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
June 20, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that water accessible to persons in care, from any source, is not heated to more than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 20, 2022
Observations: Licensing audited the hot water temperature in 20 person in care's rooms. Two person in care's bathrooms hot water measured 51.7 and 50.3 degree Celsius. This represents an immediate risk to the health and safety of persons in care. The Manager stated the Maintenance staff member will turn down the hot water temperature immediately, staff will manually check the hot water temperature again today and hot water will be checked twice per shift by staff for the next week which will be logged.
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: July 4, 2022
Observations: Licensing toured the facility and noted broken window blinds and curtains falling off the tracks on the Gladston unit as well as curtains falling off the tracks in a person in care's room.
3000 - 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 medication 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: June 20, 2022
Observations: Licensing toured the facility and noted prescription creams on the bathroom counters in two person in care's room.
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: June 20, 2022
Observations: Licensing audited the Medication Administration Records and noted three medication that were not signed for or coded on June 19, 2022 for three persons in care.
3030 - RCR 83(3)(b)
Description: A licensee must review the nutrition plan of a person in care as follows: (b) in the case of a nutrition plan developed under subsection (2), with a dietitian on a regular basis,
Corrective Actions Required: Ensure the nutrition plan of a person in care as follows: (b) in the case of a nutrition plan developed under subsection (2), with a dietitian on a regular basis.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 27, 2022
Observations: Licensing audited 20 person in care's care plans. Three persons in care last had their nutrition care plan reviewed in February 2021 and April 2021.