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
June 6, 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 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: May 30, 2023
Observations: Licensing observed duct tape on the flooring seams throughout the main common areas.
3000 - RCR 35(2)(a)
Description: A licensee must ensure that laundry facilities if used by persons in care, have a slip resistant floor surface
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensee submitted a picture of the laundry room floor with black adhesive anti slip strips on the floor.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 both regularly to ensure the employee continues to meet the requirements of this regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 23, 2023
Observations: Licensing reviewed four staff files and two staff files had performance reviews dated 2020 and 2021. The performance policy stated performance reviews were completed annually.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure persons in care have a clear and up to date record of immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2023
Observations: The nurse stated that persons in care did have immunizations but that there were no up to date records in place. Licensing did not observe any persons in care's up to date records of immunization status.
On May 30, 2023, the manager submitted an email with an update to the flooring replacement. The manager stated that he left two messages with the flooring company and has not received an update to the timeline of flooring replacement. The manager stated he would continue to follow up with the flooring company.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Licensee submitted a copy of the developed oral care plan for person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(4)(b)(ii)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year
to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan
Corrective Actions Required:
Corrective Actions Taken By Licensee: The Licensee submitted a copy of the updated care plans for persons in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: