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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AKUR-CGQQ8D
FACILITY NAME
Queen's Park Care Centre		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962L2P
FACILITY ADDRESS
315 McBride Blvd		FACILITY PHONE
(604) 520-0911
CITY
New Westminster		POSTAL CODE
V3L 5E8		MANAGER
Senija Kolocka (2 East) & Davinda Renke (2 West)
INSPECTION DATE
July 21, 2022		ADDITIONAL INSP. DATE (multi-day)
July 26, 2022		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
8
ARRIVAL
01:45 PM		DEPARTURE
04:15 PM		ARRIVAL
10:00 AM		DEPARTURE
04:00 PM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection.
The following areas were reviewed:
Licensing
Physical Facility
Staffing
Polices & Procedures
Care & Supervision
Hygiene and Communicable Disease Control
Medication
Nutrition and Food Services
Program
Records and Reporting

As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation.
Visit the CCFL website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo for:

· Additional resources and
· Links to the Legislation (CCALA & RCR
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: 2/7 PRN medications administered in July did not have the effectiveness of the PRN documented on the PRN Effect Documentation Monthly record and staff also did not initial the document as per the policy. This was brought to the attention of the staff person assisting with the inspection.

Corrective Action(s): Please ensure that all staff comply with the policies and procedures of MSAC.
Date to be Corrected: August 12, 2022

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: 2/7 wound care plans have not been implemented appropriately by staff of which 1/7 PIC's wound care dressing frequency has not been followed as per the care plan and 1/7 wound care assessment has not been documented appropriately. This was brought to the attention of the staff assisting with the inspection.

Corrective Action(s): Please ensure that the care and supervision of a PIC is consistent with the terms and conditions of the PIC's care plan.
Date to be Corrected: August 12, 2022

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): The inspection of medication cart found 1 PIC's medication cassette with a PRN medication AUD pack with expiry date of May 31, 2022. This was brought to the attention of the staff in the medication room and corrected immediately.

Corrective Action(s): Please ensure that a PIC's medication is returned the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected:

RECORDS AND REPORTING: 39630 - RCR s.91(3) - A licensee must ensure that a record relating to a person in care is accessible only to employees who require access to perform their duties in relation to the person in care.
Observation (CORRECTED DURING INSPECTION): A copy of Medication Administration Record (MAR) sheet was found in the tub room with staff using the back of the MAR sheet to note down PICs' mattress use information. This was brought to the attention of the staff assisting with the inspection and corrected immediately.

Corrective Action(s): Please ensure that all records relating to PIC is only accessible to employees who require access to perform their duties in relation to the PIC.
Date to be Corrected:


Comments

This Licensing officer (LO) has been informed that the staff performance reviews are in progress and timelines were not met due to the outbreaks at the facility. The staff files were not available for review however, the leadership informed the LO that the CRC and the certifications are tracked as needed. A section of the kitchenette on 2nd floor was found to be under renovation and health and safety plan was provided to this Licensing Officer upon request. Thank you to all the staff for their assistance with this inspection.

Should any further clarification or questions arise regarding this report, please contact your Licensing Officer.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Aug 12, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.