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Trinity Centre

75 Green Ave W Penticton BC V2A 7N6 · Residential Care - Licensing

11 inspections

  1. Substantiated complaint

    1 infraction

    • 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): It was determined that staff were not following infection control policies regarding pets in the facility; the staff and manager were unfamiliar with the policy and the required plan and processes were not followed; a rescue cat had recently been adopted and was being kept in the physio therapy area. A second cat had been living in the facility and was supposed to be confined to the office area. Both cats were able to access person in care neighbourhoods. Policies to safeguard health and safety such as allergic reactions, person in care preferences were not considered. The manager of the facility admitted that the facility was not following policy IX0400 regarding infection control and pets in facilities. There were 2 cats in the facility. One cat was removed. A plan regarding the care and supervision of the remaining cat was approved by Licensing on April 1, 2025. Subsequent information received alleged that the remaining cat was not being confined to the office as set out in the plan. Staff named in the plan were unaware of the plan details when asked; accordingly the policy was still not being followed by the facility, and the manager's plan provided to Licensing was not sustained. The facility has now confirmed that the remaining cat has been removed from the facility.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  2. Routine Inspection Follow-up

    3 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): November 2024 Inspection report was not displayed (April 2024 report was). This was 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)
    • 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): Medication Administration Records were observed during this inspection, Pro re nata medication (PRN)effectiveness was not consistently charted as required by facility policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): A review of Person in Care charts indicated that a monthly weight was not recorded. There was no reason documented for the missing weight. This is a repeat contravention.
      • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
  3. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Licensing Officer did not receive a health and safety plan regarding the recent repatriation of persons in care stemming from structural changes. Licensing was made aware during the inspection that the repatriation of persons in care successfully concluded on November 18, 2024. Therefore a contravention was documented but has been marked as corrected during the inspection.
      • R1.1C - Submit health and safety plan to licensing and receive written approval prior to making any structural changes; 8( 2 )(a)(ii)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing Officer reviewed four charts for persons in care. Of those four, one was missing the height upon admission and another was missing the height and weight upon admission. Licensing Officer reviewed four monthly weight records for persons in care. Two were missing two monthly weights in 2024 and one was missing one month in 2024.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer observed a sink accessible to persons in care with water exceeding 49 degrees and reviewed a system that did not insure compliance for Residential Care Regulation 17. Licensing Officer observed handrails which were obstructed by boxes of gloves. Licensing Officer observed a maintenance shop that was accessible to persons in care. The maintenance shop contained various power tools and other hazardous objects.
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Licensing Officer reviewed four care plans for persons in care. One care plan used by staff was an outdated copy. Another care plan for a person in care did not contain the current nutritional care plan.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  4. Routine Inspection Follow-up

    2 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing Officer reviewed documentation that indicated the parent, representative, or contact person was not notified of an incident until six days after it occurred. A compliance plan correcting the contravention was received and accepted by Licensing on May 23, 2024.
      • R4.5B - Immediately notify the parent, representative or contact person if a person in care is involved in a reportable incident; 77( 2 )(a)
    • 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): Licensing Officer reviewed documentation indicating that staff did not follow policies and procedures related to notifications, care plan charting, and completing an internal incident report. A compliance plan correcting the contravention was received and accepted by Licensing on May 23, 2024.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
  5. Routine Inspection

    6 infractions

    • R4.5 - Are incidents and notifications reported and records retained as required?
      • Observation(s): Licensing Officer observed that there had been no incident report submissions to Licensing between January 28, 2024, and April 2, 2024, despite being informed there were reportable incidents during this timeframe.
      • 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)
    • 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): Licensing Officer observed three fire extinguishers, two of which were missing monthly checks as per policy/procedure. Licensing Officer observed the temperature monitoring documentation for a medication refrigerator that was missing several daily checks, contrary to facility policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing Officer observed four charts for persons in care, specifically the last eight months of monthly weight records. One chart was missing four months of weight records and another was missing one month.
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed a refrigerator where the temperature was not being monitored ensuring the safety of food.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer observed an open room containing hazardous materials, including tools and other maintenance equipment.
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): Licensing Officer observed two charts which did not contain the necessary consents and reassessments for ongoing tray service.
      • R10.2V - Provide ongoing room tray service if necessary because of the physical or mental circumstances of the person in care, if indicated in the care plan, approved, and reassessed at least once every 30 days by the person in care's medical or nurse practitioner; 63( 3 )(c)(i)(ii)(iii)(iv)
  6. Routine Inspection

