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December 2021

Facility Kiwanis Pavilion
Health authority Vancouver Island Health Regulation/Legislation Community Care & Assisted Living Act
Street address 3034 Cedar Hill Road Accreditation status Accredited
City/postal code Victoria Accreditation expiry date not available
Phone number (250) 598-2022 Contact for complaints Director of Resident Services
Operator (Type) Oak Bay Kiwanis Health Care Society (Not For Profit) Phone number of complaint contact (250) 598-2022 x222
Opened 1982 Personal spending account Yes
Councils Family Council (residents can attend) Visitor parking (cost) Yes (no fee)
Meetings held Regular Schedule Average Wait Time From 96 to 332 days, with an average of 206 days
Current language(s) spoken by staff English, German, Spanish, Polish, Tagalog, French, Croatian, Korean, Mandarin, Cantonese, Hindi

Source: Facility

Facility Fees for Personal Services
Cable monthly service included No Other extra fees Dental hygiene and Trust account admin fee
Telephone monthly service included No
Internet monthly service included No

Source: Facility

Beds 1 (March 31, 2021) Room Configuration 2 (March 31, 2021)
Private beds (not publicly funded) 6 Private rooms 122
Publicly funded beds (short- and long-term) 116 Semi-private rooms 0
Total beds 122 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 3.35 3.36
Nursing care hours (hours per resident per day) 3.09 3.02
Registered Nurse (hours per resident per day) n/a 0.12
Licensed Practical Nurse (hours per resident per day) n/a 0.56
Care Aide (hours per resident per day) n/a 2.34
Allied health hours (hours per resident per day) 0.26 0.34
Food costs per resident per day (actual cost) 2 $8.00 $8.17
Facility per diem rate2 $236.35 $243.42

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

Licensing (2020/21)
Complaints, 2020/21
Number of licensing complaints 4 Number substantiated licensing complaints 1
Incidents, 2020/21 Total
Number
Per 100 beds Total
Number
Per 100 beds
Facility B.C. Facility B.C.
Disease outbreak or occurrence 1 0.8 0.8 Medication error with adverse event 0 0 0.1
Abuse / neglect 1 0.8 0.5 Missing or wandering person 1 0.8 0.6
Fall with injury / Adverse event 5 4.1 5.8 Other injury 1 0.8 1.0
Food or other poisoning 0 0 0.1 Aggressive behaviour 4 3.3 3.5
Unexpected illness 2 1.6 12.3 Attempted suicide 0 0 0.1
Expected death 49 40.2 23.4 Other - clinical 0 0 0.5
Unexpected death 0 0 0.6 Other - service delivery 0 0 0.4
Inspections
Risk Rating Low Risk Score 8
Number of Inspections 1 Number of licensing infractions found 1
Licensing Infractions
Licensing 0 Nutrition & food services 0
Physical facility, equipment & furnishings 0 Medication 0
Staffing 1 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 63.5% 63.6%
Percent 85 years or older 50.7% 54.1%
Percent younger than 65 years 4.9% 5.7%
Average length of stay (days) 848 900
Percent of residents diagnosed with depression 23.1% 23.4%
Percent of residents dependent in activities of daily living 31.0% 32.4%
Percent of residents in a wheelchair 39.5% 52.1%
Percent of residents with dementia (mild to severe) 82.1% 63.6%
Percent of residents with severe cognitive impairment (includes severe dementia) 53.9% 28.4%
Percent of residents with physically abusive behaviour 11.6% 8.6%
Average index of social engagement 2.5 2.6
Percent of residents with low social engagement 54.4% 50.0%
Case mix index 0.58 0.58

Source: Canadian Institute for Health Information

Care Services & Quality Indicators (2020/21) Facility B.C.
Percent of residents receiving physical therapy 6.6% 10.1%
Percent of residents receiving recreation therapy 5.7% 28.4%
Percent of residents receiving occupational therapy 11.6% 5.6%
Percent of residents receiving depression medication 50.7% 50.5%
Percent of residents taking antipsychotic drugs without a diagnosis of psychosis 23.4% 25.7%
Percent of residents with daily physical restraints 1.5% 6.5%
Percent of residents with falls in the last 30 days 16.6% 12.8%
Percent of residents with a worsened pressure ulcer 1.0% 2.3%

Source: Canadian Institute for Health Information

Vaccination Coverage (2020/21) Facility B.C.
Percent of residents vaccinated for influenza 91.7% 88.5%
Percent of health care workers vaccinated for influenza 69.7% 63.4%
Percent of residents vaccinated for COVID-19 97.4% 95.7%

Source: BC Centre for Disease Control