your case, Medicare probably will not pay for –

Items or Services: Skilled Nursing Services

Because:

The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully. • Ask us to explain, if you don’t understand why Medicare probably won’t pay. • Ask us how much these items or services will cost you (Estimated Cost: $ ), in case you have to pay for them yourself or through other insurance you may have. Your other insurance is: • If in 90 days you have not gotten a decision on your claim, contact the Medicare contractor at: Address: or at: Telephone: TTY/TDD: • If you receive these items or services, we will submit your claim for them to Medicare.

PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. DATE & SIGN THIS NOTICE. Option 1. YES. I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. I understand you will notify me when my claim is submitted and that you will not bill me for these items or services until Medicare makes its decision. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare’s decision. Option 2. NO. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won’t pay. I understand that, in the case of any physician-ordered items or services, should notify my doctor who ordered them that I did not receive them.

Patient’s Name: Patient Identification #:

Date Signature of the patient or of the authorized representative Form CMS-10055

THE HEALTH/ REHAB CENTER AT FRIENDSHIP VILLAGE KALAMAZOO

Health/ Rehab Center Admission Agreement (Continuing Care Resident)

10/10/2017 TABLE OF CONTENTS

1. HEALTH /REHAB CENTER ADMISSION AGREEMENT ...... 1 2. PAYMENT FOR CARE AND SERVICES RENDERED ...... 1 2.1 CONTINUING CARE AGREEMENT ...... 1 2.2 STANDARD CHARGE ...... 1 2.3 EXTRA CHARGES ...... 2 2.4 PAYMENT ...... 3 2.5 LATE PAYMENT ...... 3 2.6 SUPPLEMENTAL INSURANCE ...... 3 2.7 BENEFITS ...... 3 2.7.1 Medicare Benefits ...... 3 2.7.2 Third Party Insurance Benefits ...... 3 2.8 MANAGED CARE ...... 4 2.8.1 Enrollment in a Managed Care Organization...... 4 2.8.2 Notice of Change in Insurance Coverage ...... 4 2.8.3 Participating Provider ...... 4 2.8.4 Not a Participating Provider ...... 4 2.8.5 Negotiated Managed Care Rate ...... 4 2.8.6 No Negotiated Managed Care Rate ...... 4 2.8.7 Withdrawal from Participation in the Managed Care Plan ...... 5 2.8.8 Exhaustion of Benefits ...... 5 3. ADJUSTMENTS TO PAYMENT FOR CARE AND SERVICES RENDERED ...... 5 3.1 CHANGES IN CHARGES ...... 5 3.2 REFUND PROVISIONS ...... 5 3.3 DISCHARGE FOR NONPAYMENT ...... 5 4. YOUR RIGHTS AND RESPONSIBILITIES ...... 5 4.1 RESIDENT INFORMATION ...... 6 4.2 PHYSICIAN'S ORDERS ...... 6 4.3 DURABLE POWER OF ATTORNEY FOR BUSINESS AND FINANCIAL DECISION- MAKING ...... 6 4.4 RECORDS ...... 6 4.5 PERSONAL ITEMS AND PROPERTY ...... 6 4.6 RULES AND REGULATIONS ...... 7 4.7 ATTENDING PHYSICIAN ...... 7 4.8 FINANCIAL RESPONSIBILITY ...... 7 4.9 RELEASE ...... 7 4.10 NON-SMOKING POLICY ...... 7 4.11 YOUR COMPETENCY ...... 7 4.12 FUNERAL AND BURIAL SERVICES ...... 7 4.13 PRIVATE EMPLOYEES OF RESIDENT ...... 7 4.14 PHARMACY ...... 8 4.15 REMOVAL OF PERSONAL ITEMS AND PROPERTY ...... 8

i 5. OUR RIGHTS AND RESPONSIBILITIES ...... 8 5.1 UPON ADMISSION ...... 8 5.2 APPLICATION FOR BENEFITS ...... 8 5.3 RESIDENT ASSESSMENTS AND CARE PLANS ...... 8 5.4 PHYSICIAN CARE ...... 8 5.4.1 Medical Director ...... 8 5.4.2 Private Physician ...... 9 5.4.3 Dental Services ...... 9 5.5 HOSPITAL TRANSFER AND EMERGENCY CARE ...... 9 5.6 CONFIDENTIAL RECORDS ...... 9 5.7 MANAGEMENT OF RESIDENT FUNDS ...... 9 5.8 TEMPORARY ABSENCE ...... 9 6. BED HOLD POLICY ...... 9 7. NOTICES FOR TRANSFER, DISCHARGE OR CHANGE IN CONDITION ...... 9 7.1 INVOLUNTARY TRANSFER OR DISCHARGE ...... 10 7.2 VOLUNTARY TRANSFER OR DISCHARGE ...... 11 8. MISCELLANEOUS LEGAL PROVISIONS...... 11 8.1 SEPARABILITY ...... 11 8.2 ARBITRATION ...... 11 8.3 COMPLIANCE ...... 11 8.4 ASSIGNMENT ...... 11 8.5 AGREEMENT MODIFICATIONS ...... 12 8.6 CAPACITY ...... 12 8.7 COUNTERPARTS ...... 12 8.8 ENTIRE AGREEMENT ...... 12 8.9 SUBORDINATION ...... 12 8.10 NATURE OF RIGHTS ...... 12 8.11 NON-WAIVER ...... 12 8.12 INDEMNITY ...... 13 8.13 TRANSFERS ...... 13 8.14 TREATMENT AUTHORIZATION...... 13 8.15 CONSENT TO PHOTOGRAPH ...... 13 8.16 GOVERNING LAW ...... 13 8.17 NOTICES ...... 13 9. AFFIRMATION ...... 13 10. ACKNOWLEDGMENT OF RECEIPT OF DOCUMENTS ...... 14

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Health/ Rehab Center Admission Agreement

1. HEALTH/ REHAB CENTER ADMISSION AGREEMENT. This Health/ Rehab Center Admission Agreement ("Agreement") is made and entered into on this [dd] day of [Month] 20[yy] by and between Lifecare, Inc. ("we", "us", or "our"), d/b/a Friendship Village (hereafter the "Com- munity"), and [Resident Name(s)], ("Resident" or "you"). Where the term Resident or you is used in this Agreement, it shall mean a Resident in Health/ Rehab Center at the Community unless otherwise stated. The Health/ Rehab Center at the Community is a long-term care facility ("Health Center") that is Medicare certified only.

The Agreement is a legally binding agreement that defines the rights and obligations of each person or party signing the contract. Please read this Agreement carefully before you sign it. If you have any questions please discuss them with the Community staff before you sign this agreement.

If you are able to do so, you are required to sign this Agreement to be admitted to the Health Center. If you are unable to sign the Agreement, your Resident Representative (defined below) may sign it for you.

By signing this Agreement you and Health Center agree to its terms and conditions as set forth herein.

2. PAYMENT FOR CARE AND SERVICES RENDERED.

2.1 Continuing Care Agreement. We and you acknowledge the existence of a Con- tinuing Care Agreement entered into by and between Lifecare, Inc. and you dated [Month] [dd], 20[yy] (the "Continuing Care Agreement"), which establishes the terms of payment for the ser- vices and accommodations provided to you during your occupancy in the Health Center. During your stay in the Health Center, the Continuing Care Agreement will remain in full force and effect. In the event of any conflict between the Continuing Care Agreement and this Health Center Ad- mission Agreement, the provisions of this Health Center Admission Agreement shall govern dur- ing your occupancy in the Health Center. In the event you return to your residence at Friendship Village, this Agreement will automatically cancel.

2.2 Standard Charge. You agree to pay all applicable charges required under the terms of the Continuing Care Agreement the (the "Standard Charge") in consideration for the standard services and accommodations provided to you by us (Standard Services). Under the terms of your Continuing Care Agreement, you are entitled to receive a continuing care health care ben- efit in the Health Center. If your stay in the Health Center is a Medicare-qualified stay, the health care benefit which you are entitled to receive in accordance with the terms of your Continuing 1 Care Agreement will not be applied until after the expiration of your Medicare-qualified stay providing you have Medicare Part A, Medicare Part B, and acceptable supplemental health insur- ance or equivalent insurance coverage. You shall pay the Standard Charge by the fifth (5th) day of the month following receipt of our monthly statement. Included in the Health Center Resident Handbook is a list of Standard Charges. A copy of the Health Center Resident Handbook is in- cluded with the other documents you are receiving as described in the attached Checklist. The Standard Services provided for the Standard Charge shall include:

2.2.1 Private or Semiprivate room. A room shared with another resident of the same sex, or the Resident's spouse, or significant other provided the living arrangement is in ac- cordance with the respective Resident's comprehensive care plans;

2.2.2 Board consisting of three meals daily in the dining room or meals delivered to your room. Snacks are available anytime. Regular and special diets are available as arranged through the Health Center dining services staff. Diets will be prepared based on physician’s or- ders;

2.2.3 Nursing care, personal care, or custodial care services in accordance with the Resident's written comprehensive care plan;

2.2.4 Laundered linens, bedding and basic personal laundry;

2.2.5 Housekeeping and maintenance;

2.2.6 Social services;

2.2.7 Planned activities. Planned social, culture, spiritual, educational and recre- ational activities for those who wish to participate;

2.2.8 Emergency Response. Twenty-four (24) hour emergency response system monitored by the Health Center staff; and

2.2.9 Use of Common Areas. Use of recreational and other common areas lo- cated within the Health Center

Where changes in coverage are made to items and services covered by Medicare, we will provide you with written notice as soon as is reasonably possible. We will provide sixty (60) days' advance written notice for changes made to Standard Charges and Extra Charges not covered by Medicare.

2.3 Extra Charges. You agree to pay the then-current rates of Extra Charges for the additional services, supplies, and/or equipment ("SSE") that you or your Resident Representative has specifically requested and that are not included in the Standard Charge. Included in the Health Center Resident Handbook is a list of Extra Charges. You should refer to the Health Center Res- ident Handbook to determine whether an Extra Charge is or is not covered by Medicare. A copy of the Health Center Resident Handbook is included with the other documents you are receiving as described in the attached Checklist.

