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
JSAT-CWWLAZ

FACILITY NAME
Waverly Seniors Village
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
LSEO-AG9ULX
FACILITY ADDRESS
8445 Young Rd
FACILITY PHONE
(604) 792-6340
CITY
Chilliwack
POSTAL CODE
V2P 4P2
MANAGER
Sarah Riddell

INSPECTION DATE
October 24, 2023
ADDITIONAL INSP. DATE (multi-day)
October 25, 2023
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
10:00 AM
DEPARTURE
03:00 PM
ARRIVAL
10:00 AM
DEPARTURE
01:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
53

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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.

Care systems reviewed during inspections include: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & Reporting.

As part of the 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 CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to the legislation (CCALA & 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: 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: 1 of 5 persons in care had signed consent to receive dental hygiene services, however the person had not been seen by the dental hygienist in the past year. Discussion with staff determined, it is unknown why the person was not seen the last time the hygienist was on site.
Corrective Action(s): Ensure that each person in care is encouraged to be examined by a dental health care professional at least once every year.
Date to be Corrected: November 10, 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: Review of 5 person in care's files found that, 1 person in care did not have a fall care plan documented.
Corrective Action(s): Ensure that every person in Long Term Care, has a fall prevention plan to prevent the person in care from falling.
Date to be Corrected: November 10, 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: Of 5 person in care files reviewed, one person had a change in their mobility/fall status, that was not documented in the care plan.
Corrective Action(s): Ensure that each person in care's care plan is reviewed, and if necessary, modified if there has been a substantial change in circumstance.
Date to be Corrected: Corrected before day 2 of the inspection.

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: 2 of 5 person in care (PIC) files reviewed found the following:
-1 PIC did not have evidence of immunization in their file
-1 PIC had a TB form in their file, however it had not been filled out or signed as completed.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and TB control program.
Date to be Corrected: November 10, 2023


Comments

It is requested that a written response be submitted on or before November 10th, describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing.

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.

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
Nov 10, 2023

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