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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
WCLK-AQ5RTV
FACILITY NAME
Waverly Seniors Village		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9ULX
FACILITY ADDRESS
8445 Young Rd		FACILITY PHONE
(604) 620-1893
CITY
Chilliwack		POSTAL CODE
V2P 4P2		MANAGER
Debbie Davidson
INSPECTION DATE
August 04, 2017		ADDITIONAL INSP. DATE (multi-day)
August 11, 2017		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
12:00 PM		DEPARTURE
02:40 PM		ARRIVAL
10:15 AM		DEPARTURE
04:30 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# CHILDREN ENROLLED
Introduction

A scheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s(LO) observations, review of facility records and information provided by facility staff at the time of the inspection.

As part of the Routine Inspection a 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.

A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights.

Visit CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to legislation (CCALA and RCR)
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
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Five person in care's rooms were inspected and 4 of the rooms were observed to have either several chips in the walls exposing drywall or dark scuff marks along the walls in either or both the bathrooms and main living spaces. The chipping and scuffing were consistent with damage caused by wheel chairs and/or lifts used to transfer persons in care. One other room had a wooden gate at the door entrance and 2 of the spindles were missing and 2 small dowels were exposed on the bottom plate. Although Licensing recongnizes maintenance is ongoing, the damage observed on the first day of the inspection appeared to not be recent as some of the chips were quite large and deep.
Corrective Action(s): Please ensure rooms are audited to identify maintenance concerns and that they are addressed in a timely manner.
Date to be Corrected: Please submit a compliance plan on or before Aug.28, 2017

STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: A random audit of 7 staff files from various departments was completed and 6 of the 7 did not have evidence of reviews being completed as per facility policy. Staff also confirmed they were aware performance plans are over due
Corrective Action(s): Please submit a compliance plan with timeline as to when the performance reviews will be completed.
Date to be Corrected: Aug. 28, 2017

CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Review of 5 person in care's care plans all had an oral health plan, however 2 of the 5 the last date documented as being seen by the dental health professional was 2015.
Corrective Action(s): Please ensure persons in care are encouraged to be seen annually.
Date to be Corrected: Aug. 28, 2017
Comments

Physical Facility
Licensing observed the outdoor space usually accessible to persons in care, located next to the lounge, was secured due to repairs and maintenance. Staff informed that the space may be restricted for use until the fall. Staff informed the additional outside space located next to the kitchen could be accessed with supervision and due to the current air quality many persons in care would not be accessing the out doors as their health could be compromised. On the upper level of the facility Licensing also observed large white air tubes hanging from the ceiling for air conditioning as it was explained the air conditioning was being repaired.
Upper level tub room has been out of service since February 2017. The upper level tub room has been dismantled and re-assembled in suite 104, lower level bathing room is out of service. The plan is for both tub rooms to be renovated and functional by Oct.31, 2017.
Staffing
The facility is in the process of filling various Management/Leadership staffing positions and has interim staff providing clinical support.
A Support Services Manager has been hired and she has memberships with the Canadian Society of Nutrition Management (CSNM), therefore the previously approved exemption is no longer required.

This report was reviewed and discussed with the General Manager and copy of this report and the risk assessment was provided.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Aug 28, 2017
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.