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Com unity Advisory Committee Quarterly/Annual Visitation Report County: Facility Type: Facility Name/Address: Orange ❑Family Care Home ❑Nursing Home The Stratford, 405 Smith Level Rd., CH 27516 ❑✓ Adult Care Home ❑ Visit Date:�,n;m*,,/12"9/24 Time spent in facility: hr 35 min Arrival time: 3 :45 ❑ am ❑✓ pm huu_,,h 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 Danita Thompson, Dirrector Committee Members Present: Report Completed by: Stephanie Boswell, 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: 0 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 2. Did residents say they receive assistance with personal care activities?Ex. brushing their teeth, combing their hair, inserting N/A dentures or cleaning their eyeglasses? 3. Did you see or hear residents being encouraged to participate in their care by staff members? N/A 4. Were residents interacting with staff, other residents&visitors? Yes 5. Did staff respond to or interact with residents who had difficulty N/A communicating or making their needs known verbally? 6. Did you observe restraints in use? No O 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 Residents rooms we visited were 9. Did you notice unpleasant odors in commonly used areas? No O personalized and residents appeared 10. Did you see items that could cause harm or be hazardous? No O comfortable. 11. Did residents feel their living areas were too noisy? No O 12. Does the facility accommodate smokers? Yes O Where? 0 Outside only❑ Inside only❑ Both Inside/Outside 13. Were residents able to reach their call bells with ease? N/A O 14. Did staff answer call bells in a timely&courteous manner? N/A O 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 Yes O There is a new Activities Director who activities planned for them at the facility? is polling residents about their 16. Do residents have the opportunity to purchase personal items of interests. We did see card playing, tv their choice using their monthly needs funds? Yes O watching and more games and Can residents access their monthly needs funds at their puzzles available. convenience? 17. Are residents asked their preferences about meal/snack choices? Residents are given a choice of Are the given a choice about where the refer to dine? Yes O snacks. 18. Do residents have privacy in making and receiving phone calls? N/A O There is a minister that visits every 19. Is there evidence of community involvement from other civic, Saturday and offers a service that is volunteer or religious groups? Yes O well attended. 20. Does the facility have a Resident's Council? Yes O Family Council? Areas of • Are there resident issues or topics that need follow-up or review at a later Discuss items from "Areas of Concern"Section time or during the next visit? NO O as well as any changes observed during the visit 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