Inspection Reports for The Captain Lewis Residence

ME

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Inspection Report Summary

The most recent inspection on June 24, 2025, found the facility in substantial compliance with applicable regulations and noted no deficiencies. Prior inspections showed a mix of results, with the November 13, 2024, survey identifying multiple deficiencies related primarily to medication management, documentation, resident contracts, food service sanitation, and maintenance issues. Earlier inspections, including one on September 23, 2024, found the facility largely in compliance without deficiencies. No fines, enforcement actions, or license suspensions were listed in the available reports, and no complaint investigations were noted. The inspection history suggests improvement over time, with the most recent review showing resolution of earlier cited issues.

Deficiencies (last 2 years)

Deficiencies (over 2 years) 6.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

14% worse than Maine average
Maine average: 5.7 deficiencies/year

Deficiencies per year

16 12 8 4 0
2024
2025

Census

Latest occupancy rate 26% occupied

Based on a November 2024 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

0 9 18 27 36 45 Sep 2024 Nov 2024

Inspection Report

Capacity: 34 Deficiencies: 0 Date: 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 Date: 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.

Deficiencies (13)
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.
Failed to maintain Medication Administration Records (MARs) by failing to remove medications not active or authorized for 2 of 3 resident records reviewed.
Medications discontinued by licensed practitioner were not documented as discontinued on MAR for 1 of 3 resident records reviewed.
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.
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
NameTitleContext
Elida RandallAdministratorNamed in multiple findings including bonding insurance, contract signing, medication management, incident report, and maintenance issues.
Residential Care DirectorResidential Care Director (RCD)Confirmed findings related to medication administration records, legal representative documentation, and service plan modifications.
Maintenance DirectorMaintenance DirectorInvolved 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 Date: 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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