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
January 10, 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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3000 - RCR 30(a)
Description: A licensee must ensure that all bathrooms have a door, equipped with a lock that can be opened from the outside in the case of an emergency,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3000 - RCR 30(b)
Description: A licensee must ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3000 - RCR 30(b)
Description: A licensee must ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3020 - RCR 23(3)(a)
Description: A licensee must make a policy respecting all of the following the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3050 - RCR 62(2)(a)
Description: A licensee must ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada’s Food Guide,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3050 - RCR 62(2)(a)
Description: A licensee must ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada’s Food Guide,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3060 - DOLSOP (Review Immunization Status)
Description: Immunization status reviewed on admission and regularly there after for each person care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3060 - DOLSOP (Review Immunization Status)
Description: Immunization status reviewed on admission and regularly there after for each person care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 77(2)(c)
Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 77.1(1)(b)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 82
Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 82
Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3080 - RCR 11(1)(b)
Description: A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility the most recent routine inspection record made under section 9 (1) (d) of the Act.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3080 - 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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations: