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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-CNPUY7

FACILITY NAME
Heritage Village
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962N5Y
FACILITY ADDRESS
7525 Topaz Dr
FACILITY PHONE
(604) 858-1833
CITY
Chilliwack
POSTAL CODE
V2R 3C9
MANAGER
Kendall Korda

INSPECTION DATE
February 03, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7
ARRIVAL
09:00 AM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

This unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.) and the relevant Director of Licensing Standards of Practice (D.L.S.P.). Evidence for this report was based on the Licensing Officer's observations, review of the facility records, and information provided by the facility staff at the time of the inspection.

The following areas were reviewed:

- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this routine inspection a facility risk assessment tool is completed and a copy is provided. The risk assessment includes non-compliance identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

Visit the Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XUHwhWyos2z for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).

Contraventions
Previous Inspection - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
CARE AND/OR SUPERVISION: 34470 - RCR s.73(2)(c) - In addition to the requirements under subsection 73(1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care.
Observation: One person in care who required the use of two different restraints, did not have information regarding the use of the restraints documented in their care plan.
Corrective Action(s): Please ensure the use of restraints is included in the PICs care plan as required.
Date to be Corrected: February 17, 2023

CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: The care plans of five persons in care were reviewed and none included a plan for their recreation or leisure.
Corrective Action(s): Please ensure that a PIC's care plan includes a plan for their recreation and leisure.
Date to be Corrected: February 17, 2023

CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: The care plan of one PIC did not include a fall prevention plan.
Corrective Action(s): Please ensure a fall prevention plan is include in a PICs care plan as required.
Date to be Corrected: February 17, 2023

CARE AND/OR SUPERVISION: 34710 - RCR s.81(3)(f)(ii) - A care plan must include all of the following: (f) if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan (ii) if the person in care leaves without notification, to locate the person in care.
Observation: One PIC who had been assessed and identified as at risk for elopement from the facility had a care plan related to preventing their elopement, however did not include a plan to locate the PIC if elopement were successful.
Corrective Action(s): Please ensure to include a location plan.
Date to be Corrected: February 17, 2023

CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: Care plans for five persons in care were reviewed and the following observations were made:
- One PIC has hip protectors in use, however they were not included in the care plan. The PIC also no longer required the use of their dentures, however their care plan was not updated in all areas to reflect the change.
- One PIC required the use of special pressure relieving devices, however their care plan was not updated.
Corrective Action(s): Please ensure that each PICs care plan is reviewed and updated as changes in their care needs occur.
Date to be Corrected: February 17, 2023

HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: The records of five persons in care (PIC) were reviewed and the following observations made:
Four PIC's did not have completed Immunization Screening forms.
One PIC did not have a completed TB Screening form.
Corrective Action(s): Please ensure all PICs comply with the Provinces program for Immunization and TB Control
Date to be Corrected: February 17, 2023


Comments


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Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.