The Golden Plough Lodge is facing a $16,500 administrative monetary penalty after inspectors identified multiple areas of non-compliance involving infection prevention and control, resident safety, food sanitation, hot water temperatures and staff response to resident calls for assistance.
The inspection occurred onsite on the following date(s): September 8-11, and 14-17, 2026
The inspection findings resulted in a series of compliance orders under Ontario’s Fixing Long-Term Care Act, 2021, requiring the home to implement corrective measures, provide staff education and introduce regular audits to ensure procedures are being followed.
One of the most significant findings involved the home’s Resident-Staff Communication and Response System (RSCRS), which is designed to alert staff when residents require assistance.
Inspectors found that staff were not consistently carrying or using the handheld communication devices that receive resident calls.
Instead, the devices were frequently left at nursing stations or charging stations.
The inspection also identified difficulties among staff in accessing and interpreting information displayed on the devices.
During the inspection, resident call bells remained active for prolonged periods before being acknowledged.
The report stated that when communication devices were not consistently used, staff relied on alternative methods to identify resident calls, creating a risk that requests for assistance would not be identified and responded to in a timely manner.
The home was ordered to develop a process requiring staff to carry and use the devices throughout their shifts, establish procedures for malfunctioning equipment and introduce contingency measures in the event of system failure.
Registered Nurses, Registered Practical Nurses, Personal Support Workers and agency staff responsible for responding to resident calls must receive education on the procedures.
Following the training, clinical management must conduct audits once per shift for three consecutive weeks, covering all shifts.
Dishwasher temperatures raised concerns
Another compliance order involved the home’s food production and sanitation equipment.
The home opened to residents on August 23, 2026. Three days later, a memo from the Dietary Services Manager indicated that dishwashing machines were out of service and disposable dishes and cutlery would be used until the equipment was repaired.
The memo remained in effect until the end of the inspection.
New dishwashers were installed in all three resident home area serveries on September 8, 2026.
However, inspectors found the machines were not consistently reaching the required final rinse temperature of 180°F to effectively sanitize dishes, utensils and food service equipment.
Temperature records showed readings of 154°F on the first floor, 165°F on the second floor and 166°F on the third floor during morning checks.
The second-floor dishwasher reached 184°F during an afternoon check.
The inspection also found that corrective actions were not consistently recorded when temperatures fell below the required level.
The Dietary Services Supervisor told inspectors a new procedure required staff to allow the machines to warm up for approximately 20 to 30 minutes after being turned on and to wait at least one minute between cycles, or until the rinse temperature set point reached 190°F, before starting another cycle.
Despite that procedure, the third-floor dishwasher still failed to reach the required sanitizing temperature.
An employee interviewed during the inspection said they were unaware of the new procedure and had not received instruction on operating the dishwasher under the revised requirements.
Inspectors warned that failure to achieve the required temperature compromised the effective cleaning and sanitization of dishes and food service equipment, potentially exposing residents to foodborne pathogens.
The home was ordered to consult the dishwasher manufacturer, establish a process to ensure all three machines consistently reach the required temperature and educate dietary aides.
Hot water temperatures exceeded safety limits
Inspectors also found hot water temperatures at resident-accessible handwashing sinks exceeded the maximum permitted temperature of 49°C.
Under Ontario regulations, water serving resident-accessible hand basins, showers and bathtubs must not exceed 49°C and must be controlled by a device inaccessible to residents.
The compliance order stated that the home’s Administrator, working with the Maintenance Manager, must develop a process to monitor, document and review water temperatures.
The order specifically requires an alternative monitoring process if the home’s computerized monitoring system cannot provide accessible and reviewable temperature records.
Staff responsible for monitoring water temperatures must receive education, followed by weekly audits for four consecutive weeks.
The inspector warned that excessively hot water increased the risk of residents sustaining burns.
Hazardous cleaning products left unsecured
Another finding involved hazardous substances being left in areas accessible to residents.
Inspectors observed cleaning products, disinfectants and disinfectant wipes identified as hazardous substances inside an unlocked shower room and a tub room.
The rooms were accessible to residents, and the products were not secured.
The report stated residents were at risk of accidental exposure, ingestion, misuse or injury.
The home was ordered to ensure hazardous substances used, stored or temporarily placed in resident care areas remain inaccessible to residents whenever they are not under the direct supervision of staff.
Daily audits of resident care areas where hazardous substances are used or stored must be conducted for four consecutive weeks.
Infection prevention and control failures
The most substantial compliance order involved the home’s infection prevention and control program.
Inspectors found staff responsible for cleaning and reprocessing resident care equipment demonstrated an inconsistent understanding of the home’s procedures.
Interviews, observations and a review of documentation identified that approved procedures for cleaning, disinfection, storage and reprocessing equipment were not consistently understood or followed.
Staff descriptions of the practices varied and did not consistently align with the home’s established procedures.
The inspection identified potential risks involving bedpans, urinals, wash basins, K-basins and other resident care equipment.
Inspectors warned that inconsistent cleaning and disinfection could expose residents to infectious microorganisms and increase the potential for cross-contamination between residents.
The inspection also identified concerns involving the storage of clean towels and washcloths.
Clean towels and washcloths were observed stored uncovered on shelving units in multiple tub and shower rooms.
In several locations, the shelving units were directly beside collection hampers containing soiled towels and personal items.
Inspectors said the arrangement increased the potential for cross-contamination and compromised the separation of clean and soiled items.
The home was ordered to review and revise its infection prevention and control policies, educate staff and conduct weekly audits for four consecutive weeks.
The audits must examine equipment storage, cleaning and disinfection procedures, disposal practices, labelling and staff compliance.
Any deficiencies must result in corrective action and, where necessary, additional staff education.
Third monetary penalty for infection prevention and control
In addition to the compliance orders, the Ministry issued Administrative Monetary Penalty AMP #001 in connection with the infection prevention and control order.
The licensee has been ordered to pay $16,500 within 30 days of the invoice date.
According to the notice, this is the third administrative monetary penalty issued to the licensee for failing to comply with the same infection prevention and control requirement.
The compliance history identifies a previous order, numbered 2024-1553-0003, issued June 26, 2024, under Ontario Regulation 246/22, section 102 (2) (b).
That earlier violation resulted in an $11,000 administrative monetary penalty.
The latest penalty was issued because the licensee had failed to comply with the same requirement within the three years preceding the latest compliance order.
The notice states the $16,500 penalty must be paid from funds outside the Ministry’s resident-care funding envelopes, including Nursing and Personal Care, Program and Support Services, and Raw Food.
The compliance orders require the home to maintain documentation of staff education, audits, deficiencies and corrective actions and make those records available to inspectors upon request.
The deadlines for the various orders included October 16, 2026, for the dishwasher requirements, and November 30, 2026, for the other identified corrective measures.
The inspection findings raise questions about the consistency of procedures designed to protect residents in areas as fundamental as answering calls for help, sanitizing dishes, controlling hot water temperatures, securing cleaning chemicals and preventing the spread of infection.
Author: Pete Fisher
Has been a photojournalist for over 30-years and have been honoured to win numerous awards for photography and writing over the years. Best selling author for the book Highway of Heroes - True Patriot Love
