When an inspector from the Maine Department of Health and Human Services visited one of the Lee Residential Care homes in Hampden in March 2022 that housed two residents, the inspector found that the bathroom floor felt “spongy.”
When the inspector applied pressure to the area in front of the toilet, moisture “seeped between the floor planks.”
That revelation was among the more shocking details to emerge from inspection reports of the care facilities in 2021 and 2022 that the Bangor Daily News obtained through a Freedom of Access Act request. Bedroom furniture that failed to meet state standards, incomplete contracts and dangerous utility conditions were also among the findings.
The inspection reports provide the first insight into what life was like at the residential care facility where four men were criminally charged for abusing residents to the point of torture. The failures flagged in the reports indicate a lack of experience among management, a long-term care expert said.
The abuse began in 2019 and continued until March 2022, when a Lee administrator conducted an investigation and reported his findings to DHHS, which then reported it to police, according to court records. It included waterboarding and sodomizing a developmentally disabled, autistic and nonverbal man. A second man was also abused.
Inspections are critical because they ensure state standards are being met and plans for residents to receive care are in place, said Lori Smetanka, the executive director of National Consumer Voice for Quality Long-Term Care. The nonprofit advocates primarily for older adults in nursing homes but also for all people in long-term care.
“It’s so important to hold the owners and operators responsible for meeting the standards and ensuring that people are not being harmed, by either neglect, or lack of care, or lack of skill or practice,” Smetanka said.
The inspections found water from the kitchen sink was too hot at seven facilities, with the hottest at 136 degrees. Burns will happen within 30 seconds of exposure to water at 130 degrees, according to the U.S. Consumer Product Safety Commission.
A bathroom vanity in another home was so saturated with urine that the wood had ballooned and the smell was noticeable. There were multiple stains on the floor, wall and toilet.
Two bedrooms had mattresses and box springs on the floor. Two homes had bedrooms that didn’t meet the requirement of a “comfortable nonfolding chair in good repair.” Others didn’t have a bedside table or lamp.
The majority of the 2022 reports found contracts between Lee and the resident or their guardian were not signed. Most inspection reports found Lee did not have written permission to manage residents’ finances and did not assess residents to determine if they could self-adminster medicine.
Those failures in documentation can point to a lack of higher skill from management, Smetanka said, as it shows they cannot meet the state’s standards, which are often the bare minimum.
“When the standards are low there aren’t many people that are going to go above and beyond to ensure that they’re doing better,” Smetanka said. “Folks will just work to meet the basic minimums at best. Oftentimes that’s just not enough for the level of care or services that are needed by the people that are living in congregate care settings.”
Four facilities failed to conduct emergency drills while residents were sleeping, according to the reports. Drills are supposed to be completed at irregular intervals to ensure residents are prepared for emergencies.
Lee Residential Care CEO Karen Lee was reached by telephone but declined to comment and did not respond to additional requests.
Inspections and licensing rules are to help guarantee basic safety at those agencies, said Betsy Hopkins, the Associate Director Developmental Disability and Brain Injury Services for DHHS.
“At the basics we really want to have people be healthy and safe in these homes and a lot of the rules that we have in place are really meant to do that,” Hopkins said.
Lee was caring for 23 people in 16 homes as of September, DHHS spokesperson Lindsay Hammes said previously.
Inspection reports for Lee Residential Care stopped after the facility voluntarily surrendered its licenses in February 2023. It is not required to be licensed because its homes are one- to two-bed facilities, which are licensed voluntarily, Hammes said.
Facilities that are unlicensed do not have yearly inspections. Inspections occur if an issue is reported to DHHS, such as medication errors, physical alterations, serious injury and transportation accidents.
The department commonly sees violations such as a residential facility having policies that don’t align with DHHS requirements, including not having policies about mandatory reporters, Hopkins said.
Lee Residential Care will soon be required to resume regular inspections. Recent legislation requires a license for every residential care facility, regardless of size, that “provides a setting for an adult with an intellectual disability, autism spectrum disorder … or an acquired brain injury.” It also requires a license for any facility of any size to receive MaineCare reimbursements.
The change will likely take place in late winter or early spring, Hopkins said.
Two of the Lee employees who were accused of committing the abuse, Zachary Conners and Rene Dubois III, pleaded guilty to intentionally endangering the welfare of a dependent person and were sentenced to prison. Criminal charges against Michael Slater and Joshua Martin are still pending.
“We were very deeply disturbed by everything that happened in this most recent situation in Hampden,” Hopkins said. “We’ve taken it very seriously and taken a number of different steps when we learned about this through some of the criminal reports that we saw.”
