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 4, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 that policies and procedures are reviewed and if necessary, revised at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 4, 2022
Observations: Licensing reviewed the facility policies which were last reviewed in 2016, 2017 and 2019.
3050 - RCR 62(2)(b)
Description: A licensee must ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada’s Food Guide,
Corrective Actions Required: Ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada’s Food Guide,
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 11, 2022
Observations: Licensing toured the facility and observed the facility menu which had not included snacks.
3070 - RCR 81(3)(e)(i)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address an assessment of the nature of the risk of falling presented by the person in care
Corrective Actions Required: Ensure that if a person in care may be prone to falling, they have a fall prevention plan, which addresses a plan to follow upon falls suffered by the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 11, 2022
Observations: This item had been carried over from Routine Inspection HOBN-C3LQAM dated June 2, 2021. Licensing audited one person in care's care plan who was at risk for falls who had not had a fall prevention plan that addressed a plan to follow up on falls suffered.
3070 - RCR 81(3)(e)(ii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for preventing the person in care from falling
Corrective Actions Required: Ensure that if a person in care may be prone to falling, that they have a fall prevention plan, which addresses a plan for preventing the person in care from falling.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 11, 2022
Observations: Licensing audited one person in care's care plan who was at risk for falls who had not had a fall prevention plan to prevent the person in care from falling.
3070 - RCR 81(3)(e)(iii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care
Corrective Actions Required: Ensure that if a person in care may be prone to falling, they have a fall prevention plan, which addresses a plan to follow up on falls suffered by the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
Observations: Licensing audited one person in care's care plan who was at risk for falling who had not had a fall prevention plan that addressed a plan to follow up on falls suffered.
3090 - RCR 55(1)(a)(i)
Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care
Corrective Actions Required: Ensure there is an ongoing planned program of physical, social and recreational activities that are suitable to the needs of the persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 11, 2022
Observations: Licensing toured the facility and observed no plan of activities.