Sippican Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Sippican Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 8, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was recovering from a recent right hip fracture and whose Plan of Care indicated that he/she required the use of chair and bed alarms for safety, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her Plan of Care while meeting his/her care needs. On 12/25/24, Certified Nurse Aide (CNA) #1 transferred Resident #1 into bed but did not attach the alarm box to the bed alarm sensor pad. Resident #1 was found lying on the floor complaining of right hip pain. […]

• Actual harm, isolatedF697Aug 4, 2021

  Based on policy review, observations, record review and interviews, the facility: 1) Failed to implement their policy for pain control; 2) Failed to develop an effective pain management regimen using both pharmacological and non-pharmacological interventions; 3. Failed to perform ongoing re-assessments of the current pain management program until optimal pain management is attained; and 4) Failed to utilize the program Around the Clock dosing administering analgesics regularly (not as needed), if pain is present most of the day to prevent ongoing break through pain for one Resident (#85) who sustained multiple pelvic fractures in a fall, out of total sample of 20 residents. […]

• No harm, potential for more than minimal, widespreadF585Mar 27, 2025

  Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, the facility failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s). Findings include: Review of the facility's policy titled Grievance/Complaints, Filing, last revised April 2017, indicated but was not limited to: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. […]

• No harm, potential for more than minimal, patternF804May 19, 2026

  Based on observation and interviews, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor, and appearance, and was palatable, attractive, and at a safe and appetizing temperature for one of two test trays. Findings include:During an interview on 5/17/26 at 9:30 A.M., Resident #109 said the food has gone downhill. During an interview on 5/17/26 at 10:05 A.M., Resident #120 said the food is not good. During an interview on 5/17/26 at 10:25 A.M., Resident #59 said since the new company took over the food has not been as good. During an interview on 5/17/26 at 10:30 A.M., Resident #115 said the food is shitty. […]

• No harm, potential for more than minimal, patternF758Mar 27, 2025

  2. Resident #32 was admitted to the facility in September 2022 with diagnoses including vascular dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the MDS assessment, dated 2/13/25, indicated Resident #32 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, received antipsychotic and antidepressant medications daily and exhibited verbal behaviors toward others and behavioral symptoms not directed toward others. […]