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)
Routine
October 7, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 7, 2025
Observations: Licensing audited all person in care's Medication Administration Records, dated October 2025. One person in care had two medications that were not signed and/or coded for by staff on October 4, 2025 at 21:00hrs.
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required: Ensure that policies are implemented by employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 7, 2025
Observations: Licensing audited two staff performance reviews. One staff file did not have a performance review on file, and one staff file had a performance review last completed April 2023. The Licensee Contact stated the policy indicated performance reviews were conducted at minimum once every two years.
3070 - RCR 78(3)(a)
Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,
Corrective Actions Required: Ensure that with each person in care's records, a record is kept for consent in writing, from the person in care or a parent or representative of the person in care, to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 7, 2025
Observations: Licensing audited two person in care's records and observed one person in care did not have consent in writing, from the person in care, to call a medical practitioner, nurse practitioner or ambulance in case of accident of illness.
3080 - RCR 72(b)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Required: Ensure that all persons in care's medications were returned to the dispensing pharmacy if the expiry date on the medication had passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 7, 2025
Observations: Licensing audited the facility's medication cabinet, and observed one medication had an expiry date of September 2025.