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)
Non-Visit Follow-up
July 3, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 16(2)(b)
Description: A licensee must ensure that each bedroom, bathroom and common room is lit sufficiently to protect the health and safety of a person using the room.
Corrective Actions Required: Ensure that each bedroom, bathroom and common room is lit sufficiently to protect the health and safety of a person using the room.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 2, 2024
Observations: Licensing toured the facility and observed a burnt out light bulb in a bathroom of one person in care.
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: Ensure that all employees comply with the policies and procedures of the Medication Safety & Advisory Committee.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 25, 2024
Observations: Licensing audited the medication administration records for persons in care and observed medications had not been signed or coded by staff on multiple dates in June 2024 for multiple persons in care.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required:
Corrective Actions Taken By Licensee: On June 25, 2024 Licensing received a copy the recreation and leisure plan for one person in care.
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: 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 25, 2024
Observations: Licensing audited the medication storage area and observed two expired medications.