Inspection·October 18, 2023

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the resident has a right to personal privacy for 1 of 13 residents (Resident #25) reviewed for dignity, in that: Residents Affected - Few 1.Housekeeper D entered the Shower room after CNA B and CNA C stated patient care X 3 while showering resident # 25. This deficient practice could place residents at risk of loss of dignity. The findings were: Record review of Resident #25's face sheet, dated 10/17/23, revealed a [AGE] year-old female with an admission date of 5/29/2020 with the diagnosis that included: [Anemia] problem of not having enough healthy red blood cells to carry oxygen to the body's tissues. [COPD] a condition involving constriction of the airways and difficulty or discomfort in breathing, and [Cervical Spondylosis] is the degeneration of the bones and disks in the neck. Record review of resident # 25 quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating intact cognition. Record review of Housekeeper D's employee education file reviewed on 10/17/23 at 12 p.m. revealed he had taken Residents rights in Spanish. During an Interview with Resident # 25 On 10/17/23 at 1030 a.m., she stated that while CNA B and CNA C were showering her on 10/17/23 at 945 a.m., housekeeper D knocked on the shower door. She heard CNA A and CNA C state, Patient Care X 3, and housekeeper D walked into the shower room and picked up trash. Resident # 25 states she felt violated of her privacy since housekeeper D walked into the shower room after being told 'Patient Care . During an interview with Housekeeper D on 10/17/23 at 11:00 a.m., he stated that he heard two voices shout Patient Care, but since he does not speak English, he did not understand what was said. He states he only opened the door with a small crack and took shower room trash. During an interview with CNA B and CNA C on 10/17/23 at 11:30 a.m., both stated that when they were showering Resident # 25, they heard a knock on the shower door and yelled, Patient Care X 3 and that Housekeeper D stepped inside the shower room and took out the trash. In an Interview with the Housekeeping supervisor on 10/17/23 at 11:45 a.m., she stated that Housekeeper D has received training in Spanish on abuse and neglect to include the meaning of the word Patient Care. The housekeeping Supervisor further stated housekeeper D should have waited for the shower room to be empty to take out the trash. During an interview with the administrator on 10/17/2023 at 2:30 p.m., the Administrator stated Housekeeper D should not have entered the shower room when he heard patient care, including waiting until the shower room was unoccupied to take out the trash. Record review of the facility's policy titled Quality of Life-Dignity, revised 08/2009, revealed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Level of Harm - Minimal harm or potential for actual harm policy Statement - Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality . 6. Residents private space and property shall be respected at all times, staff will knock and request permission before entering residents' rooms. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state laws through established procedure for 1 of 8 (Resident #45) residents reviewed for abuse and neglect, in that: The facility failed to report an allegation of abuse to the State Survey Agency within 24 hours of being made by Resident #45. This deficient practice could place residents at risk of allegations not fully being investigated, and abuse, neglect, misappropriation, and exploitation. The findings included: Record review of Resident #45's Face Sheet dated 10/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis including Aspergers Syndrome (a developmental disorder affecting ability to effectively socialize and communicate). Record review of Resident #45's MDS Assessment, undated, revealed a BIMS Assessment score of 15, indicating cognitively intact. Record review of Resident #45's Nursing Progress Note, dated 10/05/2023, revealed that the resident had alleged that another resident had slapped her face and had been verbally aggressive. Record review of Incident Report for Resident #45, dated 10/08/2023, revealed that Resident #45 stated that another resident had slapped her. Record review of Nursing Note for Resident #47, dated 09/21/2023, revealed that Resident #47 was verbally abusive toward another resident in the dining hall. Record review of TULIP (Texas Unified Licensing Information Portal) revealed no reported alleged incidents of Abuse or Neglect having to do with Resident-to-Resident abuse in the last 3 months. Record review of facility abuse and neglect policy, undated, revealed that any allegations of abuse and neglect must be reported to the state agency within 24 hours of the event. Interview on 10/18/2023 at 11:20 AM, LVN K revealed that any allegations of abuse and neglect are to be reported to the DON and Administrator immediately and they must report within 24 hours so that they are thoroughly investigated. Interview on 10/18/2023 at 11:30 AM, the DON stated that it is expected to report any allegation of abuse or neglect. The DON stated without reporting allegations of abuse or neglect, an incident of actual abuse or neglect has the potential of not being addressed. The DON stated that Resident #45 was not negatively affected by this allegation, and that she moves on fairly quickly due to her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 interest in many different subjects. