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
KBEL-BYSTUC

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
March 04, 2021
ADDITIONAL INSP. DATE (multi-day)
March 10, 2021
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.25
ARRIVAL
08:45 AM
DEPARTURE
12:00 PM
ARRIVAL
09:00 AM
DEPARTURE
12:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted in the presence of the two Residential Care Coordiantors 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 inspection.

The following areas were reviewed:

- Licensing
- Physical Facility
- 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/residential-care-licensing#.W2CWtTpKipp for:

- Additional resources, and
- Links to the legislation (CCALA and RCR).

Contraventions
Previous Inspection -
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: 34360 - RCR s.63(3)(c)(iii) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iii) approved by the person in care's medical practitioner or nurse practitioner.
Observation: Two persons in care receive on-going tray service, however there is no evidence of this being approved by the person in care's medical practitioner.
Corrective Action(s): Please ensure that for any person in your care who receives on-going tray services, it has been approved by the person in care's medical practitioner.
Date to be Corrected:

CARE AND/OR SUPERVISION: 34590 - RCR s.81(2)(b) - A care plan must be developed, to the extent reasonably practical, (b) in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Observation: In a review of care plans for three persons in care (PIC), the following was determined:
-Information available in a care plan and on a bedroom ADL poster was not consistent in the direction provided regarding the use of a mechanical lift and bed alarm for one PIC.
-A second PIC is sight impaired and has specific care requirements, however this information is not included in their care plan.
-Five PIC who have specific nutritional care needs either did not have this included in their care plan or the information that was included, contradicted information found in another record.
-One PIC who is at risk for falls, did not have a fall prevention plan.
-Three PIC who use restraints, do not have those restraints included in their care plan.

Corrective Action(s): Please ensure that each person in your care has a care plan developed that takes into account their unique abilities, needs and preferences.
Date to be Corrected:

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: Of five charts for persons in care that were reviewed, three had no evidence of compliance with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Please ensure that all persons admitted into your care comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: This was corrected by day two of the routine inspection.


Comments

Staffing:

- All staff documentation is kept with Fraser Health Human Resources.

Thank you for your time to complete the routine inspection. Both the Manager and the Residential Care Coordinator appeared very pro-active in addressing things as the routine inspection went along and followed-up with the writer to address things following the routine inspection. Also thank you to all the staff the writer spoke to for making the time out of their busy schedules to answer the writer's questions which is truly appreciated.

Due to the Covid-19 pandemic, this inspection report, and risk assessment were written off-site and then emailed to the Manger for review. If there are further questions related to this routine inspection, please contact the Licensing Officer.

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
Mar 31, 2021

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