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Com unity Advisory Committee Quarterly/Annual Visitation Report <br /> County: ORANGE Facility Type: Facility Name/Address: <br /> ®Family Care Home ❑Nursing Home Livewell Assisted Living <br /> ❑Adult Care Home 202 N. Elliot Rd, Chapel Hill, NC 27514 <br /> Visit Date: 03/06/2025 Time spent in facility: Arrival time: 11:20 ® am ❑ pm <br /> hr 30 min <br /> Name of person exit interview was held with: Cassandra Cook Interview was held: ® in Person ❑ Phone <br /> ❑Admin. ❑ SIC(Supervisor in Charge) ® Other Staff Rep. <br /> Committee Members Present: Shade Little; Alicia Reid Report Completed by: Shade Little <br /> Number of Residents who received personal visits from committee members:4 <br /> Resident Rights Information is clearly visible: ®Yes ❑ No 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 /> Required for Nursing Homes Only) <br /> Resident Profile Yes/No/NA Comments/Other Observations <br /> 1. Do the residents appear neat,clean and odor free? Yes All 6 residents were resting in bed when we <br /> 2. Did residents say they receive assistance with personal care activities? visited. <br /> Ex. brushing their teeth, combing their hair,inserting dentures or cleaning NA <br /> their eyeglasses? <br /> 3. Did you see or hear residents being encouraged to participate in Yes <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 Yes <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 restraint policies? <br /> Resident Living Accommodations Yes/No/NA Comments/Other Observations <br /> 1. Did residents describe their living environment as homelike? No <br /> 2. Did you notice unpleasant odors in commonly used areas? No <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? No <br /> Where? ❑ Outside only❑ Inside only❑ Both Inside/Outside <br /> 6. Were residents able to reach their call bells with ease? Yes <br /> 7. Did staff answer call bells in a timely&courteous manner? NA <br /> If no, did you share this with the administrative staff? <br /> Residentservices •/NA Comments/Other Observations <br /> 1. Were residents asked their preferences or opinions about the No <br /> activities planned for them at the facility? <br /> 2. Do residents have the opportunity to purchase personal items of NA <br /> their choice using their monthly needs funds? <br /> Can residents access their monthly needs funds at their NA <br /> convenience? <br /> 3. Are residents asked their preferences about meal/snack choices? Yes <br /> Are they given a choice about where they prefer to dine? No <br /> 4. Do residents have privacy in making and receiving hone calls? NA <br /> 5. Is there evidence of community involvement from other civic, No <br /> volunteer or religious groups? <br /> 6. Does the facility have a Resident's Council? No <br /> Family Council? No <br /> Areas of • • <br /> /NA Exit Summary <br /> Are there resident issues or topics that need follow-up or review at a later No <br /> time or during the next 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 Copy is for the CAC's Records. <br />