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Community Advisory Committee Quarterly/Annual Visitation Report <br />County: Facility Type: <br />Family Care Home Nursing Home <br />Adult Care Home <br />Facility Name/Address: <br />Visit Date: / /Time spent in facility: hr min Arrival time: : 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) <br />Committee Members Present: Report Completed by: <br />Number of Residents who received personal visits from committee members: <br />Resident Rights Information is clearly visible: Yes No Ombudsman Contact Info is correct and clearly posted: Yes No <br />The most recent survey was readily accessible: Yes No <br />(Required for Nursing Homes Only) <br />Staffing information clearly posted: Yes No <br /> Resident Profile Yes/No/NA Comments/Other Observations <br />1.Do the residents appear neat, clean and odor free? <br />2.Did residents say they receive assistance with personal care <br />activities? Ex. brushing their teeth, combing their hair, inserting <br />dentures or cleaning their eyeglasses? <br />3.Did you see or hear residents being encouraged to participate in <br />their care by staff members? <br />4.Were residents interacting with staff, other residents & visitors? <br />5.Did staff respond to or interact with residents who had difficulty <br />communicating or making their needs known verbally? <br />6.Did you observe restraints in use? <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 />8.Did residents describe their living environment as homelike? <br />9.Did you notice unpleasant odors in commonly used areas? <br />10.Did you see items that could cause harm or be hazardous? <br />11.Did residents feel their living areas were too noisy? <br />12.Does the facility accommodate smokers? <br />Where? Outside only Inside only Both Inside/Outside <br />13.Were residents able to reach their call bells with ease? <br />14.Did staff answer call bells in a timely & courteous manner? <br />If no, did you share this with the administrative staff? <br />Resident Services Yes/No/NA Comments/Other Observations <br />15.Were residents asked their preferences or opinions about the <br />activities planned for them at the facility? <br />16.Do residents have the opportunity to purchase personal items of <br />their choice using their monthly needs funds? <br />Can residents access their monthly needs funds at their <br />convenience? <br />17.Are residents asked their preferences about meal/snack choices? <br />Are they given a choice about where they prefer to dine? <br />18.Do residents have privacy in making and receiving phone calls? <br />19.Is there evidence of community involvement from other civic, <br />volunteer or religious groups? <br />20.Does the facility have a Resident’s Council? <br />Family Council? <br /> Areas of Concern Yes/No/NA Exit Summary <br />Are there resident issues or topics that need follow-up or review at a later <br />time or during the next visit? <br />Discuss items from “Areas of Concern” Section <br />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 Copy is for the CAC’s Records. <br />Revised 1/21/2020