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December 2021

Facility Mount St. Mary Hospital
Health authority Vancouver Island Health Regulation/Legislation Hospital Act
Street address 861 Fairfield Rd. Accreditation status Not Accredited
City/postal code Victoria Accreditation expiry date not applicable
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 348 days, with an average of 190 days
Current language(s) spoken by staff German, Cantonese, French, Filipino, Polish, Cantonese, Spanish, Croatian, Japanese

Source: Facility

Facility 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 1 (March 31, 2021) Room Configuration 2 (March 31, 2021)
Private beds (not publicly funded) 0 Private rooms 184
Publicly funded beds (short- and long-term) 200 Semi-private rooms 8
Total beds 200 Multi-person rooms 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 2019/20 2020/21
Total direct care hours (hours per resident per day) 1 3.23 3.36
Nursing care hours (hours per resident per day) 3.04 3.15
Registered Nurse (hours per resident per day) n/a 0.19
Licensed Practical Nurse (hours per resident per day) n/a 0.55
Care Aide (hours per resident per day) n/a 2.42
Allied health hours (hours per resident per day) 0.19 0.21
Food costs per resident per day (actual cost) 2 $9.90 $9.51
Facility per diem rate2 $237.92 $250.54

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

Licensing (2020/21)
Complaints, 2020/21
Number of licensing complaints 7 Number substantiated licensing complaints 0
Incidents, 2020/21
Serious adverse events 6
Risk Rating Low Risk Score n/a
Number of Inspections 0 Number of licensing infractions found 0
Licensing Infractions
Licensing 0 Nutrition & food services 0
Physical facility, equipment & furnishings 0 Medication 0
Staffing 0 Program 0
Policies & procedures 0 Records & reporting 0
Care & supervision 0 Resident Bill of Rights 0
Hygiene & communicable disease control 0 Other 0

Source: Health Authority

Resident Profile (2020/21) Facility B.C.
Average age of population 84 84
Percent female 73.4% 63.6%
Percent 85 years or older 60.6% 54.1%
Percent younger than 65 years 8.9% 5.7%
Average length of stay (days) 865 900
Percent of residents diagnosed with depression 28.6% 23.4%
Percent of residents dependent in activities of daily living 35.6% 32.4%
Percent of residents in a wheelchair 60.4% 52.1%
Percent of residents with dementia (mild to severe) 50.6% 63.6%
Percent of residents with severe cognitive impairment (includes severe dementia) 27.7% 28.4%
Percent of residents with physically abusive behaviour 7.0% 8.6%
Average index of social engagement 2.5 2.6
Percent of residents with low social engagement 49.8% 50.0%
Case mix index 0.6 0.58

Source: Canadian Institute for Health Information

Care Services & Quality Indicators (2020/21) Facility B.C.
Percent of residents receiving physical therapy 1.0% 10.1%
Percent of residents receiving recreation therapy 3.9% 28.4%
Percent of residents receiving occupational therapy 35.0% 5.6%
Percent of residents receiving depression medication 55.5% 50.5%
Percent of residents taking antipsychotic drugs without a diagnosis of psychosis 23.5% 25.7%
Percent of residents with daily physical restraints 0.0% 6.5%
Percent of residents with falls in the last 30 days 14.4% 12.8%
Percent of residents with a worsened pressure ulcer 3.6% 2.3%

Source: Canadian Institute for Health Information

Vaccination Coverage (2020/21) Facility B.C.
Percent of residents vaccinated for influenza 66.0% 88.5%
Percent of health care workers vaccinated for influenza 63.2% 63.4%
Percent of residents vaccinated for COVID-19 95.7% 95.7%

Source: BC Centre for Disease Control