2 All Extra Charges (not otherwise covered by Medicare , if applicable) shall be paid to us unless the supplier of the SSE bills you directly; in which case, you shall make direct payment to the supplier of the SSE, and we assume no liability to pay for the services. We will provide you with sixty (60) days' advance written notice if we make changes to the additional SSE not included in the Standard Charge.

2.4 Payment. You agree to pay the Standard Charge and any Extra Charges not cov- ered by Medicare, as applicable, or by third-party insurers, by no later than the fifth (5th) day of each month. Payment of the Standard Charge shall be paid each month in advance. Payment of all Extra Charges shall be paid each month for the additional SSE received during the previous month.

2.5 Late Payment. Standard Charges or Extra Charges not paid by the thirtieth (30th) day of the month following the monthly statement due date are assessed a late charge of one and one-half percent (1 ½%) per month on the unpaid balance of the Standard Charges and Extra Charges. The late charge shall be considered an additional charge. If we hire a collection agency or attorney to collect the Standard Charges and Extra Charges past due from you, you are to pay any and all costs of collection including reasonable attorney’s fees, costs, and expenses associated with such collection efforts.

2.6 Supplemental Insurance. You are required to maintain Medicare Part A, Medi- care Part B, and supplemental health insurance or equivalent insurance coverage acceptable to us to assure your ability to fully cover a Medicare-qualified stay in the Health Center. Such supple- mental insurance should cover Medicare co-insurance and deductibles. You shall furnish to us such evidence of coverage as we may from time to time request. Should your supplemental health insurance or equivalent coverage not fully cover a Medicare-qualified stay in the Health Center, or should you fail to purchase supplemental health insurance or equivalent coverage to fully cover a Medicare-qualified stay in the Health Center, you shall be financially responsible for paying deductibles, co-insurance amounts, and any other charges for each Medicare-qualified stay in the Health Center.

2.7 Benefits. If you receive Standard Services and/or SSE eligible for reimbursement under the Medicare program, we shall accept such reimbursement as payment in full, and you shall not be obligated to pay any sums for such reimbursable items other than deductibles and co-insur- ance amounts.

2.7.1 Medicare Benefits. In the event we expect Medicare will not or may not pay for the Standard Services and/or SSE, we will issue to you an Advance Beneficiary Notice. If Medicare denies payment for the Standard Services and/or SSE and you have agreed to receive the Standard Services and/or SSE, with the knowledge that you may have to personally pay for the SSE either out of pocket or through your insurance, you agree to pay such charges to us by the fifth (5th) of the month following receipt of our monthly billing statement from the Health Center.

2.7.2 Third Party Insurance Benefits. In the event private third-party insurance benefits are denied for the Standard Services and/or SSE for which coverage had been expected, you agree to pay such charges to us by the fifth (5th) day of the month following receipt of a billing statement from us.

3 2.8 Managed Care. If you have chosen to participate in a managed care program, then the terms of this Agreement will be as follows:

2.8.1 Enrollment in a Managed Care Organization. Resident shall notify the Health Center in writing prior to enrolling with a managed care plan or switching Resident’s man- aged care plan enrollment. The Health Center will accept payment from the managed care plan as payment in full only for those Standard Services and/or SSE covered by the managed care plan. Resident is responsible for any co-payments or other costs assigned to Resident under the specific terms of the managed care plan. Resident also shall pay for any Standard Services and/or SSE not covered by the managed care plan under the specific terms of the managed care plan. Co-payments and other costs assigned to Resident and charges for Standard Services and/or SSE not covered by the specific terms of the managed care plan are identified in the list of Extra Charges. Managed care plans typically require pre-authorization of services by the managed care plan. If Resident chooses to have services which the managed care plan refuses to pre-authorize, Resident shall pay the Health Center for those services. Resident shall pay the Health Center in a timely manner for all non-covered services retroactive to the date of the initial delivery of services.

2.8.2 Notice of Change in Insurance Coverage. In addition to Resident’s noti- fication obligation set forth in Section 2.8.1, Resident shall notify the Health Center immediately of any change in Resident’s insurance status or coverage made by the insurance carrier including, but not limited to, being dropped by the insurance carrier for any reason, or a decrease or increase in insurance benefits. Resident shall give the Health Center notice before Resident is unable to meet Resident’s insurance premium or before Resident implements an increase, decrease or termi- nation from insurance coverage.

2.8.3 Participating Provider. If the Health Center is a participating provider with your managed care program and your stay is covered by the managed care program, we agree to accept, as full payment, reimbursement at the rate negotiated with your managed care program. Resident acknowledges that the Health Center is not responsible for and has made no representa- tions regarding the actions or decisions of any managed care plan for which the Health Center is an authorized provider, including decisions relating to a denial of coverage.

2.8.4 Not a Participating Provider. If the Health Center is not a participating provider with your managed care program and you choose to receive health care services at a managed care participating provider, then you agree to relocate for those services to be provided, and be responsible for all charges for those health care services. In addition, while receiving health care services at the managed care participating provider, you agree that unless this Agreement is terminated, we will hold your bed as set forth in Section 6 of this Agreement.

2.8.5 Negotiated Managed Care Rate. If the Health Center is not a participating provider in your managed care program and your stay is a Medicare-qualified stay, we may in our discretion attempt to negotiate an acceptable reimbursement rate with your managed care program. If we elect to negotiate an acceptable rate, we agree to accept as full payment the rate provided by your managed care program.

