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Com unity Advisory Committee Quarterly/Annual Visitation Report County: ORANGE Facility Type: Facility Name/Address: ❑Family Care Home ®Nursing Home Signature HealthCARE of Chapel Hill ❑Adult Care Home 1602 East Franklin Street, Chapel Hill, NC 27514 Visit Date: 03/12/2024 Timespent in facility: 80 min. Arrival time: 12:50 ❑ am ® m Name of person exit interview was held with: Interview was held: ® in Person ❑ Phone ❑Admin. ® SIC Supervisor in Charge) ❑ Other Staff Rep. Moses Muhairwe, Administrator Committee Members Present: Karen Green-McElveen, Shade Little Report Completed by: Shade Little Number of Residents who received personal visits from committee members: 10 Resident Rights Information is clearly visible: ®Yes ❑ No Ombudsman Contact Info is correct and clear) posted: ®Yes ❑ No The most recent survey was readily accessible: ®Yes ❑ No Staffing information clearly posted: ®Yes❑ No Required for Nursing Homes Only) Resident • •/NA Comments/Other Observations 1. Do the residents appear neat,clean and odor free? Y The residents were easy to talk with. 2. Did residents say they receive assistance with personal care activities? At least one resident conveys desires and needs to Ex. brushing their teeth, combing their hair,inserting dentures or cleaning Y staff from residents not willing/able to do so. their eyeglasses? 3. Did you see or hear residents being encouraged to participate in N 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? N 7. If so,did you ask staff about the facility's restraint policics? NA Resident Living Accommodations Yes/No/NA Comments/Other Observations 1. Did residents describe their living environment as homelike? Y Outside smoking area is well utilized. 2. Did you notice unpleasant odors in commonly used areas? N There is an outside area which may be used for 3. Did you see items that could cause harm or be hazardous? N planting and garden activities. 4. Did residents feel their living areas were too noisy? N 5. Does the facility accommodate smokers? Y Where? ® Outside only❑ Inside only❑ Both Inside/Outside 6. Were residents able to reach their call bells with ease? Y 7. Did staff answer call bells in a timely&courteous manner? Y If no, did you share this with the administrative staff? Resident • • Observations 1. Were residents asked their preferences or opinions about the Y Again, several residents appreciated the outings. activities planned for them at the facility? Activity Director posts trips(fishing, shopping)and 2. Do residents have the opportunity to purchase personal items of Y activities both monthly and daily in a conspicuous their choice using their monthly needs funds? location. Can residents access their monthly needs funds at their Y Staff continues to be helpful and caring. convenience? 3. Are residents asked their preferences about meal/snack choices? Y Are they given a choice about where they prefer to dine? Y 4. Do residents have privacy in making and receiving hone calls? Y 5. Is there evidence of community involvement from other civic, Y volunteer or religious groups? 6. Does the facility have a Resident's Council? Y Family Council? Areas of • Yes/No/NA i Exit Summary Are there resident issues or topics that need follow-up or review at a later No time or during the next visit? his Document is PUBLIC RECORD.Do not identify any Resident(s)by name or inference on this form. Bottom Copy is for the CAC's Records.