Inspection Report
Capacity: 34
Deficiencies: 0
Jun 24, 2025
Visit Reason
The inspection was conducted as a case investigation under the Maine Department of Health and Human Services Licensing and Certification for assisted housing programs, specifically for a Level IV Residential Care Facility.
Findings
Captain Lewis Residence was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control.
Inspection Report
Census: 9
Capacity: 34
Deficiencies: 13
Nov 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations governing the licensing and functioning of Level IV Residential Care Facilities and Infection Prevention and Control, including review of licensing, contracts, medication management, resident records, dietary services, sanitation, and physical plant requirements.
Findings
The facility was found non-compliant in multiple areas including failure to provide bonding insurance for resident funds, unsigned resident contracts, improper medication management and documentation, lack of documented legal representatives, incomplete incident report documentation, failure to update resident service plans, outdated diet manual, unsanitary food storage shelving, inadequate manual dishwashing procedures, uninspected heating systems, and maintenance issues such as non-functioning call bell and trip hazards on premises.
Severity Breakdown
Class III: 4
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to furnish evidence of a bond covering resident funds managed by facility staff. | — |
| Resident contracts were not signed by the provider for 1 of 3 resident records reviewed. | — |
| Discontinued medication was not removed from use and properly destroyed for 1 of 3 residents reviewed. | Class III |
| Failed to maintain Medication Administration Records (MARs) by failing to remove medications not active or authorized for 2 of 3 resident records reviewed. | Class III |
| Medications discontinued by licensed practitioner were not documented as discontinued on MAR for 1 of 3 resident records reviewed. | Class III |
| Failed to have documented proof of legal representative for 1 of 3 resident records reviewed. | — |
| Incident report was not initialed by Administrator within 72 hours for 1 of 3 resident records reviewed. | — |
| Resident service plan was not modified after identified changes for 1 of 3 resident records reviewed. | — |
| Facility failed to have a current diet manual (older than 5 years). | — |
| Shelving in food storage areas was unfinished wood creating uncleanable surfaces. | Class III |
| Manual dishwashing did not meet temperature requirements and sanitizer used lacked written approval from Department. | — |
| Three fuel heating systems were not tagged as inspected within the last year. | — |
| Facility failed to ensure routine maintenance evidenced by non-working call bell, pavement trip hazards, loose handrail, and dust accumulation on vents. | — |
Report Facts
Resident records reviewed: 3
Deficiencies cited: 13
Date of inspection: Nov 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elida Randall | Administrator | Named in multiple findings including bonding insurance, contract signing, medication management, incident report, and maintenance issues. |
| Residential Care Director | Residential Care Director (RCD) | Confirmed findings related to medication administration records, legal representative documentation, and service plan modifications. |
| Maintenance Director | Maintenance Director | Involved in confirming findings related to diet manual, food storage shelving, dishwashing, heating system inspections, and facility maintenance. |
Inspection Report
Monitoring
Census: 10
Capacity: 34
Deficiencies: 0
Sep 23, 2024
Visit Reason
Monitoring survey conducted to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities and Infection Prevention and Control.
Findings
CAPTAIN LEWIS RESIDENCE is in substantial compliance with the applicable regulations for Level IV Residential Care Facilities and Infection Prevention and Control.
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