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
May 19, 2023
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: May 30, 2023
Observations: Licensing observed duct tape on the flooring seams throughout the main common areas.
3000 - RCR 35(2)(a)
Description: A licensee must ensure that laundry facilities if used by persons in care, have a slip resistant floor surface
Corrective Actions Required: Ensure that laundry facilities if used by persons in care have a slip resistant floor surface.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2023
Observations: Licensing observed no slip resistant floor material in the laundry room. Staff stated that the persons in care access the laundry room.
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: Ensure that the performance of each employee is reviewed both regularly to ensure the employee continues to meet the requirements of this regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 23, 2023
Observations: Licensing reviewed four staff files and two staff files had performance reviews dated 2020 and 2021. The performance policy stated performance reviews were completed annually.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure persons in care have a clear and up to date record of immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2023
Observations: The nurse stated that persons in care did have immunizations but that there were no up to date records in place. Licensing did not observe any persons in care's up to date records of immunization status.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure that all care plans include an oral health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2023
Observations: Licensing reviewed three care plans and one care plan did not have an oral health care plan.
3070 - RCR 81(4)(b)(ii)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year
to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan
Corrective Actions Required: Ensure each care plan is reviewed at least once a year when there is no substantial change in the circumstances of a person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2023
Observations: Licensing reviewed three care plans and two care plans were last reviewed in March 2022.