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 1 medication storage room, reviewed for security, in that; The medication storage room was unattended and unlocked. This failure could place residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications. The findings included: During an observation on 10/15/2023 at 09:10 AM, revealed the facility's medication storage room was unattended, and unlocked. Further review revealed Resident #42 was self-ambulating, with her wheelchair, in the hallway by the medication storage room. The door to the medication storage room was ajar and revealed a room where residents medications were stored. During an interview and observation on 10/14/2023 at 09:18 AM RN X stated the door to the medication room was ajar, unlocked, and had been unsupervised, I and RN Y are the nurses on duty, we work double shifts 06:00 AM to 10:00 PM. RN X stated she was attending to residents down 100-hall and RN Y was attending residents down 200-hall. RN X stated the room should be locked. RN X stated it is the responsibility of each nurse to ensure the room is locked behind them when they exit the room. During an interview on 10/17/2023 at 01:30 PM the DON stated RN X had reported the medication storage room was unintentionally left unlocked on 10/15/2023. The DON stated the expectation was for the medication storage room to always be locked and only accessed by nursing staff. the DON stated it was the responsibility of all nurses to ensure the door to the medication room was locked. The DON stated the potential harm to residents was the loss of control of their medications with a potential for residents to receive a medication unintentionally. A record review of the facility's Medication Labeling and Storage policy dated February 2023, revealed, the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. only authorized personnel have access to the keys. medication storage: the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. compartments including, but not limited to, drawers, cabinets, rooms, carts, refrigerators, and boxes, containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 food storage locations, an ice maker, and refrigerator reviewed for food safety, in that; 1. The facility's ice maker machine presented with pink and black residues inside the ice storage compartment. 2. The residents' snack refrigerator presented with fresh foods without labeled dates to indicate a throw away date. These failures could place residents at risk for food borne illnesses. The findings included: 1. During an observation on 10/16/2023 at 11:33 AM revealed [NAME] Z filled a 2-foot x 2-foot stainless steel tub with ice from the ice maker and used the ice to keep containers of potato salad cool. During an observation and interview on 10/16/2023 at 11:40 AM the FSM stated the facility's ice maker presented with black spots and pink lines inside of the ice maker. The FSM manager stated the ice machine was dirty and the ice would be discarded. The FSM stated the ice machine was serviced monthly by the ice machine maintenance contractor and would not be used until it could be cleaned. During an observation and interview on 10/18/2023 at 10:50 AM revealed the ice machine maintenance contractor servicing the facility's ice machine. The contractor stated he had not cleaned the machine personally, but his company had routinely cleaned the machine monthly. The contractor stated the black spots and the pink colored areas on the ice machine's deflector were most likely mold and bacteria which originate from the air and deposit on surfaces inside the machine. During an interview on 10/18/2023 at 11:15 AM the FSM, the DON and the Administrator stated in the past the FSM had not supervised the contractor cleaning the ice machine and going forward would inspect the cleaning after the service. The DON stated the mold and bacteria could cause residents food borne illnesses. The Administrator stated the failure would be addressed through education for staff who use the machine to inspect the machine as they use it and report to the DON and or FSM any signs of the machine being dirty. 2. A record review of Resident #21's admission record dated 10/17/2023 revealed an admission date of 12/27/2021, with diagnoses which included schizophrenia [a severe brain disorder that affects how (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal] and GERD [Gastro-Esophageal Reflux Disease - a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach]. A record review of Resident #21's quarterly MDS assessment dated [DATE], revealed Resident #21 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 out of 15 which indicated she was cognitively intact. A record review of Resident #21's care plan dated 10/17/2023 revealed, Resident #21 has diagnosis of GERD Digestive disorder/ Acid indigestion, Will have no signs and symptoms of gastric distress in this quarter . Continue interventions. Administer medications as ordered and monitor of effectiveness, encourage to eat in sitting up position 30-60 mins. following food intake. Follow diet order, avoid spicy foods, carbonated drinks and caffeine as possible. A record review of Resident #21's physicians orders dated 10/17/2023 revealed Resident #21 was to have food which were mechanically soft, ground meats, and for liquids to be thin [regular]. During an observation and interview on 10/17/2023 at 04:28 PM revealed the employee break room hosed the residents snack refrigerator. Review of the refrigerator revealed a 1-pound container of strawberries with Resident #21's name upon the container. Further review revealed no other labels other than the commercial grocery store label. The DON stated the FSM and nursing staff were responsible for the foods in the resident's snack refrigerator. The DON stated she was not sure, but the strawberries may have been accepted by nursing staff and placed in the refrigerator for Resident #21. The DON stated foods for residents brought for residents from sources other than the kitchen must be presented to the FSM for inspection. The DON stated the failure could place residents at risk for not receiving foods per their needs, such as wrong textures and or expired foods. During an interview on 10/18/2023 at 10:40 AM the FSM stated any foods brought to residents by visitors and or families should be presented to her for inspection, and she would ensure the foods were safe for the Resident's consumption. The FSM stated at a minimum the foods would be labeled for food safety by providing a date received and a throw out date. The FSM stated foods provided to residents without the FSM's inspection could place residents at risk for harm by not meeting their dietary needs, food borne illnesses, and improper