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Com unity Advisory Committee Quarterly/Annual Visitation Report County: Orange Facility Type: Facility Name/Address: Charles House-Winmore ❑Family Care Home ❑Nursing Home 121 Della St, Chapel Hill X Adult Care Home ❑Combination Home Visit Date 12/27/23 Time spent in facility: hr 30 min Arrival time: 10:20am ❑ am ❑ pm Name of person exit interview was held with: Interview was held: X in Person ❑ Phone ❑Admin. ❑ SIC(Supervisor in Charge) ❑ Other Staff Rep. (Name& Title) Committee Members Present: Mary Lou Gelblum, Stephanie Boswell Report Completed by: Stephanie Boswell Number of Residents who received personal visits from committee members: 2 Resident Rights Information is clearly visible:X Yes ❑ No Ombudsman Contact Info is correct and clearly posted:XYes ❑ No The most recent survey was readily accessible: ❑Yes ❑ No Staffing information clearly posted: ❑Yes X No Re uired for Nursing Homes Onlo j Resident Profile •/NA Comments/Other Observations 1. Do the residents appear neat,clean and odor free? Y 2. Did residents say they receive assistance with personal care activities?Ex. brushing their teeth, combing their hair,inserting Y dentures or cleaning their eyeglasses? 3. Did you see or hear residents being encouraged to participate in NA their care by staff members? 4. Were residents interacting with staff,other residents&visitors? Y 5. Did staff respond to or interact with residents who had difficulty NA communicating or making their needs known verbally? 6. Did you observe restraints in use? NA 7. If so, did you ask staff about the facility's restraint policies? NA Resident Living Accommodations Comments/Other Observations 8. Did residents describe their living environment as homelike? Y 9. Did you notice unpleasant odors in commonly used areas? N 10. Did you see items that could cause harm or be hazardous? N 11. Did residents feel their living areas were too noisy? N 12. Does the facility accommodate smokers? Y Where?X Outside only❑ Inside only❑ Both Inside/Outside 13. Were residents able to reach their call bells with ease? NA 14. Did staff answer call bells in a timely&courteous manner? NA If no, did you share this with the administrative staff? Resident '/NA Comments/Other Observations 15. Were residents asked their preferences or opinions about the Y activities planned for them at the facility? 16. Do residents have the opportunity to purchase personal items of NA their choice using their monthly needs funds? Can residents access their monthly needs funds at their convenience? 17. Are residents asked their preferences about meal/snack choices? Y Are they given a choice about where they prefer to dine? 18. Do residents have privacy in making and receiving hone calls? Y 19. Is there evidence of community involvement from other civic, N volunteer or religious groups? 20. Does the facility have a Resident's Council? NA Family Council? Areas of Concern • /NA Exit Summary Are there resident issues or topics that need follow-up or review at a later N All residents were dressed and well time or during the next visit? groomed. No odors noted. House was clean and very home-like with regular furniture and festive decorations for the holidays. Staff was knowledgeable regarding patients'daily schedules and preferences.