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)
Follow-Up
October 25, 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 12, 2022
Observations: Licensing toured the facility and observed a hole in the wall close to the front door and damage to the hallway walls.
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:
Corrective Actions Taken By Licensee: Licensing audited the Medication Administration Record and observed all medications signed for by staff.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(3)(a)(iii)
Description: A care plan must include all of the following: a plan to address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited a person in care's care plan who required the use of a restraint. The person in care had restraints addressed in their care plan.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3080 - RCR 72(b)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the medication cupboard and observed all medications within their expiry date.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3090 - RCR 55(1)(a)(i)
Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited two person in care's activity calendars. Both persons in care had an ongoing planned program of activity.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: