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October 2022

Facility Mount St. Mary Hospital Service Type Long-Term Care
Health authority Vancouver Island Health Regulation/Legislation Hospital Act
Street address 861 Fairfield Rd. Accreditation status Unknown
City/postal code Victoria Accreditation expiry date not available
Phone number (250) 480-3103 Contact for complaints Director of Care
Operator (Type) Marie Esther Society (Not For Profit) Phone number of complaint contact (250) 480-3111
Opened 2003 Personal spending account Yes
Councils Resident & Family Council (combined) Visitor parking (cost) Yes (no fee)
Meetings held Regular Schedule Average Wait Time From 6 to 318 days, with an average of 161 days
Current language(s) spoken by staff German, Cantonese, French, Filipino, Polish, Cantonese, Spanish, Croatian, Japanese
Indigenous Territory Lekwungen peoples and the Songhees and Esquimalt Nations

Source: Facility

Resident Fees for Personal Services
Cable monthly service included No Other extra fees Monthly admin fee
Telephone monthly service included No
Internet monthly service included Yes

Source: Facility

Beds (March 31, 2022) Room Configuration (March 31, 2022)
Private beds (not publicly funded) 0 Single Occupancy 184
Publicly funded beds (short and long-term) 200 Double Occupancy 8
Total beds 200 Other Occupancy 0

Source: 1. Ministry of Health, 2. Facility

Contracted Services
Professional nursing services No Housekeeping services No
Non-regulated services (care aides) No Plant/building maintenance No
Food services provided by Operator Food prepared and cooked on site Yes

Source: Facility

Funding 2020/21 2021/22
Total direct care hours (hours per resident per day) 1 3.36 3.45
Nursing care hours (hours per resident per day) 3.15 3.22
Registered Nurse (hours per resident per day) 0.19 0.23
Licensed Practical Nurse (hours per resident per day) 0.55 0.55
Care Aide (hours per resident per day) 2.42 2.45
Allied health hours (hours per resident per day) 0.21 0.23
Food costs per resident per day (actual cost) 2 $9.51 $9.59
Facility per diem rate2 $250.54 $261.97

Source: 1. Ministry of Health, 2. Health Authority

Licensing (2021/22)
Complaints, 2021/22
Number of licensing complaints 6 Number substantiated licensing complaints 0
Incidents, 2021/22
Serious adverse events 2
Inspections
Risk Rating n/a Risk Score n/a
Number of Inspections n/a Number of licensing infractions found n/a
Licensing Infractions
Licensing n/a Nutrition & food services n/a
Physical facility, equipment & furnishings n/a Medication n/a
Staffing n/a Program n/a
Policies & procedures n/a Records & reporting n/a
Care & supervision n/a Resident Bill of Rights n/a
Hygiene & communicable disease control n/a Other n/a

Source: Health Authority

Resident Profile (2021/22) Facility B.C.
Average age of population 84 83
Percent female 71.1% 63.2%
Percent 85 years or older 59.0% 53.4%
Percent younger than 65 years 7.4% 5.8%
Average length of stay (days) 757 855
Percent of residents diagnosed with depression 26.8% 23.3%
Percent of residents dependent in activities of daily living 33.4% 32.0%
Percent of residents in a wheelchair 55.2% 52.8%
Percent of residents with dementia (mild to severe) 51.1% 63.3%
Percent of residents with severe cognitive impairment (includes severe dementia) 27.2% 27.9%
Percent of residents with physically abusive behaviour 7.2% 8.8%
Average index of social engagement 2.4 2.7
Percent of residents with low social engagement 49.9% 49.3%
Case mix index 0.61 0.58

Source: Canadian Institute for Health Information

Care Services & Quality Indicators (2021/22) Facility B.C.
Percent of residents receiving physical therapy 2.7% 10.9%
Percent of residents receiving recreation therapy 4.3% 30.1%
Percent of residents receiving occupational therapy 32.1% 5.7%
Percent of residents receiving depression medication 60.2% 51.3%
Percent of residents taking antipsychotic drugs without a diagnosis of psychosis 26.6% 27.3%
Percent of residents taking antipsychotic drugs with or without a diagnosis of psychosis 28.8% 34.0%
Percent of residents with daily physical restraints 0.0% 6.4%
Percent of residents with falls in the last 30 days 13.9% 12.9%
Percent of residents with a worsened pressure ulcer 4.4% 2.2%

Source: Canadian Institute for Health Information

Vaccination Coverage (2021/22) Facility B.C.
Percent of residents vaccinated for influenza 85.2% 90.2%
Percent of health care workers vaccinated for influenza n/a 53.7%
Percent of residents vaccinated for COVID-19 93.4% 92.6%

Source: 1. BC Centre for Disease Control; 2. Ministry of Health; 3. Health Authority; 4. Facility