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Community Advisory Committee Quarter) /Annual Visitation Report <br /> County: Facility Type: Facility Name/Address: <br /> Orange ©Family Care Home ❑Nursing Home Charles House,Winmore,121 Della St.,Carrboro 27510 <br /> ❑Adult Care Home ❑ <br /> Visit Date:.e mkk./12/19/24 Time spent in facility: hr 30 min Arrival time: 4 :45 ❑ 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. Name/Title Daniel Mazamec <br /> Committee Members Present: Report Completed by: <br /> Stephanie Boswell,Marylou Gelblum �MaryLou Gelblum <br /> Number of Residents who received personal visits from committee members:4 <br /> Resident Rights Information is clearly visible: ®Yes®No I Ombudsman Contact Info is correct and clear) posted:®Yes®No <br /> The most recent survey was readily accessible:®Yes®No Staffing information clearly posted: ©Yes❑No <br /> Re uired for Nursinq Homes Onl <br /> Resident •file Yes/NoINA Comments/Other Observations <br /> 1. Do the residents appear neat,clean and odor free? Yes <br /> 2. Did residents say they receive assistance with personal care <br /> activities?Ex.brushing their teeth,combing their hair,inserting N/A <br /> dentures or cleaning their eyeglasses? <br /> 3. Did you see or hear residents being encouraged to participate in N/A <br /> their care by staff members? <br /> 4. Were residents interacting with staff,other residents&visitors? Yes <br /> 5. Did staff respond to or interact with residents who had difficulty N/A <br /> communicating or making their needs known verbally? <br /> 6. Did you observe restraints in use? No <br /> 7. If so,did you ask staff about the facility's restraintpolicies? N/A <br /> Resident Living Accommodations Yes/No/NA Comments/Other Obse <br /> 8. Did residents describe their living environment as homelike? Yes Each resident has their own lounge <br /> 9. Did you notice unpleasant odors in commonly used areas? No chair in the living room area and <br /> 10. Did you see items that could cause harm or be hazardous? No bedrooms have large windows and <br /> 11. Did residents feel their living areas were too noisy? NO nice furnishings. <br /> 12. Does the facility accommodate smokers? Yes <br /> Where?©Outside only❑Inside only❑Both Inside/Outside <br /> 13. Were residents able to reach their call bells with ease? N/A <br /> 14. Did staff answer call bells in a timely&courteous manner? N/A <br /> If no,did you share this with the administrative staff? <br /> Resident •/NA Comments/Other Observations <br /> 15. Were residents asked their preferences or opinions about the Yes Residents are offered a variety of <br /> activities planned for them at the facility? activities centered on holidays and <br /> 16. Do residents have the opportunity to purchase personal items of their interests. <br /> their choice using their monthly needs funds? Yes <br /> Can residents access their monthly needs funds at their <br /> convenience? <br /> 17. Are residents asked their preferences about meal/snack choices? Yes <br /> Are they given a choice about where they prefer to dine? <br /> 18. Do residents have privacy in making and receiving hone calls? N/A <br /> 19. Is there evidence of community involvement from other civic, <br /> volunteer or religious groups? N/A <br /> 20. Does the facility have a Resident's Council? N/A <br /> Family Council? <br /> Areas of • <br /> Are there resident issues or topics that need follow-up or review at a later No Discuss items from"Areas of Concern"Section <br /> time or during the next visit? as well as any changes observed during the visit <br /> This Document is PUBLIC RECORD.Do not identify any Resident(s)by name or inference on this form. <br /> Top Copy is for the Regional Ombudsman's Record.Bottom Co pv is for the CAC's Records. <br /> Revised 1/21/2020 <br />