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 4, 2024
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: August 4, 2024
Observations: Licensing toured the facility and observed the carpet on the stairs to be stained.
3020 - RCR 85(1)(b)
Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year
Corrective Actions Required: Ensure policies and procedures are reviewed at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 4, 2024
Observations: Licensing audited the policies and procedures and all policies had not been reviewed in the last year.
3020 - RCR 85(2)(a.1)(i)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: if the licensee provides a type of care described as Substance Use, the monitoring of persons in care, including the use of electronic surveillance
Corrective Actions Required: Ensure there is a written policy and procedure for monitoring persons in care regarding the use of electronic surveillance.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 4, 2024
Observations: Licensing audited the policy and procedures and there was no policy for electronic surveillance.
3060 - RCR 49(1)
Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure all persons in admitted to the community care facility comply with the Province's immunization and Tuberculosis control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 4, 2024
Observations: Licensing audited the charts of two persons in care and one person in care did not have a record of immunization.
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 4, 2024
Observations: Licensing audited the medication storage area and observed one expired medicated cream and one expired PRN (as needed) medication roll.