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Com unity Advisory Committee Quarter/ /Annual Visitation Report County: Facility Type: Facility Name/Address: Orange ❑Family Care Home ❑Nursing Home 624 Jones Ferry Rd, Carrboro, NC 27510 Gracefu ❑✓ Adult Care Home ❑ Visit Date: 12/19 /25 Time spent in facility: hr 45 min Arrival time: 2 : 00 ❑ am ❑✓ pm Name of person exit interview was held with: Interview was held: ❑✓ in Person ❑ Phone 0 Admin. ❑ SIC (Supervisor in Charge) ❑ Other Staff Rep. Name/Title Anita Terry, Business Office Manager Committee Members Present: Report Completed by: Shade Little, MaryLou Gelblum �MaryLou Gelblum Number of Residents who received personal visits from committee members:10 Resident Rights Information is clearly visible: 0 Yes ❑✓ No Ombudsman Contact Info is correct and clearly posted: Z Yes ❑✓ No The most recent survey was readily accessible: ❑Yes❑✓ No Staffing information clearly posted: ❑ Yes ❑ No (Required for Nursing Homes Only) Resident Profile I Comments/Other Observations 1. Do the residents appear neat, clean and odor free? Yes O Residents were for the most part 2. Did residents say they receive assistance with personal care found in their rooms and did appear activities?Ex. brushing their teeth, combing their hair, inserting Yes O clean and odor free. A few were seen dentures or cleaning their eyeglasses? being helped with ADLs by staff, 3. Did you see or hear residents being encouraged to participate in Yes O others were sitting, a few were their care by staff members? g watchin a movie in movie room. One 4. Were residents interacting with staff, other residents&visitors? Yes O resident complained of having to have 5. Did staff respond to or interact with residents who had difficulty communicating or making their needs known verbally? N/A a bath everyday, and having a male 6. Did you observe restraints in use? No 0 assist. 7. If so, did you ask staff about the facility's restraintpolicies? N/A Resident Living Accommodations Yes/No/NA Comments/Other Observations 8. Did residents describe their living environment as homelike? Yes O For the first time in years, there was 9. Did you notice unpleasant odors in commonly used areas? No O no unpleasant odor upon entering the 10. Did you see items that could cause harm or be hazardous? No O building. Credit was given to the 11. Did residents feel their living areas were too noisy? No O current cleaner who we saw mopping. 12. Does the facility accommodate smokers? No O Smokers have a space w chairs Where? 0 Outside only❑ Inside only E] Both Inside/Outside outside. Call bells seem to be 13. Were residents able to reach their call bells with ease? Yes O answered timely. No unlocked med 14. Did staff answer call bells in a timely&courteous manner? Yes O carts or unlocked supply closet noted. 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 No O There is no activities director currently, activities planned for them at the facility? and no activities posted. Menus were 16. Do residents have the opportunity to purchase personal items of posted. their choice using their monthly needs funds? Yes O No phone is available on the men's or Can residentaccess their monthly needs funds at their women's halls. Staff reported they are convenience? 17. Are residents asked their preferences about meal/snack choices? stolen quickly. Residents must go to Are the given a choice about where the refer to dine? Yes office and request use of a phone 18. Do residents have privacy in making and receiving phone calls? No 0 there. 19. Is there evidence of community involvement from other civic, We observed a volunteer delivering volunteer or religious groups? Yes 0 materials for the activities room. A 20. Does the facility have a Resident's Council? resident who enjoys assisting with FamilyCouncil? Yes O activities was helping put them away. Areas of • • /NA Exit Summary Are there resident issues or topics that need follow-up or review at a later Yes O Discuss items from "Areas of Concern"Section time or during the next visit? as well as any changes observed during the visit We will review whether daily baths are mandatory and We discussed areas of concern with whether a request to have female-only staff assist can the Business Office Manager who has be accommodated. been on the job for less than 2 weeks. We will/ follow up on the rights of residents to make The Director was not in. We will follow up on issues on our next visit. private phonecalls and whether a solution to the problem has been implemented. We commented on the improved We will ask whether it is a common problem for lighting and overall smell in the building. residents to be transported late to appointments. In the room of one resident we noticed two full urinals that needed emptying. The resident is in a wheelchair and may have trouble transporting and emptying them. We will ask if this is monitored. 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. Revised 1/21/2020