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Phoenix Centre

922 3 Ave Kamloops BC V2C 6W5 · Residential Care - Licensing

12 inspections

  1. Routine Inspection

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The most recent routine inspection report was not posted. When the most recent routine inspection record is not posted, persons in care cannot access information to which they are entitled, which could negatively impact their health, safety and dignity. Submit a corrective action plan by March 26, 2026, indicating how the licensee will ensure a system is in place to have the most recent routine inspection displayed in a prominent place.
      • R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Medication administration records reviewed, observed inconsistent documentation of “as needed” (PRN) medications effectiveness. In one person in care’s chart, five PRN medications were administered with no evidence of effects being documented. When effect of PRN medication is not documented, there is increased risk of medication errors and potential for negative health impacts of person in care. Submit a corrective action plan by March 26, 2026, indicating how the licensee will ensure that PRN effectiveness is documented.
      • R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): RCR 49 (2) When doing chart reviews, there was no evidence of recording the height of each person in care on admission. When persons in care height is not documented, not all admission data is collected which could potentially lead to negative health outcomes. Submit a corrective action plan by March 26, 2026, indicating how the licensee will ensure a system is in place to have record of height of each person in care on admission. RCR 78(3)(a) When reviewing charts, there was no evidence of written consent from person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness. If written consent from persons in care for medical attention is not obtained, it could cause a delay in treatment and be detrimental to their health, safety, and/or dignity. Submit a corrective action plan by March 26, 2026, indicating how the licensee will ensure a system is in place to have consent in writing to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness for all persons in care.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1L - Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
  2. Routine Inspection

    2 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The previously accepted Compliance Plan, dated January 29, 2024, for the legislative minimum of weekly menus for this service type had been not followed and/or completed. Compliance plans, once approved, are required to be followed as written, or a re-submission of an alternate plan to Licensing for approval prior to implementation is the alternative measure to ensure ongoing compliance.
      • R1.1W - Regularly monitor the physical environment and the care and services provided; 61
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Facility did not have a weekly menu posted at the time of inspection. Daily meals were written on a white board, and a generic "menu" was posted that did not show planned meals. This is a repeated contravention from the last routine inspection.
      • R5.1A - Develop a weekly menu for persons in care accommodated for 6 weeks or fewer; 62( 1 )(a)
  3. Substantiated complaint

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): The system for reporting to Licensing the occurrence of Reportable Incidents is ineffective. The facility failed to identify and report to Licensing instances of emotional abuse and neglect.
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): RCR 43(1)(b) - The complainant alleged that action was not taken by staff in a timely manner, when a person in care reported a physical response, which was a result of a medication provided while in care. It is also alleged by the complainant that due to staff not having acted in a timely manner, the person in care now suffers long term health effects as a result. During the Licensing Officer’s investigation, staff stated they did not believe the physical response the person in care reported was a side effect to medication and therefore did not complete an assessment. Licensing Officer reviewed the medication resource guide kept in the facility, which showed the reported physical response was a side effect of the prescribed medication and did require additional assessment and/or intervention. The facility provided evidence that a medication, which is frequently administered to persons in care in this facility, had been administered to the person in care.
      • R3.1R - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): RCR 52(1)(a)(i) - Emotional Abuse The complainant made an allegation of emotional abuse where a staff person had said an inappropriate response when the person in care reported a physical response, which resulted in the person in care’s dignity being diminished. Evidence was provided by the facility that the alleged staff person did inform their supervisor of having said an inappropriate comment to a person in care, which matches the allegation, thereby confirming the occurrence of emotional abuse. RCR 52(1)(a)(iii) - Neglect The complainant made an allegation of neglect where a staff person was informed of a physical response concern by the person in care and they did not act in a timely manner, which has resulted in ongoing health issues. Evidence was provided showing the person in care had informed a staff person of a physical concern, and staff person then reported it to the nurse on duty. There was no documentation of the concern and there was no evidence that the nurse completed an assessment when the concern was reported. The nurse involved stated during the complaint investigation “from a nursing perspective, this wasn’t a serious medical issue.” The person in care received intervention from the nurse on the next shift, approximately 12.5 hours after they had initially reported the concern and was subsequently transferred to hospital for further intervention.
      • R10.2D - Ensure persons in care are not subjected to financial, emotional, physical, sexual abuse or neglect; 52( 1 )(a)
  4. Routine Inspection

