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
October 20, 2021
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 16(2)(a)
Description: A licensee must ensure that each bedroom, bathroom and common room is lit sufficiently to
(a) permit a person to carry out effectively the types of activities that would be reasonably expected in the ordinary use of the room
Corrective Actions Required: Ensure that each bedroom, bathroom and common area is lit sufficiently to (a) permit a person to carry out effectively the types of activities that would be reasonably expected in the ordinary use of the room.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 20, 2021
Observations: Licensing toured the facility and observed the bathroom light in a person in care's room had not worked when the light switch was turned on.
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. On this date, the Manager notified the maintenance department who turned down the hot water temperature. Maintenance will check three different areas once daily for the next two months to ensure the water temperature is less than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 20, 2021
Observations: Licensing toured the facility and took water temperatures from two person in care's rooms and one common bathroom which read 50.8, 51.7 and 54.2 degrees Celsius.
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: December 1, 2021
Observations: Licensing toured the facility and observed missing paint and scrapes in the wall in the first floor tub room as well as missing paint and scrapes on the walls in a person in care's room.
3010 - RCR 37(1)(b)
Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: character references in respect of the person
Corrective Actions Required: Ensure that each staff have character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 20, 2021
Observations: Licensing audited 14 staff files. Two staff had not had character references on file.
3030 - RCR 83(5)(a)
Description: If a person in care refuses or is unable to be weighed, the licensee must record in the nutrition plan of the person in care the reason why the person in care was not weighed
Corrective Actions Required: Ensure that if a person in care refuses or is unable to be weighed, the licensee must record in the nutrition plan of the person in care the reason why the person in care was not weighed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2022
Observations: Licensing audited eight person in care's weight records. One person in care, who had refused to be weighed, had not had the reason why the person in care refused to be weighed recorded.
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 persons in care have a oral health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 27, 2021
Observations: Licensing audited eight person in care's care plans. One person in care had not had an oral health care plan.
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 all persons in care, who receive 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 27, 2021
Observations: Licensing audited eight person in care's care plans. Two persons in care, who were at risk for falls, had not had a follow up to falls suffered included in their care plan.
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 that each person in care is weighed at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2022
Observations: Licensing audited eight person in care's weight records. Three persons in care had multiple weights missing since November 2020.
3080 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure the community care facility promotes the health, safety and dignity or persons in care. Specifically following the Provincial Health Orders.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 20, 2021
Observations: Licensing was not asked to provide proof of vaccination status upon entrance to the facility as required by the Provincial Health Orders.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure that a pharmacist packages all medications.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2021
Observations: Licensing observed a Naloxone kit that had not been labelled by pharmacist in the first floor nursing station.