Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)
Routine
October 28, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(1)(b)
Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair
Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 28, 2022
Observations: Licensing toured the facility and observed marks to the walls on both floors and a hole in the ceiling on the second floor.
3010 - RCR 68(4)
Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the Medication Safety and Advisory Committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 28, 2022
Observations: Licensing audited the Medication Administration Record. Two persons in care, did not have medications signed for or coded by staff on October 25, 2022.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure that all persons in care have recreation and leisure addressed in their care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing audited four person in care's care plans. One person in care had no recreation or leisure plan.
3070 - RCR 81(3)(e)(iii)
Description: A care plan must include all of the following: 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 a plan for following up on any falls suffered by a person in care
Corrective Actions Required: Ensure that persons in care who are at risk for falls, have a plan to follow up on falls suffered by the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 4, 2022
Observations: Licensing audited four person in care's care plans. One person in care, who was at risk for falls, had no follow up to falls suffered included in their care plan.
3080 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure that the community care facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, that persons in care who require monitoring of a restraint, have safety checks completed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 28, 2022
Observations: Licensing audited a person in care's hourly restraint documentation. One hour checks, as indicated in their care plan, had not been signed for by staff from October 1-23, 2022.