    2 infractions

    • RB1.18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
      • Observation(s): The facility hosts weekly gatherings, which include persons from the public. The facility reports they do not currently have a method to ensure the persons from the public will not pose a risk to persons in care, within the Licensed Facility. These persons often loiter before and after the gathering as well, and meet within the main area of the facility, where access to all areas of the facility is possible.
      • RB1.18A - Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Facility does not have a weekly menu developed prior to food service. Daily meals are posted on a white board, and a generic "menu" is posted that does not change or show the planned meals. Ensure weekly menus are developed in accordance with the Canada Food Guide, please keep past menus for review. Meal substitutions from the menu must be documented. The facility currently doesn't use a method to document substitutions as the food is cooked as per "whatever we want to cook that day", and does not follow a meal plan. A process to audit the menus/meal plans was not being used by the facility to monitor whether all persons in care are receiving a variety of foods which meet the daily nutritional needs for persons in care, as per Canada's Food Guide.
      • R5.1A - Develop a weekly menu for persons in care accommodated for 6 weeks or fewer; 62( 1 )(a)
      • R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
      • R5.1S - Provide adequate food to meet the personal nutritional needs based on Canada's Food Guide, and the person in care's nutrition plan; 66 ( 1 )
  5. Substantiated complaint

    2 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Evidence reviewed by Licensing which directly stated that the Medication Safety and Advisory Committee had not been informed by the Licensee of the changes to the facsimile process/system/policy. The Medication Safety and Advisory Committee was not afforded an opportunity to review what training may be needed for staff, in relation to how these changes may have affected medication administration. A review of documentation and correspondence shows inconsistent and/or a lack of information with regard to the type of training employees received for the newly installed fax system, and ineffective timeliness of the training in relation to the receipt of the complaint. Due to not being informed of the changes to communication systems, the Medication Safety and Advisory Committee was unable to review facsimile process/system/policies and procedures related to medication administration. Therefore, any policies and procedures which might have required revision due to the installation of the new system as part of medication administration were not completed.
      • R2.1M - Establish and review training and orientation programs for employees who store, handle or administer medications to persons in care; 68( 3 )(a)
      • R2.1N - Establish and review policies and procedures on safe and effective storage, handling and administration of medications; 68( 3 )(b)(i)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing reviewed documentation which showed evidence the facility did not successfully fax a prescription to the pharmacy for a person in care upon their discharge from the facility, and therefore the pharmacy was not promptly informed of changes to the person in care's medications.
      • R4.1B - Ensure that changes in directions for use of a medication made by a medical or nurse practitioner are promptly recorded on the person in care's medication administration record and that the dispensing pharmacy is promptly notified; 71(b)(i)(ii)
  6. Routine Inspection

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Missed medication charting observed during this inspection in medication administration records. PRN effectiveness was inconsistently charted during this inspection. Current policy indicates charting will be completed in nurses notes. Please review process as this item was noted during the last routine inspection as well.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): The most recent routine inspection was not posted when licensing arrived. Resolved during the inspection.
      • R1.1O - Display, in a prominent place in the facility, the most recent routine inspection record. (Does not apply to Child and Youth Residential or Community Living); 11( 1 )(b)
    • RB1.17 - Is the most recent routine inspection report displayed in a prominent place? (does not apply to Child and Youth Residential or Community Living)
      • Observation(s): The most recent routine inspection was not posted when licensing arrived. Resolved during the inspection.
      • RB1.17A - Post the most recent routine inspection in a prominent place.
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Some initial performance reviews are overdue for employees. Inform licensing on what systems will be put in place to ensure employee performance reviews are completed according to facility policy. Facility policy indicates all nurses have first aid/CPR, one staff file reviewed did not include a copy of the first aid/CPR certificate or an expiry date for their first aid certification. Inform licensing on what systems will be put in place to ensure there is a staff on site at all times with valid first aid/CPR.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
      • R3.1O - Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
  7. Routine Inspection

