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 14, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 21(c)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair,
Corrective Actions Required: Ensure that all furniture and equipment for use by persons in care 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 14, 2023
Observations: Licensing toured the facility and observed a broken dresser in a person in care bedroom.
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 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 14, 2023
Observations: Licensing toured the facility and observed a bedroom door had been broken off a bedroom of a person in care.
3000 - RCR 26(1)
Description: A licensee must ensure that each bedroom meets the needs and provides for the health, safety and dignity of the occupant.
Corrective Actions Required: Ensure that each bedroom meets the needs and provides for the health, safety, and dignity of the occupant.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 14, 2023
Observations: Licensing toured the facility and observed that a bedroom door had been broken off a person in care bedroom. The Manager stated it had been broken since February.
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 all employees comply with 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 14, 2023
Observations: Licensing audited the medication administration record of two person in care and there were missing signature for medication administered on April 1 at 20:00 and on April 2 for 08:00. Licensing audited the medication cupboard and one PRN medicated cream was missing a label from the pharmacy.
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required: Ensure each person in care is weighed at least once a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 14, 2023
Observations: Licensing audited the weight charts of two persons in care and both were missing records for the month of January and March 2023.
3070 - RCR 87(b)
Description: A licensee must keep a record of the following matters respecting food services menus and menu substitutions
Corrective Actions Required: Ensure a record of menu substitutions is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 14, 2023
Observations: Licensing audited the menu and there was no substitution list provided
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 person's in care 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: May 14, 2023
Observations: Licensing audited the medication storage area and found one PRN medicated cream that had expired in 2022.