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)
Follow-Up
December 12, 2022
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: A Licensee must ensure that all rooms and common areas are maintained and in good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 31, 2022
Observations: Licensing toured the facility and observed holes in the tile in the downstairs bathroom tub with a plexi glass cover over top. Licensing observed a hole in the wall behind the hallway door downstairs. Licensing observed multiple light switches broken throughout the facility. Licensing observed burnt out light bulbs throughout the facility.
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: A Licensee must ensure that each bedroom meets the needs and provides healthy, 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: November 24, 2022
Observations: Licensing toured the facility and observed a bedroom downstairs with no door to the bedroom. Licensing observed two 3/4 doors, one to downstairs hallway connected to the front entry and one to the laundry room off of the downstairs lounge space. Both doors are off the a bedroom used by a person in care that does not have a door.
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: Licensing toured the facility and observed all medication safely and securely stored..
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 40(1)(a)
Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received copies of ten performance evaluations by the Manager.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: November 24, 2022
Observations:
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 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: October 31, 2022
Observations: Licensing audited the medication administration record of three person in care. Two dates were not recorded for the reason and result of PRN administration on two person in care medication administration record.
3050 - RCR 62(2)(d)
Description: A licensee must ensure that each menu provides for substitutions to be made that are from the same food group and have a similar nutritional value.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the menu plan for the facility and observed that there was a substitution list available to record substitutions from the same food group and have the same nutritional value.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: November 24, 2022
Observations:
3080 - RCR 8(2)(a)(i)
Description: A licensee must not make any structural change to a community care facility unless the licensee first submits to a medical health officer plans for the change
Corrective Actions Required: Ensure all structural changes to the community care facility are submitted to the medical health officer for review.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 24, 2022
Observations: Licensing toured the facility and observed a downstairs bedroom that was made for a person in care that was not part of the original floor plan submitted and approved by the Licensing program.