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Holyrood Manor - Complaint Information
General Details
Facility TypeResidential Care (Hospital Act) - 400
Investigation CompletedJanuary 30, 2023
Reason for Investigation - Staffing
- Policies and procedures
- Care and supervision
- Medication
Report of Findings
On November 24, 2022, Licensing received a complaint regarding Nutrition, Care and Supervision, Policies & Procedures and Medication.
The complainant alleged the following:
• The Person in Care’s needs for nutrition, oral care and medication were not met.
• The PIC had many personal items go missing.

All areas of the complaint were fully investigated. Evidence was obtained through on-site inspection, correspondence and documentation.
Licensing confirmed that a requirement of the Regulation related to Care and Supervision was not met.
Licensing determined the following requirement was not met:
- Section 83(4)(b) Care and Supervision
Substantiated Contraventions: Evidence for this summary report is based on a combination of the Licensing Officer’s observations, a review of facility records and information provided by the facility staff at the time of the investigation.
Observed Violations/Contraventions: A summary of the violations found during the complaint investigation are listed below.
Code Category/Description
34890 - RCR s.83(4)(b)Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Licensing determined health advice from a health care provider was not immediately sought when required.
Corrective action: Corrective action required.
Actions Required by Licensee/Operator
- Corrective action plan to be developed and submitted.
Action Required by Licensing Officer or Medical Health Officer
- Review and monitor corrective action plan > Follow up inspection required.