textures. The FSM stated she was unaware Resident #21 had received strawberries yesterday and had not inspected the food for safety. A record review of the facility's Food Receiving and Storage policy dated October 2017 revealed, foods shall be received and stored in a manner that complies with safe food handling practices . food services, or other designated staff, will always maintain clean food storage areas. when food is delivered to the facility it will be inspected for safe transport and quality before being accepted. foods that are prepared off site will only be accepted from institutions that are subject to federal, state or local inspection. the food and nutrition services manager shall verify the latest approved inspection and monitor the food quality of the supplier. residents may consume foods from sources not procured by the facility . refrigerated foods must be stored below 41 degrees Fahrenheit unless otherwise specified by law all food stored in the refrigerator or freezer will be covered, labeled and dated used by date . food items and snacks kept on the nursing units must be maintained as indicated below: all food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurses station and labeled with a used by date. All foods belonging to residents must be labeled with the Resident's name, the item, and the use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff and obtain the required information for 1 of 12 (Resident # 48) reviewed for hospice services, in that: 1. The facility failed to obtain Resident #48's most recent hospice plan of care, names and contact information for hospice personnel involved in hospice care of each resident, and documentation by specific interdisciplinary hospice staff providing services This failure could place the resident who received hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Record review of Resident #48's face sheet, dated 10/17/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: [Spinal stenosis] happens when the spaces in the spine narrow and creates pressure on the spinal cord and nerve root. [Type II Diabetes] happens because of a problem in the way the body regulates and uses sugar as a fuel, and [Malignant neoplasm of vertical column] are cancerous tumors in the spinal column. Record review of Resident #48's admission MDS dated [DATE] revealed a BIMS of 14, which indicated cognitive intactness. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #48's comprehensive care plan initiated 08/03/2023 revealed a problem Admit to Hospice Company A Dx. [Malignant neoplasm of vertical column] Call [phone number] for any changes in condition, questions, or concerns. No labs or x-rays without hospice approval. RN Hospice nurse to pronounce. Record review of Resident #48's electronic medical record active orders as of 10/17/2023 revealed an order on 08/02/2023 for: Admit to Hospice Company A Dx. [Malignant neoplasm of vertical column] Call [phone number] for any changes in condition, questions or concerns. No labs or x-rays without hospice approval. RN Hospice nurse to pronounce. In an interview with RN A on 10/17/2023 at 11:55 a.m., RN A revealed all records regarding resident care was kept in the resident's electronic medical record. RN A revealed that only hospice residents have additional paper records kept in hospice binders. RN A was unable to locate a hospice binder for Resident #48 . RN A was asked who is responsible for organizing hospice services for residents and RN A stated the SW meets with families when the doctor orders hospice so the family can choose which agency they want. RN A was asked how resident care is coordinated between hospice and nursing staff and RN A revealed when the hospice nurse is finished with the visit, they stop by the nursing station and give a report. In an interview with the SW on 10/17/2023 at 12:35 p.m., the SW revealed that after the resident/family had chosen which hospice agency they wanted to use, she wouldn't play a part in coordinating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 hospice services unless something was needed. Level of Harm - Minimal harm or potential for actual harm In an interview with the DON on 10/17/2023 at 12:54 p.m., the DON was asked who is responsible for the coordination of hospice care for the residents. The DON revealed the ADON staff had been the point of contact at one time for the assigned hospice nurse case manager to update following each visit. The DON added the hospice nurses now communicate more closely with the charge nurses. Residents Affected - Few Record review of the facility's hospice services agreement with Hospice Company A, with an effective date of May 11, 2015, revealed in 2.12 Plan of Care .The Hospice and Nursing facility will jointly develop and agree upon a coordinated Plan of Care that is consistent with the hospice philosophy and is responsive to the unique needs of the Residential Hospice Patient and his/her expressed desire for hospice care. 3.2 (i) Hospice shall furnish the Nursing Facility with a copy of the Plan of Care. 3.15 Providing Information. At a minimum Hospice shall provide the following information to the Facility for each Hospice Patient residing at the Facility: A. Hospice Plan of Care . 6.1. Liaison. On or prior to the execution of this Agreement, Hospice and Nursing Facility shall each designate two (2) representative(s) to serve as designees between them and to facilitate cooperative efforts in the performance of their respective obligations under this Agreement. Record review of the facility policy Hospice Program , 2001, Revised July 2017, revealed (D) Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident. (2) hospice election form, (3) Physician certification of terminal illness specific to each resident (4) Names and contact information for hospice personnel involved in hospice care of each resident. (5) Instructions on how to access the hospice 24-hour on-call system. (6) Hospice medication information specific to each resident/ (7) Hospice physician and attending physician (if any) orders specific to each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 10 of 10