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\.....UIlIIIIUlIllY t-\.U '.l.)UI Y '-'U..llll.ll....\,. '.,lU"' L"I IJ' L .............. .. .~u.............u ....."'y..... .. ICounty Facilily Type. 0 Family Care Home Facility Name Cabarrus 0 Adult Care Home 0 Nursing Home Concord Retirement Center o Combination Home Visit Dale 05/ OS/2005 Time S enl in Factlil 1 hr 30 m,n Arrival Time 1 :00 . Dam 0 pm Name of Person Exillnterview was held with Inlerview was held 0 In.Person DPhone OAdmn. o SIC(s,,,_.c....1 Veronica Culbertson DOther Slaff (Name &Ti/le) ~~~~~ ~~~~ Gail Hall, Karen Pensgen, Joanne Yurchison Joanne Yurchison Number of Residents who received personal visits from committee members: 12 and 1 famil member Resident Rights Information is clearly visible [RIVes 0 No Ombudsman contact infonnation is correct and clearly posted. [RJ Ves The p01terl1 ilnoldone oNo The most recent survey was readily accessible.DYes 0 No Staffing ,nformation is posted. 0 Yes0 No Required for Nursing Homes Only) 1. Do the residents appear neat, clean and odor free? [RJ Yes 0 No 2. Did residents say they receive assistance with personal care activities, Ex. brushing their teeth, combing their hair, inserling dentures or cleaning their eyeglasses? 0Yes 0 No. 3, Did you see or hear residents being encouraged to participate in their care by staff members? DYes [E] No 4, Were residents interacting wi staff, other residents & visitors? DYes [E] f\b 5. Did staff respond to or interact with residents who had difficulty communicating or making their needs known verbally? 0 Yes 0 No N/A 6. Did you observe restraints in use? DYes [E] No 7. If so, did you ask staff about the facility's,restraint policies? 0 YfS [EJ I\b .. Slitt a 101 of wheelchairs in use for an assisted living .. Staff all sitting around a dining table when we arrived . Room #9. Fan taying face down on a wet bed_ MaUress had a deep indention where the resident would normally have to tie dawn. . Bathroom in Room #9 - water runs into a bucket under the sink instead of down the drain. No tight. . Residents distressed that "no snacks nor drinks. are allowed in the rooms - posted signs on every door. Resident Living Accommodations Comments & Other Observations 8, Did residents describe their living environment as homelike? DYes [E]. No 9. Did you notice unpleasant odors in commonly used areas? DYes lID No 10. Did you see items that could cause hann or be hazardous? (E] Yes D No 11,.oid residents feel their living areas were too noisy? OYes[E] No 12. Does the facility accommodate smokers? 00 Yes 0 No 12a. Where? 0 Outside only D Inside only 0 80th Inside & Outside. 13. Were residents able to reach their call belts with ease? DYes [B) No No 14. Did staff answer caU bells in a timely & courteous manner? DYes 0 No 14a. If no, did you share this with the administrative staff? 0 Yes 0 No . Sheet remains haphazardly draped over window in bathroom across from #3; towel rack broken, wooden post holding up sink; light over sink inoperable .. Baseboards. windowsills and perimeter or Roor very dirty in Room 10. Curtains very dirty. . No lockable space for personal items . Residenl wilh oxygen in dining area had her oxygen lines crossing the hallway from her room to the dining tables using- very easy to trip someone . Q. 13. No call bells . In back bathroom, bathtub does not work .. Halt bathroom had no paper towels .. Not all residents have lockable space for personal items . Exit sign at back door is a sign, not a lighted fixture Resident Services Comments & Other Observations 15, Were residents asked their preferences or opinions about the activities planned for them at the facility? DYes 0 No 16. Do residents have the opportunity to purchase personal items of their choice using their monthly needs funds? [RJ Yes [RJ No u, 16a. Can residents access their monthly needs funds at their convenience? DYes 00 No 17, Are residents asked their preferences about meal & snack choices? DYes 0 No 17a, Are they given a choice about where they prefer to dine? DYes [E] No 18. 00 residents have privacy in making and receiving phone calls? DYes 0 No 19. Is there evidence of community involvement from other civic, votunteeror religious groups? DYes (8] No 20. Does the facility have a Resident's Council? DYes 0 No Family Council? DYes [RJ No . Lack of meaningful activities; no activilies posted; most are card, game playing between residenls; no trips outside home available, . Meals -.) No menus posted o No alternative meals posted o Residents would tike more meat o Would like a variety or vegetables . Seems like personal funds are available only when Ms. Jones comes to the facility_ Mr. Lopez stili does not have any money . No bedside reading lights for residents , light bulbs miSSing or burned out in many ceiling lights . No privacy for calls - only phone is middle of hall, across from dining room . No working exhaust-fan in bathroom across from Room #8 Areas of Concern Exit Summary Several residents complained they do not get their telephone messages Continuing concerns about bedridden, paralyzed resident. Appears depressed, quiet. unsmiling. somewhat withdrawn. Conversation with SIC detailing our observalions; she did noltake any notes so not sure if our concerns are ever shared wilh the owner. CAC believes this facility needs continuous/frequent monitoring by regulatory agencies and Reg. Ombudsman. Absentee administrator a arent. This Document is a PUBLIC RECORD. Do not identify any Resident(s) by name or inference on this form. ~ is for the Regional Ombudsman's Record. Bottom COpy is for the CAe's Records. OHHS OAAS.022J2004 G-~)...