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December 2021

Facility Acacia Ty Mawr
Health authority Vancouver Island Health Regulation/Legislation Community Care & Assisted Living Act
Street address 2655 E Shawnigan Lake Rd Accreditation status Accredited
City/postal code Shawnigan Lake Accreditation expiry date October 2023
Phone number (250) 743-2124 Contact for complaints Director of Care
Operator (Type) Trillium Communities (For Profit) Phone number of complaint contact (250) 743-2124 x2
Opened 1990 Personal spending account Yes
Councils Family Council Visitor parking (cost) Yes (no fee)
Meetings held Regular Schedule Average Wait Time suppressed
Current language(s) spoken by staff English, Dutch, French

Source: Facility

Facility Fees for Personal Services
Cable monthly service included No Other extra fees Hygiene items
Telephone monthly service included No
Internet monthly service included n/a

Source: Facility

Beds 1 (March 31, 2021) Room Configuration 2 (March 31, 2021)
Private beds (not publicly funded) 0 Private rooms 31
Publicly funded beds (short- and long-term) 35 Semi-private rooms 2
Total beds 35 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 Yes
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 2.98 3.36
Nursing care hours (hours per resident per day) 2.81 3.01
Registered Nurse (hours per resident per day) n/a 0.43
Licensed Practical Nurse (hours per resident per day) n/a 0.51
Care Aide (hours per resident per day) n/a 2.07
Allied health hours (hours per resident per day) 0.17 0.35
Food costs per resident per day (actual cost) 2 $10.32 $11.19
Facility per diem rate2 $250.14 $266.60

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

Licensing (2020/21)
Complaints, 2020/21
Number of licensing complaints 6 Number substantiated licensing complaints 3
Incidents, 2020/21 Total
Number
Per 100 beds Total
Number
Per 100 beds
Facility B.C. Facility B.C.
Disease outbreak or occurrence 1 2.9 0.8 Medication error with adverse event 0 0 0.1
Abuse / neglect 2 5.7 0.5 Missing or wandering person 1 2.9 0.6
Fall with injury / Adverse event 3 8.6 5.8 Other injury 0 0 1.0
Food or other poisoning 1 2.9 0.1 Aggressive behaviour 3 8.6 3.5
Unexpected illness 0 0 12.3 Attempted suicide 0 0 0.1
Expected death 7 20 23.4 Other - clinical 0 0 0.5
Unexpected death 1 2.9 0.6 Other - service delivery 0 0 0.4
Inspections
Risk Rating Low Risk Score 13
Number of Inspections 1 Number of licensing infractions found 10
Licensing Infractions
Licensing 0 Nutrition & food services 0
Physical facility, equipment & furnishings 1 Medication 2
Staffing 1 Program 0
Policies & procedures 1 Records & reporting 5
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 83 84
Percent female 65.4% 63.6%
Percent 85 years or older 50.0% 54.1%
Percent younger than 65 years 3.8% 5.7%
Average length of stay (days) n/a 900
Percent of residents diagnosed with depression n/a 23.4%
Percent of residents dependent in activities of daily living n/a 32.4%
Percent of residents in a wheelchair n/a 52.1%
Percent of residents with dementia (mild to severe) n/a 63.6%
Percent of residents with severe cognitive impairment (includes severe dementia) n/a 28.4%
Percent of residents with physically abusive behaviour n/a 8.6%
Average index of social engagement n/a 2.6
Percent of residents with low social engagement n/a 50.0%
Case mix index n/a 0.58

Source: Canadian Institute for Health Information

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

Source: Canadian Institute for Health Information

Vaccination Coverage (2020/21) Facility B.C.
Percent of residents vaccinated for influenza 100.0% 88.5%
Percent of health care workers vaccinated for influenza 45.6% 63.4%
Percent of residents vaccinated for COVID-19 97.1% 95.7%

Source: BC Centre for Disease Control