2.8.6 No Negotiated Managed Care Rate. If the Health Center is not a partici- pating provider in your managed care program and a negotiated rate is not agreed upon and you would still like to receive health care in the Health Center during a Medicare-qualified stay, you 4 agree to pay the Standard Charge for your care in the Health Center, in addition to the Extra Charges. Resident acknowledges that a managed care organization for whom the Health Center is not an authorized provider may not approve payment for services provided by the Health Center. Resident acknowledges that the Health Center is not responsible for and has made no representa- tions regarding the actions or decisions of any managed care plan including decisions relating to a denial of coverage.

2.8.7 Withdrawal from Participation in the Managed Care Plan. The Health Center reserves the right to terminate its contractual relationship and its status as a network or authorized provider with one or more of the listed managed care plans at any time in accordance with law and the terms of the applicable agreement. In the event that the Health Center terminates its contractual relationship with the managed care plan in which Resident is enrolled, Resident may convert his or her coverage to a health plan for which the Health Center is an authorized provider or transfer to a Health Center that is an authorized provider for Resident’s managed care plan. The Health Center shall provide sixty (60) days advance notice of its decision to withdraw as a participating provider from Resident’s managed care plan so Resident and the managed care plan can coordinate a transfer to another Health Center.

2.8.8 Exhaustion of Benefits. After you have exhausted all benefits under Med- icare or your third party payor, you will be responsible for all charges in accordance with Sections 2.2 - 2.5 of the Agreement at the rates charged to continuing care residents.

3. ADJUSTMENTS TO PAYMENT FOR CARE AND SERVICES RENDERED.

3.1 Changes in Charges. We reserve the right to adjust the Standard Charges or Extra Charges if we, in our sole discretion, deem it necessary to meet the financial needs of the Health Center. Written notification will be given to you as set forth above in Sections 2.2 and 2.3 unless changes are required due to licensing requirements.

3.2 Refund Provisions. We shall refund to you or your Resident Representative de- fined in Section 4.3 any advance payment made by you for any unused days for which payment has been made, without interest, within thirty (30) days following the date of your discharge from the Health Center. In the event of your death, we shall refund any deposit or charges already paid, less the Standard Charge and Extra Charge, if applicable for the days you actually resided or re- served or retained a bed in the Health Center to your estate or your Resident Representative. Any other refunds owed by us to you, if any, are governed by the terms of the Continuing Care Agree- ment.

3.3 Discharge for Nonpayment. If you become financially unable to pay the charges required under the terms of this Agreement, you or your Resident Representative will be respon- sible for applying for Medicaid. The Health Center is not certified to provide care under the Med- icaid program and you shall be subject to discharge and relocation to a Medicaid certified Health Center. In accordance with Section 11.2.2 of the Continuing Care Agreement, the Agreement shall not be cancelled solely by reason of your financial inability to pay the Standard Charges and Extra Charges, if applicable except under circumstances as set forth in the Continuing Care Agreement.

4. YOUR RIGHTS AND RESPONSIBILITIES.

5 4.1 Resident Information. At the time of admission, you agree to provide complete information regarding yourself, and thereafter to provide updated information on a regular basis at our request.

4.2 Physician's Orders. At the time of admission, you shall provide, and we shall ensure receiving, licensed physician's orders for your admission to the Health Center, immediate care and current medical findings and diagnosis. Within fourteen (14) days of admission, we shall ensure receiving a medical history from your attending physician.

4.3 Durable Power of Attorney for Business and Financial Decision-Making. At the time of admission, you shall provide us with the name and contact information of your Resident Representative as well as any document granting authority to your Resident Representative. A Resident Representative means an individual of your choice who has access to information and participates in healthcare discussions or a personal representative with legal standing such as a power of attorney, legal guardian or health care surrogate appointed or designated in accordance with state law. The person named as your Resident Representative is [Name of Representative]. You shall promptly update us with any name and/or contact information changes regarding your Resident Representative. The person named as your Resident Representative shall not be a person employed by us or any other entity engaged in the management of the Community. Nothing herein shall be construed as requiring you to execute a Durable Power of Attorney or other such author- izing document which grants another person to make health care decisions for you. We may apply to be a representative payee, petition a court to appoint a Guardian and take other legal action if we reasonably believe that your needs are not being properly met or the duties imposed by this Agreement are not being fulfilled.

4.4 Records. You shall have the right, upon an oral or written request, to access all records regarding yourself including current clinical records within twenty-four (24) hours (ex- cluding weekends and holidays). After receipt of your records for inspection, you have the right to purchase for a charge (not to exceed the Heather Center standard) photocopies of your records or any portion of your record upon request and two working days advance notice to the Health Center. The charges shall consist of labor for copying your records whether in paper or electronic format and supplies for creating the paper copy or electronic media and postage if you requested the records be mailed. A third party shall not be given a copy of your medical record without your prior written authorization, except as required because of transfer to a health care facility as re- quired by law including to be reported to a health or government authority or third party payment contract.

4.5 Personal Items and Property. Upon admission, we will complete a written in- ventory of your personal effects, money, and valuables. You shall inform us of when items are removed from (and brought into) the Health Center so your inventory can be updated. We will safe keep your personal clothing and effects, when you have delivered them to us. At such time, we will provide you or your Resident Representative with a written receipt for such items. Whenever necessary for the protection of valuables or to avoid unreasonable responsibility therefore, we may require that such valuables be excluded or removed from the Health Center and kept at some place not subject to our control. If you refuse to remove such valuables from the Health Center, you may incur an Extra Charge for the additional safekeeping measures we may be required to provide.

6 4.6 Rules and Regulations. You shall be fully informed of your rights and responsi- bilities as a Resident and of all the Health Center rules and regulations governing your conduct and responsibilities. You agree to comply with all such rules and regulations. A copy of the Health Center rules and regulations are provided along with the other documents listed in the attached Checklist.

4.7 Attending Physician. You shall have the right to choose an attending physician and other providers of services, participate in planning your care or treatment, be informed of your total health status and medical condition by your attending physician, refuse treatment and be in- formed of the consequences of refusing treatment, and be afforded confidentiality of treatment.

4.8 Financial Responsibility. You shall:

4.8.1 Be legally accountable and personally responsible for the payment of all financial obligations including the Standard Charges and any Extra Charges for the receiving of SSE under this Agreement that are not otherwise covered by Medicare and/or third-party insurance benefits, if applicable;

4.8.2 Be responsible for any charges related to checks returned for insufficient funds in accordance with applicable law; and

4.8.3 Be responsible for, and agree to pay for, all costs and reasonable attorneys' fees associated with any collection action if your account is sent to an attorney or collection agency for collection.

4.9 Release. You release us, our owners, operators, managers, directors, officers, med- ical directors, and employees from all liability for any personal injury, illness, or deterioration in your condition which may occur while you are temporarily absent from the Health Center.

4.10 Non-Smoking Policy. Smoking is prohibited in the Health Center and premises. The Health Center and the entire Community campus is a smoke-free environment. You hereby agree that if you are injured or any property of yours is damaged or destroyed by reason of your smoking, we shall not be liable for and we are hereby held harmless from all liability for such injury, damage, or destruction.

4.11 Your Competency. In the event that a Resident Representative is not a party to this Agreement, you hereby represent to us (i) that you have not been adjudicated incompetent for any purpose; (ii) that no petition for such adjudication is pending in any court; (iii) that no physi- cian has determined that you are disabled so as to be unable to consent to placement in a facility; and (iv) that you are being admitted to the Health Center on your own free act and will.

4.12 Funeral and Burial Services. Funeral or burial services or expenses will not be provided by us pursuant to this Agreement. You agree to make funeral and burial arrangements before occupying the Health Center. We shall document upon admission, or as soon after as pos- sible, the arrangements you have made regarding funeral and burial.

4.13 Private Employees of Resident. If you need additional services, you can obtain these needed services from a private employee, an independent contractor, or through an agency 7 (personal service provider). In such instances, we strongly advise you to obtain these needed ser- vices from a licensed and/or certified home health agency. Further, you must comply with our policy regarding personal service providers and ensure that your private employee, independent contractor, or person you employ through an agency complies with our policies and rules of con- duct set forth in a personal service provider policy. If you fail to follow or enforce the policy and rules of conduct, then we may elect to intervene if the health or safety of yourself or others is endangered.

4.14 Pharmacy. The Health Center does now or may in the future use the unit dose system of dispensing medication. If the Health Center is using the unit dose system, you agree to accept the pharmaceutical arrangement made by us or to use a pharmacy utilizing a drug distribu- tion system compatible with the system used by us.

4.15 Removal of Personal Items and Property. Upon your death or your transfer or discharge from the Health Center, you or your estate shall be responsible for the removal of your personal items and property. If removal of your personal items and property is not accomplished within a timely manner, then we may remove and store such personal items and property at the expense and risk of you or your estate.

5. OUR RIGHTS AND RESPONSIBILITIES.

5.1 Upon Admission. At the time of admission, we shall:

5.1.1 Administer a tuberculosis skin test to you and any other communicable dis- ease test in accordance with your attending physician’s recommendation; and

5.1.2 Provide a copy of the documents listed in the attached Checklist.

5.2 Application for Benefits. The Health Center participates in the Medicare program. Upon your request, we will assist you in applying for Medicare, as applicable and third party in- surance benefits. You will be liable only for those charges that are non-covered services under Medicare, and third-party insurance if you qualify for coverage under Medicare, or third-party insurance.

5.3 Resident Assessments and Care Plans. We will perform a baseline care plan and/or comprehensive care plan, and update, reassess and change your plan in accordance with applicable Federal and State laws and regulations.

5.4 Physician Care.

5.4.1 Medical Director. We have designated a member in good standing with the state of Michigan to act as Medical Director for the Health Center. The Medical Director may be available to perform services for you. We will not be responsible for the cost of medical treat- ment by the Medical Director.

8 5.4.2. Private Physician. The Health Center shall assist you in obtaining the services of a substitute physician or provider at your expense if your attending physician or pro- vider is not available, is failing to serve you, or is failing to comply with applicable regulations or our professional credentialing requirements.

5.4.3 Dental Services. We will arrange for routine and emergency dental ser- vices at your expense. You have the right to utilize dental services of your choice.

5.5 Hospital Transfer and Emergency Care. The Health Center shall arrange for your transfer to a hospital or other health care facility at your expense when ordered by your at- tending physician or substitute physician. You expressly authorize us to obtain necessary emer- gency care at your expense, subject to the Resident's Bill of Rights as provided under Federal and State laws and regulations, and any valid advance directive that may exist. You understand that all life-saving measures will be utilized in the event of an emergency unless advance directives have been received by us to the contrary. The right to give advance directives has been disclosed to you. Our staff will not accompany you for hospital or emergency care delivered away from the Health Center.

5.6 Confidential Records. We are required to keep your personal and clinical records confidential except that the Health Center shall be allowed to use or disclose personal health in- formation for your treatment, for payment, or for health care operations. You shall receive a Notice regarding the privacy of your health information. If you would like family or another person(s) to have access to your health care information you must sign an Authorization. The Notice and Au- thorization are included in our Health Center Resident Handbook.

5.7 Management of Resident Funds. If you desire for us to manage your personal funds in a nominal amount, we will do so with your written authorization as written authorization is required. Such management will be limited to the nominal funds held by us for you. Your funds will be kept separate from the Health Center's funds. We shall furnish you, or your Resident Representative, with a quarterly, verified statement of all transactions made on your behalf. If you wish for us to manage funds above fifty dollars ($50), the funds will be placed in an interest- bearing account. Any unused funds will be refunded to you within ten (10) days of discharge or to your estate in the event of your death. With you or your estate’s consent, unused funds may be applied to any outstanding charges.

5.8 Temporary Absence. We shall not assume responsibility for any personal injury, illness, or deterioration in your condition which occurs while you are temporarily absent from the Health Center and not under the direct care and supervision of the Health Center, including times when you leave the Health Center for any reason without first giving notice.

6. BED HOLD POLICY. If you are absent from the Health Center, we shall hold your bed in accordance with our current bed hold policy. A copy of the current bed hold policy is included in the documents listed in the attached Checklist. We reserve the right to change our bed hold policy from time to time in accordance with applicable laws and regulations. A copy of the current bed hold policy shall be provided to you and your family member or Resident Representative before your transfer.

7. NOTICES FOR TRANSFER, DISCHARGE OR CHANGE IN CONDITION 9

7.1 Involuntary Transfer or Discharge. We reserve the right to involuntarily transfer or discharge you to another facility for any of the following reasons:

7.1.1 Your welfare and your needs cannot be met in the Health Center;

7.1.2 The health or safety of others is endangered due to the clinical or behavioral status of the resident;

7.1.3 Except as otherwise restricted by your Continuing Care Agreement, you have failed after reasonable and appropriate notice to pay for (or to have paid under Medicare, as applicable) a stay at the Health Center when you have failed to submit the necessary paperwork for third party payment or the third party, including Medicare, as applicable, denies your claim and you refuse to pay for your stay;

7.1.4 Your health has improved sufficiently so you no longer require the services provided by the Health Center; or

7.1.5 The Health Center ceases to operate.

We shall consult with your attending physician when a decision is made to transfer or dis- charge you from the Health Center. We shall give you, your family member or your Resident Representative verbal notice, if appropriate, and at least thirty (30) days' written notice before involuntarily transferring or discharging you. The notice shall state: (i) the specific reason for the transfer or discharge; (ii) the effective date of the transfer or discharge; (iii) the location to which you will be transferred or discharged; (iv) a statement that you have the right to appeal the action to the appropriate state agency; and (v) the name, address, and telephone number of the state long- term care ombudsman. The reason for transfer or discharge shall be documented in your clinical records by the attending physician. You and your family member or Resident Representative, if any, must be notified of the reason for the transfer or discharge and shall be consulted in choosing another facility. If you are not removed, you agree that we have the right to make appropriate arrangements to relocate you.

An exception is made to giving thirty (30) days' written notice if your attending physician or the emergency physician determines that (i) the giving of notice or the waiting period might endanger the health or safety of yourself or other residents due to the clinical or behavioral status of the resident; (ii) you have urgent medical needs; (iii) you have not resided in the Health Center for thirty (30) days; or (iv) your health improves sufficiently to no longer require the services provided by the Health Center. Then, such notice and/or waiting period before transfer or dis- charge shall not be required. The reason for immediate transfer or discharge shall be documented by your attending physician or the emergency physician in your clinical records.

We must immediately consult with your physician, inform you and notify your Resident Representative if there is an accident, injury, significant change in your condition, a need to alter treatment significantly or a decision to transfer or discharge you. You and your Resident Repre- sentative shall be notified promptly following the emergency transfer or discharge. We must also promptly notify you and your Resident Representative when there is a change in room or roommate assignment or a change in resident rights under Federal or State law. 10

An involuntary transfer or discharge will not relieve you from any sums due and owing under the terms of this Agreement.

7.2 Voluntary Transfer or Discharge. You shall have the right at all times to volun- tarily transfer or discharge yourself from the Health Center. We request that thirty (30) days' written notice be given to the Community's administrative office when such transfer or discharge is not the result of an emergency. However, a voluntary transfer or discharge shall become effec- tive on the date you leave the Health Center. Nothing herein shall be construed to require you to remain in the Health Center against your will for any length of time. Voluntary transfer or dis- charge will not relieve you from any sums due and owing under the terms of this Agreement.

