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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JBAY-C9VUH4
FACILITY NAME
Holyrood Manor		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTLK
FACILITY ADDRESS
22710 Holyrood Av		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Danielle Briggs
INSPECTION DATE
December 20, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
1
ARRIVAL
11:00 AM		DEPARTURE
12:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

This second follow-up to routine inspection was conducted in accordance with the Community Care and Assisted Living Act (CCALA) and Residential Care Regulation (RCR).  
 
The purpose of this inspection was to determine if concerns identified during routine inspection # JBAY-C4JUV6 (dated June 25, 2021) and follow-up inspection # JBAY-C86SCB (dated October 26, 2021) had been corrected. Licensing had received a written response to the repeat concerns identified on November 12, 2021.

For resources for licensees, links to the Legislation (CCALA and RCR), and Residential Care Facility Inspection Reports posted online go to: www.fraserhealth.ca/residentialcare
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
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: A person in care, who historically (since 2019) has worn hip protectors, was found to be without hip protectors on. When facility leadership asked staff why the person in care was not wearing hip protectors, staff indicated that the hip protectors were being laundered but that the person in care usually wears them. Upon reviewing the care plan, no hip protectors were found to listed even though the person in care reportedly usually wears them which is not consistent with the terms and conditions of the care plan. On the day of the inspection, hip protectors were once again added to the care plan.
Corrective Action(s): Ensure that the care and supervision of persons in care is consistent with the terms and conditions of the care plans of the persons in care.
Date to be Corrected: December 21, 2021
Comments

Please submit a written response by January 7, 2022 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements.

This inspection report was not signed by management as it was written off site, reviewed with management over the telephone, and was sent via email to the facility to reduce the amount of time the licensing officer had to spend on site as per COVID-19 prevention measures.
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
Jan 07, 2022
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.