    3 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN effectiveness was noted during this inspection to be inconsistently charted.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): Facility currently does not have a weekly menu developed prior to food service. Daily meals are posted on a white board. Ensure weekly menus are developed in accordance with the Canada Food Guide, please keep past menus for review. Meal substitutions from the menu must be documented.
      • R5.1A - Develop a weekly menu for persons in care accommodated for 6 weeks or fewer; 62( 1 )(a)
    • R9.1 - Are medications stored, handled, and administered appropriately?
      • Observation(s): Facility currently has handwritten medications noted in the facility MAR. Facility plans to submit an exemption request to this regulation.
      • R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
  8. Routine Inspection

    4 infractions

    • R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Facility emergency plans indicate monthly drills with staff and PIC's will take place, due to recent staff changeover the drills have not occurred for the past few months.
      • R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Performance evaluations have been noted as behind for the past few licensing inspections.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Documentation of staff compliance with the province's tuberculosis program is incomplete. This contravention was also noted during the last licensing visit to the site.
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The door to the medication room was locked at the time of this inspection, however facility policy indicates the med cabinet within the room is also locked, the cabinet was found unlocked during this inspection.
      • R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
  9. Monitoring

    3 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): One situation was discussed during this inspection which required reporting to Licensing, Licensing had not received the incident report at the time of this inspection. The report was submitted to Licensing immediately after the completion of this inspection (completed). Inform Licensing on what systems/audits are in place to ensure Licensing receives incident reports regarding all reportable incidents.
      • R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Facility is currently behind on employee regular performance evaluations, inform Licensing on what systems are in place to get/keep employee reviews up to date.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • R4.4 - Are records kept on each employee with the necessary requirements?
      • Observation(s): Two new employee files were reviewed during this inspection that did not contain information in regard to a TB test. Inform Licensing that all staff will have a TB test on file and on what systems/audits will be put in place to ensure TB tests are completed upon hire in the future.
      • R4.4C - Keep records of employee compliance with the Province's immunization and tuberculosis control programs; 86(c)
  10. Monitoring

    2 infractions

    • R6.1 - Do employee records have evidence of continued compliance with the Province’s immunization and tuberculosis control programs?
      • Observation(s): One staff file reviewed did not include a TB test result, when reviewing staff qualification checklist, there were other staff which did not include information for a TB test. Review staff hiring processes and staff qualification tracking procedures to ensure required information is received and documented. In the response to Licensing please include how this information is audited.
      • R6.1A - Ensure there is evidence that employees have continued compliance with the Province’s immunization and tuberculosis control programs; 39 ( 1 )
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Facility has recently updated their procedure on staff performance evaluation frequency, at this time there are still some staff performance evaluations which are overdue. Inform licensing on when the overdue evaluations will be completed and what systems and audits will be put in place to ensure evaluations are completed on time in the future.
      • R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
  11. Monitoring

    3 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Missed medication charting noted twice during review of MAR's, ensure all medications are charted.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Some staff performance evaluations are behind, please submit a plan indicating how the overdue performance evaluation will be completed.
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): One hallway observed during this inspection with wear patterns due to rubbing with housekeeping cart. Ensure this area is re-painted. Inform licensing on when this will be completed.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
  12. Monitoring

    2 infractions

    • 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
      • Observation(s): Ensure admission procedures include informing PIC's on how to make a complaint or express a concern. Complaint procedures should include the ability of a PIC or their representative to contact Licensing if needed.
      • Prior to admission, advise of policies respecting: expressing concerns, making complaints, and resolving disputes; 48(1)(b)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): One staff file reviewed indicated a staff commenced employment prior to facility receiving criminal record clearance. Ensure all required information is obtained for staff prior to beginning work with PIC's. Facility policy is to complete staff performance evaluations annually, two staff files reviewed indicated they were overdue for annual evaluation. Please inform Licensing in writing on how/when evaluations will be up to date.
      • Ensure criminal record checks are obtained for all employed persons; 37(1)(a)
      • Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40(1)(a)(b)