8. MISCELLANEOUS LEGAL PROVISIONS.

8.1 Separability. The parties agree that should any provision of this Agreement be declared invalid by any court of competent jurisdiction, or rendered invalid by any statute or reg- ulation, the remainder of this Agreement will remain binding and in full force and effect.

8.2 Arbitration. You agree that any dispute, claim, or controversy of any kind be- tween you and us arising out of, in connection with, or relating to this Agreement and any amend- ment hereof, or the breach hereof, which cannot be resolved by mutual agreement or in small claims court, will be submitted to and determined by arbitration in Kalamazoo County, Michigan in accordance with the Federal Arbitration Act and the then current commercial arbitration rules of the Federal Arbitration Act. You and we will jointly agree on an arbitrator and the arbitrator will be selected according to the procedure set forth in state law, if applicable. In reaching a decision, the arbitrator shall prepare findings of fact and conclusions of law. Any direct arbitration costs incurred by you will be borne by you. Costs of arbitration, including our legal costs and attorneys' fees, arbitrators' fees, and similar costs, will be borne by all Residents of Lifecare, Inc. d/b/a Friendship Village provided that the arbitrator may choose to award the costs of arbitration against us if the arbitrator determines that the proposed resolution urged by us was not reasonable. If the issue affects more than one (1) resident, we may elect to join all affected residents into a single arbitration proceeding, and you hereby consent to such joinder.

You may withdraw your agreement to arbitrate within thirty (30) days after signing this Agreement by giving written notice of your withdrawal to us. This arbitration clause binds all parties to this Agreement and their spouses, heirs, representatives, executors, administrators, suc- cessors, and assigns, as applicable. After cancellation of this Agreement, this arbitration clause shall remain in effect for the resolution of all claims and disputes that are unresolved as of that date.

8.3 Compliance. Failure by any party to this Agreement at any time to require com- pliance with a particular term of this Agreement shall not be construed as a waiver of that party's right to require compliance with that or any other provision at any future time.

8.4 Assignment. The parties hereto understand that this Agreement is not a lease and does not create any interest in real estate or the property owned by the Health Center. The right of occupancy does not inure to the benefit of your heirs, assignees, or representatives. This Agree- ment shall inure to the benefit of our heirs, successors, and assigns. 11

8.5 Agreement Modifications. This Agreement may be modified by us at any time in order to comply with applicable laws and regulations. Notice of such changes shall be provided to you or your Resident Representative, if any.

8.6 Capacity. This Agreement has been executed on our behalf by our duly authorized agent, and no officer, director, agent, or employee of ours shall have any personal liability under this Agreement under any circumstances. This Agreement will become effective upon acceptance and execution by us.

8.7 Counterparts. This Agreement may be executed in counterparts, each of which will be deemed to be an original, but all of which taken together shall constitute but one and the same instrument.

8.8 Entire Agreement. This Agreement and the Continuing Care Agreement, consti- tutes the entire Agreement between you, your Resident Representative, and us and replaces any other negotiations, discussions, agreements, undertakings and understandings of the parties, whether written or oral. No representation, promise, or inducement not included in this Agreement is binding upon either party. No oral or implied Agreement or understanding will cancel or vary the terms of this Agreement. No modification of this Agreement will be binding unless it is in writing and signed by both parties. Notwithstanding this provision, the parties acknowledge and agree that no written modification of this Agreement is required should the documents contained in the Checklist change as required by law or by the business needs of the Health Center upon proper prior notice to you.

8.9 Subordination. Your rights under this Agreement are and shall at all times be subject and subordinate to the rights of the holder of any debt secured by us.

8.10 Nature of Rights. You understand and agree that this Agreement or your rights (including the use of the room) under it, may not be assigned, and no rights or benefits under this Agreement will inure to the benefit of your heirs, legatees, assignees, or designated representatives. This Agreement and your contractual right to occupy the room will exist and continue to exist during your lifetime unless canceled as provided herein. This Agreement and your rights hereun- der may not be assigned or sublet except as expressly stated herein. This Agreement grants you the right to occupy and use space in the Health Center, but does not give you exclusive possession of the room against us. You will not be entitled to any rights of specific performance, but will be limited to such remedies as set forth herein and as provided by applicable Michigan laws and regulations. This Agreement is not a lease or easement and does not transfer or grant you any interest in real property owned by us. This Agreement grants us complete decision-making au- thority regarding the management and operation of the Health Center.

8.11 Non-Waiver. If we fail to insist in any instance upon performance of any of the terms, covenants, or conditions of this Agreement, it shall not be construed as a waiver or relinquishment of the future performance of any such terms, covenants, or conditions, but your obligations with respect to such future performances shall continue in full force and effect.

12 8.12 Indemnity. To the extent allowed by law, we will not be liable for, and you agree to indemnify, defend, and hold us harmless from, claims, damages, and expenses, including attor- neys' fees and court costs, resulting from any injury or death to persons and any damages to prop- erty to the extent caused by, resulting from, attributable to, or in any way connected with your negligent or intentional acts or omissions or those of your guests.

8.13 Transfers. We may sell or transfer interest in Friendship Village, including the Health Center, provided the buyer will agree to assume this Agreement and all other existing con- tinuing care agreements. Upon the assumption of this Agreement by the buyer and its agreement to perform this Agreement and all other agreements, we will have no further obligations hereunder. In addition, we may sell or otherwise transfer the land or other portions of Friendship Village including the Health Center. Your signature hereto constitutes your consent and approval to any such future transfers.

8.14 Treatment Authorization. You authorize us to provide care and treatment con- sistent with the terms of this Agreement. You also authorize us to obtain all necessary clinical and/or financial information from the health care facility from which you may be transferring.

8.15 Consent to Photograph. Health Center personnel may photograph or record you for treatment purposes (including, without limitation, for telemedicine purposes) with your in- formed consent. Further, you may be photographed or recorded (i) as part of Health Center activ- ities (including, without limitation, special event parties and other celebrations, bus rides, wellness programs, continuing education and entertainment at the Health Center), and (ii) for publicity or marketing purposes with your informed consent.

8.16 Governing Law. This Agreement shall be interpreted and enforced in accordance with the laws of the State of Michigan.

8.17 Notices. Notices required by this Agreement will be in writing and delivered either by personal delivery or mail. If delivered by mail, notices will be sent by Express Mail, or by certified or registered mail, return receipt requested, with all postage and charges prepaid. All notices and other written communications required under this Agreement will be addressed to you or to your Resident Representative at the address provided to us. Notices shall be sent to us at the following address.

Friendship Village Attn: Administrator 1400 N. Drake Rd. Kalamazoo, MI 49006

9. AFFIRMATION. Resident affirms that the information provided in the Pre-Admission Application is true and correct to the best of his/her knowledge, and acknowledges that the sub- mission of any false information may constitute grounds to terminate this Agreement.

13 10. ACKNOWLEDGMENT OF RECEIPT OF DOCUMENTS. You and your Resident Representative, if signing this Agreement on your behalf, acknowledge and represent that you have read and agree to the terms of this Agreement. You or your Resident Representative acknowledges that we have provided you information regarding the availability of hospice care at the Health Center. You agree to be bound by its terms and conditions and your Resident Representative, if signing this Agreement on your behalf, agrees you shall be bound by its terms and conditions, as well as any future changes to the documents contained in the attached Checklist. You and your Resident Representative, if signing this Agreement on your behalf, acknowledge and agree you have received the documents contained on the attached Checklist.

Executed on this ____ day of ______, Approved this ____ day of ______, 20______. 20______.

______LIFECARE, INC. RESIDENT d/b/a Friendship Village

______Witness By: ______Authorized Representative ______RESIDENT'S RESIDENT REPRESENTATIVE, AS AUTHORIZED AGENT FOR RESIDENT

______Witness

Billing Address: 10/10/2017 ______J:\Complnc\FV Kalamazoo\Agreements - URM\Health Center Agreements - URM\Health Rehab Center Admission Agreement - Continuing ______Care Resident (2017-10-10).docx

______

______

14

FRIENDSHIP VILLAGE SOURCE OF PAYMENT ADDENDUM TO HEALTH CENTER ADMISSION AGREEMENT

This Source of Payment Addendum to Health Center Admission Agreement ("Addendum") is made this ____ day of ______, 20______by and between ______("Resident", "you", or "your") and Lifecare, Inc. ("we", "us", or "our"), the owner of the Health Center at Friendship Village ("Health Center").

RECITALS:

WHEREAS, we entered into a Health Center Admission Agreement dated ______, ______with you regarding the terms of your stay in the Health Center.

WHEREAS, Section 21766(1)(c) of the Michigan Public Health Code requires that the Health Center Admission Agreement be modified by you and us at any time there is a change in the source of payment for your Health Center care and services.

WHEREAS, the purpose of this Addendum is to acknowledge the current source of payment for your Health Center care and services.

NOW THEREFORE, we and you acknowledge this Addendum supplements and is an integral part of the Health Center Admission Agreement, and effective ______, 20___, the source of payment for your Health Center care and services is:

___ Medicare Part A

___ Payment terms associated with being a Life Plan resident at Friendship Village

___ Private pay with Medicare Part B

___ Private pay with Medicare Part B and Medicare Part D

___ Managed Care

Resident reaffirms the payment terms and obligations contained in the Health Center Admission Agreement pertaining to the applicable source of payment. The terms and conditions of the Health Center Admission Agreement remain unchanged and in full force and effect and are hereby ratified and confirmed by Resident and us. LIFECARE, INC. d/b/a Friendship Village ______RESIDENT By: ______Authorized Representative Witness 01/06/2017 Source of Payment Addendum to Health Care Admission Agreement (2017.01.06) CLEAN.docx

Resident Name: ______

I have received the following:

• Pneumonia and Influenza information

• Privacy Act Statement/HIPAA

• Complaint Procedure

• Medicare Part A and B Benefits

• Advance Directives

• Business Office Procedures

• Bed Hold Policy

• Trust Account Information

• Health Center Supply Charge List

• Resident Rights and Responsibilities booklet reviewed and given to resident ______Resident Initials Resident Refused Booklet

Resident______Date______

Responsible Party______Date______

Updated 12/2016