    7 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): Licensing Officer observed an unlocked clean linen room that was not being monitored. The room contained hazardous items for persons in care, this was contrary to facility policy. As per facility policy, the Medication Safety and Advisory Committee meets every 6 months. Facility records indicate the previous meeting occurred in May of 2022. Licensing Officer was informed about the complaint process. It included a complaint mailbox where persons could complete a form and submit it into the locked mailbox. Upon observation, the mailbox had been removed from the wall and there were no complaint forms present that could be completed.
      • R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing Officer observed weight records for two persons in care. One was missing four months in 2022. The other was missing January of 2023. Licensing Officer observed three persons in care's charts, one did not contain the height and weight record upon admission.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
      • Observation(s): The Licensee did not have a snack menu.
      • R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed three refrigerators where the temperature was not being monitored.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Licensing Officer observed two emergency exits that were obstructed in a manner that could hinder exit in an emergency.
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): There was no system to ensure that persons in care who temporarily left the facility had the required written documentation.
      • R10.2L - Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
    • R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): Licensing Officer observed a care plan that did not contain all the current terms and conditions from a previous care plan, despite those items still being implemented by staff. The same care plan also didn't contain additional terms and conditions that were being implemented by staff.
      • R10.3M - Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
  7. Routine Inspection

    6 infractions

    • R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
      • Observation(s): LO reviewed a person in care's restraint care plan. The plan was missing a documented General Practitioner or Nurse Practitioner agreement for the restraint.
      • R2.2B - Reassess the need for restraint that continues for more than 24 hours and obtain agreement in writing and comply with conditions set out in section 73( 2 ); 75( 2 )(a)(i)(ii)(b)
    • 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): Licensing Officer (LO) reviewed a Medication Administration Record that did not have the results documented for take as needed (PRN) medications, this was contrary to facility policy. LO reviewed a person in care's chart which had the funeral service form, the financial responsibility form, and the admission assessment checklist all not completed which was contrary to facility policy. LO reviewed two person in care's admission records which both had incomplete immunization screening which was contrary to facility policy. LO called the facility on May 25 and staff was unaware who the covering manager was; there was an assigned coverage but staff was unaware contrary to facility policy.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): LO reviewed two persons in care's care plans. Both care plans had missing monthly weights recorded in their charts with no reasoning as to why they were not recorded. The Licensee does not have a system in place to record the sex of the person in care.
      • R4.1C - Keep for each person in care a record showing the name, sex, date of birth, medical insurance plan number and immunization status; 78( 1 )(a) Director of Licensing Standards of Practice: Immunization records
      • R4.1R - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): LO observed a fridge during the inspection that did not have a thermometer in the freezer and as a result, the temperature was not monitored to ensure food was safely stored.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): LO observed a push cart that was blocking an emergency exit. LO measured the temperature of two taps that were accessible to persons in care, they were both 56 degrees. LO was informed that the Licensee was aware and were currently repairing the "recert pump" which was causing higher temperatures. This will not be listed as a contravention in this inspection.
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
    • R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): The Licensee does not have a system in place to ensure persons in care have the proper identification when they temporarily leave the facility.
      • R10.2L - Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
  8. Routine Inspection

    3 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Treatment administration records reviewed were found to have missing entries for this month, week, and day.
      • R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Documentation for restraint monitoring is not consistent with the terms identified in the restraint care plans.
      • R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): - Employee performance reviews have not been completed or are overdue for two identified departments. - Employees with valid first aid and CPR certificates are not always present when persons in care are participating in off-site facility functions.
      • 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)
  9. Monitoring

    2 infractions

    • R4.3 - Is documentation concerning restraints adequate?
      • Observation(s): It was observed that a person in care's restraint monitoring documentation was last completed by staff June 29, 2017 (as per documentation reviewed). When the Licensing Officer inquired whether the restraint was no longer in place, the Residential Care Coordinator indicated it was still being used. Upon review of the same person in care's care plan, it was noted that the directives indicate the restraint should be assessed every 30 days, however the last assessment was noted to be completed February 28, 2017.
      • R4.3D - Keep a record of the duration of the restraint and the monitoring of the person in care during the restraint in the persons care plan; 84(d)
      • R4.3E - Keep a record of the result of any reassessment for the use of the restraint in the persons care plan; 84(e)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The hot water temperature was tested in the public washroom (57 degrees C), in a person in care's room (55 degrees C), and in the 'cozy corner' (54 degress C) at the time of visit. As noted, the hot water temperature in all rooms consistently measured above 49 degrees Celsius. One emergency exit was observed to be partially obstructed by a "Detecto" machine; the label on the piece of equipment indicates "return to tub room when not in use". The keys used to access rooms where potentially hazardous items are stored (i.e.: chemicals) are still hung by the doors (with a long coil-style cord or a hook). These keys are accessible to persons in care resulting in the rooms being potentially accessible. In addition, the coil-style cords also pose a potential entanglement risk to persons in care. This is a reoccurring infraction (indicated on inspection report dated June 24, 2016).
      • R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • R7.1K - Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  10. Monitoring

