Resident Agreement

Resident Agreement DATE: ______________ RESIDENT NAME: ________________________________________________ NAME OF RESPONSIBLE PERSON: ______________________________________________________ DEFINITION OF TREATMENT: The Inn on Barton Creek is an Assisted Living Facility (the “Facility”). The Facility is not licensed for and will not provide medical or skilled nursing care. This agreement is between the Facility, the Resident, and the Responsible Person. The Facility agrees to rent apartment # _________ and to provide services outlined in this agreement. This Agreement if effective from ____/____/____ (date) until its revision or termination. This agreement supersedes any and all previous agreements. SERVICES PROVIDED: The Facility will provide the Resident with a Lifestyle Program based upon the specific needs of the Resident as determined by the resident assessment. The Lifestyle Program may be changed at any time by the Facility as the Resident’s needs increase or decrease. The Resident and Responsible Person will be notified within 48 hours of a Lifestyle Program change. ROOM AND BOARD: The Resident and the Responsible Person agree to pay the following room and board fee for the rental of the specified apartment and services as outlined in this agreement: APARTMENT TYPE: ____________________________ DAILY RENT: __________________________ LIFESTYLE PROGRAM: _________________________ LIFESTYLE MONTHLY FEE: _____________ PERSONAL LAUNDRY SERVICES: [ ] Independent and Level 1 - $100 per month [ ] Family will provide OPTIONAL SERVICES: [ ] Covered Parking - $20 per month [ ] Telephone - $20 per month ESTIMATED MONTHLY TOTAL: ___________ 1. The Lifestyle Program fee is subject to immediate change if the Resident’s needs increase or decrease 2. If fees are increased for reasons other than a change in the Resident’s need for service, the Resident or Responsible Person will be given a 30 day written notice 3. There will be no refund of any portion of a prepaid fee, except in the event of the death of the Resident. Payment will be calculated up to and including the date that all personal belongings are removed from the apartment 4. There is a one-time, non-refundable $500.00 move-in fee, payable at the time of move-in to the Facility 5. The total monthly fee is due on the 1st day of each month. A $25.00 late fee will be charged if payment is received after the 10th of the month. A $25.00 fee will be charged for any checks returned for insufficient funds. TERMINATION OF OCCUPANCY: A. The Facility may upon thirty (30) days written notice to the Resident and the Responsible Party, discharge, transfer or evict the Resident for one of more of the following reasons: 1. Non-payment for services within ten days of the due date 2. Failure of the Resident to comply with the state or local laws, or failure to comply with written policies or rules of the facility as outlined in the Resident Guide 3. The resident poses a danger to self or others 4. Inability of the Facility to meet the Resident’s needs 5. Inability of the Resident to take life saving action in an emergency with the assistance of one person 6. The resident wishes to transfer 7. A change in the use or ownership of the Facility, or it ceases to operate B. The Facility may require the Resident to vacate the Facility immediately by serving the Resident and the Responsible Person with a written notice if the Resident or someone in the Resident’s control is endangering the mental and/or physical health or safety of himself/herself or others in the Facility, or is damaging or threatening immediate damage to the Facility, or if the Resident’s medical emergency required immediate discharge or transfer. The cost of all repairs as a result of any damage caused by the Resident or someone in the Resident’s control will be paid by Resident and the Responsible Person within thirty (30) days after receipt of an itemized bill for repairs C. The notice shall include the reasons for the termination of occupancy D. The Resident agrees to give the Facility thirty (30) days written notice of intent to move from the Facility. Exceptions may be granted if the Resident’s condition prevents this from occurring E. The Resident agrees to give the Facility the right to show the Resident’s apartment to prospective Residents after written notice of intent to move is given by the Resident of the Facility

