Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-AXBPSE

FACILITY NAME
Peace Arch Hospital
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962LQ8
FACILITY ADDRESS
15521 Russell Ave
FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Jane Rodwell (Weatherby Pavilion)

INSPECTION DATE
March 29, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1.75
ARRIVAL
09:45 AM
DEPARTURE
11:30 AM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up
# CHILDREN ENROLLED

Introduction

This is a follow-up inspection completed with the Manager for Weatherby Pavillion and the Residential Care Coordinator for main floor/first floor for Weatherby Pavillion to the routine inspection report # CRAU - AVSVMT (completed on February 8, 2018).

Contraventions
Previous Inspection - Not Applicable
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice.

Observed Violations
No violations were found during the inspection.

Comments

Nutrition audits:

-The writer met with the Dietitian and the nutrition care plan audit has been completed and another follow-up will take place in 6 months as the percentage to be achieved was not achieved.

-There is a Dietitians Committee for the owned and operated facilities who are working on the nutrition audits.

PRN (as needed) medications:

- A random review of the two medication administration record charts for the Weatherby Pavillion on the main / first floor indicated overall the results/effects are noted however there are a few not noted with the results/effects. In discussion with the Residential Care Coordinator they have a plan to address this and have been trying to address this on an on-going basis. Given overall the PRN charting is thoroughly with the exception of a few gaps with no effect/result noted, and there is an ongoing plan to address this, this was not made a contravention.

Thank you for your time to complete today's inspection.

If there are any questions related to this report, please contact your Licensing Officer.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.