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)
Complaint
June 3, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure to operate the community care facility in a manner that will promote the health, safety, and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 28 and May 12, 2025, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included that all staff were to read and sign the nutrition care plan for a person in care, the Manager was to monitor staff to ensure nutrition care plans were followed and audit the grocery fund receipts to ensure supplies for persons in care was utilized appropriately and monthly reports were to be provided to ensure accuracy and completion. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2025
Observations: Regarding intake March 17, 2025. Through the investigation process, Licensing determined that the licensee did not operate a community care facility in a manner that will promote the health, safety, and dignity of persons in care, specifically, staff skills.
3050 - RCR 62(3)
Description: The licensee must take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection (2).
Corrective Actions Required: Ensure to take all reasonable steps to ensure that the food served to persons in care follows the menu and, if unable to do so because of unforeseen circumstances, that the food provided to persons in care meets the nutritional requirements set out in subsection 2. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 28 and May 12, 2025, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the Manager was directed to ensure that mealtime substitutions were to be documented in perpetuity and any staff nonadherence was to be addressed immediately. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2025
Observations: Regarding intake dated March 17, 2025. Through the investigation process, Licensing determined that the licensee did not take all reasonable steps to ensure that the food served to persons in care follows the menu and if unable to do so because of unforeseen circumstances, that the food provided to persons in care met the nutritional requirements set out in subsection 2.
3050 - RCR 66(1)
Description: A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada’s Food Guide and the person in care’s nutrition plan.
Corrective Actions Required: Ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 28 and May 12, 2025, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included direction to the Manager that bread will not be served to a person in care unless prepared and served as indicated in their nutrition care plan. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2025
Observations: Regarding intake March 17, 2025. Through the investigation process, Licensing determined that the licensee did not ensure that each person in care received adequate food to meet their personal nutritional needs, based on the Canada's Food Guide, and the person in care's nutrition plan.
3050 - RCR 67(1)(a)
Description: A licensee must provide each person in care with nutrition supplements required by the person in care’s nutrition plan or ordered by the person in care’s medical practitioner or nurse practitioner,
Corrective Actions Required: Ensure to provide each person in care with nutrition supplements required by the person in care's nutrition plan or ordered by the person in care's medical practitioner or nurse practitioner. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 28 and May 12, 2025, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included meal supplements were ordered through a company product distribution centre for persons in care. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2025
Observations: Regarding intake March 17, 2025. Through the investigation process, Licensing determined that the Licensee did not provide each person in care with the nutrition supplements required by the person in care's nutrition plan.
3070 - CCALA 7(1)(b)(i)
Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Corrective Actions Required: Ensure to operate the community care facility in a manner that will promote the health, safety, and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 28, and May 12, 2025, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included that all staff were to read and sign off on the nutrition care plan for a person in care and the Manager was to update the menu to ensure all food served to the person in care was prepared and served in accordance with Nutrition care plans. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2025
Observations: Regarding intake March 17, 2025. Through the investigation process, Licensing determined that the licensee did not operate the community care facility in a manner that will promote the health safety and dignity of persons in care, specifically related to documentation.
3070 - RCR 82
Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Corrective Actions Required: Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On April 28, and May 12, 2025, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included that staff were to read and sign the person in care's nutrition care plan and the Manager was to ensure no bread was served to the person in care unless prepared and served as indicated in the nutrition care plan. The corrective action plan was reviewed and accepted by Licensing.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2025
Observations: Regarding intake March 17, 2025. Through the investigation process, Licensing determined that the care and supervision of a person in care was not consistent with the terms and conditions of the person in care's care plan.