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
April 18, 2023
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 all rooms and common areas are maintained and 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: May 18, 2023
Observations: Licensing observed one bedroom of a person in care with significant wall damage.
3010 - RCR 40(1)(a)
Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,
Corrective Actions Required: Ensure that the performance of each employee is reviewed regularly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 18, 2023
Observations: Licensing audited 14 staff files. 11 staff files had performance reviews dated 2021, one performance review was dated 2015, one performance review was dated 2009, and one staff was missing a performance review.
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: May 18, 2023
Observations: Licensing audited the narcotic counts on three floors and observed multiple counts were missing signatures.
3010 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure a criminal record check is kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 18, 2023
Observations: Licensing audited 14 staff files. One staff was missing a criminal record check.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure clear and up to date records of immunization status are kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 18, 2023
Observations: Licensing audited eight care records for persons in care. Three persons in care were missing records of immunization status.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure care plans include a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 18, 2023
Observations: Licensing audited eight care plans for persons in care. Four care plans were missing a recreation and leisure plan.
3080 - RCR 69(3)(a)
Description: A licensee must ensure that all medications in the community care facility are safely and securely stored.
Corrective Actions Required: Ensure that all medications in the community care facility are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 18, 2023
Observations: Licensing audited eight bedrooms of persons in care and observed medicated creams not securely stored in multiple bathrooms of persons in care.
3080 - RCR 72(a)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy the person in care is no longer taking the medication
Corrective Actions Required: Ensure that a person in care's medication is returned to the dispensing pharmacy when no longer in use.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 18, 2023
Observations: Licensing observed an eye drop medication in the fridge that was no longer in use, and a secondary naloxone kit dated 2022 no longer in use.