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MISCELLANEOUS PROVISIONS: A. The Resident agrees to cooperate with and abide by the general policies of the Facility that make it possible for the Residents to live together in a pleasant environment. A copy of the Facility’s Resident Guide will be provided to the Resident. The Facility management reserves the right to make reasonable modifications to these policies as they judge necessary to enhance the quality of care, safety and lifestyle of all Residents. Notice of any additional policies or changes shall be given to the Resident in writing. I have reviewed and understand the general policies of the Facility as contained in the Resident Guide and agree to abide by them at all times. A copy of the Resident Guide has been given to me for my records. __________ (Initials) B. The Resident has received a copy of the Notice of Privacy Practices for South Davis Community Hospital and/or affiliated providers, The Inn on Barton Creek, Orchard Cove, South Davis Home Health, and South Davis Hospice. I have received a copy of the Privacy Notice for SDCH. __________ (Initials) C. The Facility makes every effort to provide a safe environment for all the Residents and their belongings. Personal effects (including but not limited to cash, clothing and jewelry) and furniture are not covered by the Facility’s insurance. The Facility recommends that these items be insured by the Resident for fire, theft, flood and earthquake. I have reviewed and understand the Facility’s theft and loss policy and have read the above statement regarding insurance for my personal belongings. __________ (Initials) D. The Resident may choose to allow the Facility to post Resident’s name outside apartment door and publish Resident’s name and phone number in the Barton Creek Directory. I give permission to the Facility to release my name and phone number for the Barton Creek Directory and post my name outside my door. __________ (Initials) E. No animals, birds or pets of any kind shall be permitted without written consent of the Facility management. F. The State Department of Health may examine Resident records as part of its evaluation of the Facility G. The Facility management shall have a right to enter the Resident’s apartment in case of emergency, inspection for damage or repair, or delivery of legal notices H. The Resident shall not redecorate or alter Resident’s apartment without the written permission of the Facility management I. In the event of an accident in which the Resident falls or is injured in any way and the Resident desires to have the non-medical assistance of the Facility staff or a fellow Resident assist the Resident to his/her feet, to a chair or to the Resident’s apartment at the specific verbal request of the Resident, then the Resident agrees to waive any and all liability claims against the Facility and the person or persons who provide such assistance J. The Resident hereby acknowledges that the Facility is not licensed for and does not provide medical or skilled nursing care, and that it is the Facility’s policy to dial 911 on behalf of the resident in the event it appears to be to the Resident’s benefit in the sole discretion of the Facility staff. K. The Resident hereby acknowledges that he/she has received a copy of the Resident’s Rights and has reviewed and understands these rights L. This agreement is governed by the laws of the State of Utah. In the event any suit or action is brought to collect any fees or to enforce any provision of this Agreement, reasonable attorney’s fees and necessary costs shall be awarded by the trial and appellate courts to the prevailing parting in such suit or action M. The Facility will monitor any and all care provided to the Resident by outside persons and agencies. Anyone providing care for the Resident will be required to inform the Office when they are seeing the Resident and must leave a written report regarding the services provided with management when they have completed their visit. If services by an outside source do not meet the Facility’s standards, the Facility reserves the right to request that other care arrangements be made. All outside persons or agencies must supply the Facility with proof of a valid business license, liability insurance and, if applicable, worker’s compensation insurance N. The Responsible Party agrees to assume responsibility for the Resident’s well-being as required by the State Department of Health

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PARTIES TO THIS AGREEMENT: ______________________________________________________ Resident

_____________________ Date

______________________________________________________ Responsible Person

_____________________ Date

______________________________________________________ The Inn on Barton Creek

_____________________ Date

The original Resident Agreement, completed and signed, is retained by the Facility and a copy is given to the Resident and to the Responsible Party. Addendum A Additional Services and Charges A resident may require or desire services in addition to their Lifestyle Program. The Inn on Barton Creek is eager to provide services as needed. A menu of services available and charges for those services is listed below. Services will be totaled at the end of each month and will appear on the next month’s statement. Special diet preparation and/or monitoring – $100 per month, includes cutting up food, monitoring diabetic, low salt or other prescribed diets. Guest meals – Guest meals should be reserved with customer service one day in advance (except breakfast). Guest meals may be paid for in advance through customer service or may be charged to your account at the rate of $3 for breakfast, $7 for lunch, and $5 for dinner. Tray Service – Each resident may receive three days of meals delivered to their apartment, during temporary illness. Every additional tray is $2 per tray. Special Clean-ups – Clean-ups due to illness, incontinence, misuse of plumbing, etc. will be charged to your account at a minimum of $20 per incident. This charge includes laundry necessary for clean up. Carpet Cleaning – Carpets may be cleaned by the maintenance department up to twice a year free of charge. Additional carpet cleaning either at your request or management discretion will be charged to your account at $35 per cleaning depending on a resident’s Lifestyle Program. Maintenance Assistance – Resident requests for assistance with maintenance items such as hanging pictures, moving furniture, or simple repairs will be done as time permits and at a charge of $10 per fifteen minutes. Market Items – Barton Creek offers items such as stamps, combs, tissues, batteries, lotion, soap, etc. Some items may even be special ordered. Market items will be charged to your account. Outside Activities – Occasionally special activities outside of Barton Creek will require residents to contribute a small fee to participate. These costs will vary and will always be listed on the sign-up sheet for that activity.

November 2008

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