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Community Advisory Committee Quarterly/Annual Visitation Report <br />County: ORANGE Facility Type: <br />Family Care Home Nursing Home <br />Adult Care Home <br />Facility Name/Address: Charles House Yorktown <br />303 Yorktown Dr, Chapel Hill NC 27516 <br />Census – current/licensed: 4/6 <br />Visit Date: 9 /17 /2019 Time spent in facility: hr 50 min Arrival time: :40 am pm <br />Name of person exit interview was held with: Interview was held: in Person Phone <br /> Admin. SIC (Supervisor in Charge) Other Staff Rep. Marla <br />Committee Members Present: Karen Green-McElveen , MaryLou Gelblum , Shade Little Report Completed by: Shade Little <br />Number of Residents who received personal visits from committee members: <br />Resident Rights Information is clearly visible: Yes No Ombudsman Contact Info is correct and clearly posted: Yes No <br />The most recent survey was readily accessible: Yes No <br />(Required for Nursing Homes Only) <br />Staffing information clearly posted: Yes No <br /> Resident Profile Yes/No/NA Comments/Other Observations <br />Do the residents appear neat, clean and odor free? Yes 2 residents sleep in bed. The 103 year old <br />receives a hospice visit weekly. <br />1 loves Lucy and Carol Burnett watched TV but <br />also responded to both TV and staff and CACer. <br />1 received assurances from Marla on the progress <br />of her sandwich and the accompanying type of <br />drink. <br />Did residents say they receive assistance with personal care activities? Ex. <br />brushing their teeth, combing their hair, inserting dentures or cleaning <br />their eyeglasses? <br />No <br />Did you see or hear residents being encouraged to participate in their care <br />by staff members? No <br /> Were residents interacting with staff, other residents & visitors? Yes <br />Did staff respond to or interact with residents who had difficulty <br />communicating or making their needs known verbally? Yes <br />Did you observe restraints in use? No <br />If so, did you ask staff about the facility’s restraint policies? NA Resident Living Accommodations Yes/No/NA Comments/Other Observations <br />1. Did residents describe their living environment as homelike? NA 1. WE observed the environment as homelike. <br />2. Urine scent in hallway <br />4. WE observed a very quiet house. <br />2. Did you notice unpleasant odors in commonly used areas? Yes <br />3. Did you see items that could cause harm or be hazardous? No <br />4. Did residents feel their living areas were too noisy? NA <br />5. Does the facility accommodate smokers? <br />Where? Outside only Inside only Both Inside/Outside <br />No <br />6. Were residents able to reach their call bells with ease? NA <br />7. Did staff answer call bells in a timely & courteous manner? <br />If no, did you share this with the administrative staff? <br />NA <br /> <br />Resident Services Yes/No/NA Comments/Other Observations <br />8. Were residents asked their preferences or opinions about the <br />activities planned for them at the facility? <br />No 9. Due to the level of dementia for these <br />residents, they do not manage their own finances. <br />11. Residents are unable to communicate on the <br />phone. <br />13. The residents cannot have a council due their <br />dementia. <br />10. One offered fruit, the other choice of sandwich <br />when she was wheeled to the room after a nap. <br /> <br />We observed an excellent activity calendar. <br />Most staff been there (Marla4 yrs, Tanya 11) for a <br />while, some movement of younger staff. <br />9. Do residents have the opportunity to purchase personal items of <br />their choice using their monthly needs funds? <br />Can residents access their monthly needs funds at their <br />convenience? <br />NA <br /> <br />NA <br />10. Are residents asked their preferences about meal/snack choices? <br />Are they given a choice about where they prefer to dine? <br />Yes <br />No <br />11. Do residents have privacy in making and receiving phone calls? NA <br />12. Is there evidence of community involvement from other civic, <br />volunteer or religious groups? <br /> <br />13. Does the facility have a Resident’s Council? <br />Family Council? <br />No <br />No Areas of Concern Yes/No/NA Exit Summary <br />Are there resident issues or topics that need follow-up or review at a later <br />time or during the next visit? <br />The alarm on kitchen door is broken, part has been ordered. <br /> <br />Yes We told of the urine smell. It was attributed to the <br />resident who awoke from her nap and needed <br />changing. We did NOT go by her room to check. <br />Do that next time. <br />This Document is PUBLIC RECORD. Do not identify any Resident(s) by name or inference on this form. Top Copy is for the Regional Ombudsman’s Record. Bottom Copy is for the CAC’s Records.