Sippican Rehabilitation and Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to follow the planned menu for one Resident (#8), out of a total sample of 24 residents. Specifically, the facility failed to ensure staff followed the Resident's diet slips, resulting in food items not being provided to Resident #8 for three of three observed meals.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was at high risk for falls, was on an anti-coagulant medication and was severely cognitively impaired, the Facility failed to ensure staff provided care consistent with professional standards of practice, when on 11/07/25 at 6:09 A.M., Resident #1 was found after unwitnessed fall on the floor sitting upright in front of his/her roommates bed, he/she was unable to communicate the circumstances surrounding the fall or whether or not he/she sustained a head strike, however neurological assessments were not initiated or conducted, per facility protocol, by nursing after his/her unwitnessed fall.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who upon admission, was assessed as being at high risk for elopement, and on 06/29/25 walked away from the activity patio area unbeknownst to staff, and was found walking outside, unattended, in the front of the building by a visitor, the Facility failed to ensure nursing developed and implemented a comprehensive person-centered care plan with interventions, treatment goals and outcomes that addressed his/her risk of elopement.

Inspectors wroteBased 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).

Inspectors wroteBased on record review and interview, the facility failed for three Residents (#8, #32, and #97), out of a total sample of 22 residents, to ensure that each resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed: 1. For Resident #8, to ensure a sufficient documented rationale was in place for the ongoing extended use of as needed (PRN) psychotropic medications including clonazepam (anti-anxiety medication) and triazolam (benzodiazepine - sedative, treats insomnia and anxiety); 2. For Resident #32, to ensure PRN use of Seroquel (antipsychotic) was limited to 14 days and the prescriber documented an evaluation of the Resident's current condition and the appropriateness to continue the use of PRN Seroquel and the rationale, benefit, duration and response to treatment; and 3. [...]

Inspectors wroteBased on document review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Maintain an accurate surveillance system that reflected potential illnesses and infections in the facility and calculate an accurate facility infection attack rate in accordance with their pre-defined McGeer criteria; 2A. Ensure personal protective equipment (PPE) was used properly by staff while cleaning an isolation room with Contact precautions in place for Resident #360; and B. Ensure staff wore the appropriate PPE while providing care for Resident #34, who was on droplet precautions, to prevent the potential spread of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medications were not self-administered without a physician's order and an assessment for self-administration for one Resident (#52), out of a total sample of 22 residents. Specifically, the facility failed to assess Resident #53's ability to self-administer and manage supplemental oxygen independently.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered individualized comprehensive care plan was developed and implemented for one Resident (#4), in a total sample of 22 residents. Specifically, the facility failed for Resident #4, to: A. individualize their pain care plan with a Resident stated goal and individualized interventions that were in use, offered or attempted and failed in attempts to manage the Resident's actual pain; and B. develop and implement a person-centered care plan with non-pharmacological individualized interventions and targeted behaviors to help manage the Resident's ongoing psychiatric issues including anxiety, delusions, and weepiness.

Inspectors wroteBased on record review and interviews, the facility failed to update and revise the dietary care plan for one Resident (#64), out of a sample of 22 residents. Specifically, the facility failed to revise the care plan after being informed by the Resident's family that he/she was no longer considered to have an inability to digest gluten (a protein naturally found in some grains including wheat, barley, and rye).

Inspectors wroteBased on interviews and review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), the facility failed to provide written notice to the State agency when a change in the facility's Director of Nurses (DON) occurred.

Inspectors wroteBased 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. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation and was diagnosed with a new right non-displaced greater trochanter fracture (upper part of the femur) which was inoperable.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure staff provided the necessary respiratory care and services in accordance with professional standards of practice for three Residents (#43, #83 and #86), in a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #43, to ensure proper care and storage of the Resident's nebulizer machine and tubing was maintained in a clean and sanitary manner, to help decrease the risk of contamination and infection, and Oxygen was provided to the Resident according to Physician's orders; 2. For Resident #83, the nebulizer machine and tubing were maintained in a clean and sanitary manner, to help decrease the risk of contamination and infection; and 3. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure for two Residents (#35 and #38), out of a total sample of 21 residents, each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure psychotropic medications were monitored for adverse consequences of their use.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with facility policy on 2 of 3 Units. Specifically, the facility failed to ensure that staff kept the medication cart locked when not in use or under the direct supervision of the nurse.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that staff developed and implemented a baseline care plan within 48 hours of the resident's admission, that included the instructions needed to provide effective and person-centered care to the resident that provided information at a minimum so that staff could provide the necessary care and services to properly meet their care needs for one Resident (#204), in a total sample of 21 residents. Specifically, the facility failed to ensure a baseline care plan was developed for the Resident's legal blindness.

Inspectors wroteBased on interviews, record review, policy review, and observations, the facility failed to maintain an environment free of accident hazards for one Resident (#82), out of a total sample of 21 residents. Specifically, the facility failed to ensure individualized safety interventions, including a lid for hot beverages, was documented in the medical record, and consistently implemented to reduce the risk of the Resident being burned by hot liquids as identified in a burn incident report.