    4 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Upon review of medication administration records, it was observed on multiple records that signatures were missing for medication administration on June 3, 2016.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
      • Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
    • 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): Upon review of multiple medication administration records (MARs), it was observed that signatures were missing on June 3, 2016. When discussing this with the Residential Care Coordinator, it was apparent that the facility policy and procedure for double-checking MARs had not been followed.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Personal care products (2 hair brushes) were found to be unlabelled and stored in a cupboard in one of the bathing rooms.
      • Establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene; 54 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): In the larger outdoor patio area, a garden hose was observed laying on the ground and there are a number of large roots sticking out of the ground; both of which are potential tripping hazards for persons in care. At the back end of the walking pathway (behind the facility) , metal posts and metal debris were lying along the path and a small jerry can of fuel was placed on the sidewalk. The Manager stated this walkway is used by persons in care. Rooms where potentially hazardous items are stored (i.e.: chemicals) were secured at the time of visit; however, the keys to each of the rooms were hung at the door (either on the door frame with a long coil-style cord or on a nail beside the door frame). These keys are accessible to persons in care resulting in the rooms being potentially accessible. In addition, the coil-style cords also pose a potential entanglement risk to persons in care. The Physiotherapy office was found to be unsecured at time of visit. In the office was sharp scissors, cavi-wipes, tools, and a silicone spray can (label stated "Fatal if swallowed"). This issue of concern was also noted on the previous inspection report of November 26, 2015.
      • Maintain all rooms and common areas in a good state of repair; 22( 1 )(b)
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
  11. Monitoring

    8 infractions

    • 13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
      • Observation(s): Please see documentation under Section 10; Care and Supervision
      • Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
    • 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): OUTSTANDING INFRACTION from 26-Aug-2014 -It was noted that prn medication effectiveness was not consistently documented as indicated on the prn administration record.
      • Ensure policies are implemented by employees; 85( 1 )(d)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): NEW INFRACTION from 10-Dec-2015 -It was noted that valid CPR/First Aid certification was not being tracked by the facility. A Health and Safety Plan was put into place during the inspection.
      • 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)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): OUTSTANDING INFRACTIONS from 26-Aug-2014 -It was noted that monthly weights were missing in some resident's charts. -It was noted that admission height and weight were missing from some resident's charts. NEW INFRACTION from 10-Dec-2015 -It was noted that some documentation in resident's charts did not contain a complete date.
      • Record the height and weight of each person in care on admission; 49 ( 2 )
      • Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): NEW INFRACTION from 10-Dec-2015 -It was noted that some residents had personal fridges in their rooms and that one contained out-dated food. This was discussed with the manager and the manager reported that an auditing system would be put into place.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): OUTSTANDING INFRACTIONS from 26-Aug-2014 -It was noted that water temperature measured 50.5 and 52.4 degrees Celsius at the time of inspection. -It was noted that hand railings in some areas were in need of cleaning. -It was noted that an unlocked prescription cream was in one resident's room. NEW INFRACTIONS from 10-Dec-2015 -It was noted that a laundry cart was parked in a hallway limiting access to an emergency exit. -It was noted that one resident's room contained hazardous products. -It was noted that the door to the Physiotherapy room was propped open and unoccupied: hazardous materials were accessible to the residents. -It was noted that one staff locker was not locked and personal medication was accessible to residents. -It was noted that the activity room was not locked when unoccupied; a stove that was present did not have a safety switch, and hazardous materials (dishwashing liquids) were accessible to residents. -It was noted that un uncovered propane tank was sitting on the ground in the courtyard.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
      • Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
      • Ensure emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency; 22 ( 2 )
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
    • 10.2 Do care and supervision practices ensure health, safety and dignity of persons in care?
      • Observation(s): NEW INFRACTIONS from 10-Dec-2015 -It was noted that some residents were being administered medication and prn medication for pain, and pain assessments could not be located. -It was noted that one resident had received antibiotic therapy and a post antibiotic therapy assessment could not be located.
      • Monitor the health and safety of each person in care regularly to determine if their needs continue to be met; 50 ( 1 )
    • 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
      • Observation(s): NEW INFRACTIONS from 10-Dec-2015 -It was noted that the care plans that were reviewed did not contain evidence of an oral health care plan, a nutrition plan, or a recreation and leisure plan. This was discussed with the manager and the manager reported that a plan would be put into place within one week to update the care plans to include oral, nutrition and recreation plans.
      • Care plans must includes an oral health care plan; 81( 3 )(b)
      • Ensure the care plan includes a nutrition plan that assesses nutrition status and specifies nutrition to be provided, including the requirement of any therapeutic diets; 81( 3 )(c)(i), (ii)
      • Care plans must include a recreation and leisure plan; 81( 3 )(d)