The Orléans seniors' home where a resident wandered off and was later found dead has been visited 28 times by provincial inspectors since it opened in November 2013.

Jean Proulx, an 80-year-old who suffered from dementia and diabetes, was found dead in the woods behind Moments Manor four days after he disappeared earlier this month. The home's management says it is now reviewing its security policy.

A closer look at the investigations into Moments Manor by the Retirement Homes Regulatory Authority paints a disturbing picture.

'We have definitely done a lot of inspections of Moments Manor. We are watching the home.' - Bonnie Rose, CEO and registrar of the Retirement Homes Regulatory Authority

"We have definitely done a lot of inspections of Moments Manor. We are watching the home," said Bonnie Rose, the CEO and registrar of the provincial agency.

Under the Retirement Homes Act, the regulatory authority is mandated to inspect homes at least once every three years.

But if the agency has concerns about the homes, they can be inspected more frequently. Rose confirmed that since Moments Manor opened in November 2013, it has been visited 28 times by provincial inspectors.

Three compliance orders issued

Almost all the inspections were "mandatory," meaning they were prompted by concerns raised over residents' safety.  

"When we receive a mandatory report, we inspect immediately," said Rose.

The mandatory reports about Moments Manor are wide ranging, and document instances where residents fell, dementia patients were not properly monitored, and residents were found soaked in their own urine.

In each case, the inspector issued a formal report, including corrective actions to be made by Moments Manor.

"If we cite a home, and we are in there and cite them, and we are back and cite them again, we will put on compliance orders," said Rose.

Moments Manor in Orleans

The Moments Manor assisted care facility on St. Joseph Boulevard specializes in caring for residents with Alzheimers and dementia. (Judy Trinh/CBC)

Since November 2013, three compliance orders have been issued against Moments Manor for not meeting the standards laid out in the Retirement Homes Act.

The manor was fined twice by the regulatory authority. As well, in September 2016, a third compliance order was issued, requiring the home to hire a third party to train staff.

After the outside training was completed last September, Moments Manor did pass a routine inspection in April, according to Rose.

The  Retirement Homes Regulatory Authority does have the power to revoke a home's licence if it is worried about residents' safety.

But Rose argued that closing homes and relocating residents is often not in their best interest since their average age is 88.

"In many cases the best thing is to get the home to be compliant with the act, so we focus on that first," she said.

The executive director of Moments Manor declined to comment on the number of inspections.