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
August 22, 2024
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: September 16, 2024
Observations: This contravention was carried forward from Routine Inspection dated March 28, 2023. On this date, the Manager stated that construction staff were still installing wall boards to prevent continual wear and tear on the walls and to cover up the existing worn walls. This project was not completed.
3000 - RCR 22(1)(c)
Description: A licensee must ensure that all rooms and common areas are maintained in a safe and clean condition.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed a person in care's room that was audited on the previous inspection. There were no unlabeled medications or drug paraphernalia in the room. Licensing observed another person in care's room and there was no drug paraphernalia in the room.
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: Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer subsection (2) to ensure that 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 17, 2024
Observations: This contravention was carried forward from Routine Inspection dated March 28, 2023. The manager stated that staff performance reviews had not been completed and on May 17, 2024, the manager stated she did not have access to staff files for the different departments as she did not have the staff to pull the files.
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 clear and up to dated records of immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 17, 2024
Observations: Licensing reviewed thirty person in care's files and four files did not have clear and up to date records of immunization status.
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:
Corrective Actions Taken By Licensee: Licensing reviewed ten person's in care weight records for July and August 2024 and monthly weights were completed.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: