Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sippican Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Food Quality and Temperature Concerns: Residents repeatedly reported poor food quality, inconsistent temperatures, salty items, and unappetizing meals, and a test tray showed scrambled eggs that were visually unappealing with a strong sulfur taste while milk, yogurt, and juice were warmer than expected. The FSM said the eggs may have been mixed with hard-boiled eggs after liquid eggs ran out, and the Administrator stated the food should be appealing to residents.
A resident with DM, dementia, dysphagia, CKD, and GERD repeatedly did not receive all items listed on the meal ticket, including soup, a sandwich, fruit, yogurt, and other ordered foods during observed meals. The resident and family member reported missing items, and the dietitian, FSD, and menu specialist confirmed the tray should have matched the diet slip and physician-ordered meal additions.
A resident with severe cognitive impairment, high fall risk, and on anticoagulant therapy experienced an unwitnessed fall and was unable to communicate details of the incident. Despite facility protocol requiring neurological assessments after unwitnessed falls, nursing staff did not initiate or document these assessments, relying instead on a roommate's statement that no head strike occurred. Leadership interviews confirmed the expectation for such assessments, but none were performed or recorded.
A resident with multiple diagnoses, including dementia and mobility issues, was assessed as high risk for elopement but did not have a care plan addressing this risk. The resident left the activity patio area unnoticed and was found outside by a visitor, after which staff redirected the resident back inside. Facility staff did not update or implement an elopement risk care plan following the incident, contrary to facility policy.
The facility failed to ensure residents were aware of the grievance process, as nine out of twelve residents did not know how to file grievances other than telling staff. The surveyor found no postings or grievance forms in any of the units, and the Social Worker and Administrator confirmed the absence of grievance information and forms, as well as a process for anonymous filing.
The facility failed to ensure proper documentation and evaluation for the extended use of PRN psychotropic medications for three residents. One resident continued to receive clonazepam and triazolam without sufficient rationale, while another had PRN Seroquel orders extended beyond the 14-day limit without proper evaluation. A third resident's PRN Seroquel was renewed multiple times without necessary documentation. The lack of documentation and evaluation was acknowledged by staff, including the DON and NP.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in their surveillance system and improper PPE usage. The surveillance system inaccurately documented infections, leading to incorrect infection rates. Staff did not consistently use PPE correctly, as seen with a housekeeper entering a contact precaution room without proper attire and multiple staff members failing to wear eye protection for a resident on droplet precautions.
A facility failed to assess a resident's ability to self-administer and manage supplemental oxygen independently, as required by policy. The resident, with diagnoses including COPD, was observed managing their oxygen therapy without a formal assessment or physician's order. The resident was cognitively intact and independent in daily tasks but was seen with an oxygen concentrator turned off, leading to an oxygen saturation of 91%. Nursing staff were unaware of the need for a formal assessment, and the care plan lacked documentation of the resident's independence in managing oxygen therapy.
A facility failed to create a person-centered care plan for a resident with chronic pain and psychiatric issues. The resident's care plan did not reflect their actual chronic pain or include non-medicinal interventions that had been attempted and failed. Additionally, the care plan lacked specific targeted behaviors for medication use and non-medicinal interventions for managing psychiatric issues. Staff interviews revealed that the care plans were generic and not tailored to the resident's needs, failing to provide clear guidance for effective management.
A facility failed to update a resident's dietary care plan after being informed by the family that the resident was no longer restricted from gluten. Despite the resident's severe cognitive impairment and dependency for all activities of daily living, the care plan continued to include a gluten-free diet. Interviews revealed that staff were unaware of the dietary change, and the care plan was not updated for eight months.
The facility did not notify the State agency of a change in the Director of Nurses (DON). The current DON began in July 2023, but the last update in the Health Care Facility Reporting System was in June 2021. The Administrator acknowledged the oversight, believing the update had been made.
A resident recovering from a hip fracture fell due to a CNA's failure to attach a bed alarm as required by the resident's Plan of Care. Despite having a printed assignment sheet indicating the need for bed and chair alarms, the CNA did not follow the care directives, leading to the resident's fall and a new hip fracture. The facility's process for reviewing care directives with oncoming CNAs was not effectively followed.
Food Quality and Temperature Concerns
Penalty
Summary
The facility failed to ensure residents received food prepared by methods that conserved nutritive value, flavor, and appearance, and that was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported concerns about the quality of the food, including that it had gone downhill, was not good, had not been as good since a new company took over, was sometimes at room temperature and reheated by staff, and that a resident did not receive the expected amount of chili. Resident Council minutes also documented concerns that the quality of food had changed and was salty at times, and during a Resident Council meeting 13 residents described ongoing problems with the kitchen, including cold soups, inconsistent temperatures, overcooked or undercooked items, salty gravy, and fatty, hard pot roast. During a test tray observation, the surveyor and Food Service Manager found scrambled eggs at 132 degrees Fahrenheit that were visually yellow with clumps of gray and green eggs and had a very strong sulfur taste. Oatmeal, sausage, coffee, and the meal tray items were otherwise tested, but the milk and yogurt were warmer than expected, and the juice served from the kitchen tasted warm. The Food Service Manager stated she did not know why the eggs looked gray and green, said the kitchen had run out of liquid eggs and thought the cook may have mixed in hard-boiled eggs, and agreed the drinks and yogurt could be colder. The Administrator stated the food should be appealing to residents.
Missing Meal Items Despite Diet Slip Instructions
Penalty
Summary
The facility failed to follow the planned menu and diet slips for one resident, resulting in food items being missing from the resident’s meal trays during three observed meals. Resident #8 was admitted with diagnoses including type 2 diabetes mellitus, dementia, anxiety disorder, dysphagia, adjustment disorder with depressed mood, chronic kidney disease, and gastro-esophageal reflux disease. The resident’s MDS assessment dated 3/19/26 indicated the resident was cognitively intact with a BIMS score of 14 out of 15, required setup or clean-up assistance for meals, and was on a regular diet. During an observation on 5/17/26, the resident stated some desired food items were not received on the lunch tray. The diet slip listed multiple items, including milk, cola, soup, pot roast, gravy, potatoes, vegetables, fruit cup, yogurt, a white sandwich, chef salad, ranch dressing, saltine crackers, and pepper, but several items were missing from the tray, including soup, pot roast, gravy, potatoes, vegetables, yogurt, fruit, the white sandwich, and saltines. During another observation on 5/18/26, the resident’s family member said food items were often missing, and the white sandwich listed on the diet slip was not present on the lunch tray. On 5/19/26, a CNA delivered the resident’s lunch tray and left the room after placing it on the overbed table; the resident stated the sandwich was not received. The diet slip for that meal listed milk, cola, soup, yogurt, fruit cup, chef salad, ranch dressing, a white sandwich, saltine crackers, and pepper, and the white sandwich was not on the tray. The physician’s orders required a regular diet with fruit on every tray, a side sandwich and two bowls of soup at every lunch and dinner, and a large salad at every lunch and dinner. The dietitian, food service director, and menu specialist all stated the resident should have received the items listed on the meal ticket, and the dietitian said this was not uncommon and had been an ongoing issue.
Failure to Initiate Neurological Assessments After Unwitnessed Fall
Penalty
Summary
A resident with severe cognitive impairment, high fall risk, and on daily aspirin for anticoagulation was found sitting upright on the floor after an unwitnessed fall. The resident was unable to communicate the circumstances of the fall or whether a head strike occurred. Despite facility protocol requiring neurological assessments after any unwitnessed fall, especially for residents on anticoagulants, nursing staff did not initiate or conduct neurological assessments following the incident. The Unit Manager relied on the roommate's statement that no head strike occurred and did not perform the required assessments, even though the resident's medical record showed no documentation of such evaluations. Interviews with the Unit Manager, Director of Staff Development, and DON confirmed that it was facility protocol to perform neurological assessments after any unwitnessed fall, regardless of witness statements. The DON acknowledged that, although there was no specific written policy, the expectation was clear among leadership that neurological assessments should be completed for 72 hours post-fall. The failure to follow this protocol was confirmed by the absence of documentation in the resident's medical record and by staff interviews.
Failure to Develop and Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the elopement risk for a resident who was assessed as high risk for elopement upon admission. Despite the resident's medical history, which included dementia, cognitive communication deficit, difficulty walking, and other significant diagnoses, and a documented high risk for elopement on an evaluation, there was no care plan in place to address this risk. On one occasion, the resident was able to leave the activity patio area through a side gate without staff awareness and was found outside the building by a visitor, who then notified staff. The resident was redirected back into the facility by staff after being found outside. Interviews with facility staff, including the Unit Manager and DON, revealed that they did not consider the incident to be an elopement and therefore did not implement or update an elopement risk care plan for the resident after the event. Review of the resident's comprehensive care plan confirmed there was no documentation of interventions or updates following the incident to address the resident's wandering behavior and elopement risk, despite facility policies requiring such actions for residents identified as at risk.
Lack of Resident Awareness of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were fully aware of the grievance process, as required by their policy. During a resident group meeting, nine out of twelve residents reported that they had not seen any postings about the grievance process and did not know how to file a grievance other than by informing a staff member. The residents were unaware of the availability of grievance forms or the option to file grievances anonymously. One resident expressed concern about being labeled a complainer, which deterred them from voicing grievances. The surveyor's tour of the facility revealed that none of the three units had postings about the grievance process or available grievance forms. The Mayfair Unit had a document holder labeled for grievance forms, but it contained a resident census list instead. The Windsor and [NAME] Units also lacked postings and forms. Interviews with the Social Worker and Administrator confirmed the absence of grievance information and forms, and the lack of a process for anonymous grievance filing.
Failure to Document Rationale for Extended Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents' drug regimens were free from unnecessary psychotropic medications. For one resident, there was insufficient documentation for the ongoing extended use of PRN psychotropic medications, including clonazepam and triazolam. The resident was admitted with a history of bipolar disorder, anxiety, and depression, and the medications were continued without a clear rationale or documentation of risk versus benefit. Interviews with the Unit Manager and Nurse Practitioner revealed that while evaluations were conducted, the necessary documentation to support the extended use of these medications was lacking. Another resident was prescribed PRN Seroquel for severe agitation and anxiety, but the order was extended beyond the 14-day limit without proper evaluation and documentation by the prescriber. The resident had severe cognitive impairment and exhibited behavioral symptoms, yet the medical record did not reflect an assessment of the resident's condition or the appropriateness of continuing the PRN Seroquel. The Charge Nurse acknowledged that reminders were given to the prescribers, but the necessary documentation was not consistently completed. A third resident, with diagnoses including dementia and behavioral disturbances, was also prescribed PRN Seroquel. The order was renewed multiple times without the required evaluations and documentation. The Director of Nursing confirmed that the process for reviewing PRN antipsychotic medications was not adequately followed, resulting in a lack of documentation for the clinical rationale and other required information for the continuation of these medications.
Infection Control Deficiencies in Surveillance and PPE Usage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by deficiencies in their surveillance system and improper use of personal protective equipment (PPE). The surveillance system did not accurately reflect potential illnesses and infections, as it failed to categorize and document symptoms in accordance with the McGeer criteria. This resulted in inaccurate infection attack rates, as seen in the cases of several residents whose symptoms were not properly documented or counted, despite meeting the criteria for infections such as gastroenteritis. Additionally, the facility did not ensure proper use of PPE by staff when dealing with residents on isolation precautions. In one instance, a housekeeper entered a resident's room, which was under contact precautions for vancomycin-resistant enterococci (VRE), without wearing the required gown and gloves. This oversight was only corrected after a charge nurse intervened. Similarly, multiple staff members, including a unit secretary, certified nursing assistants (CNAs), and a speech-language pathologist, failed to don the necessary eye protection when entering the room of a resident on droplet precautions for Influenza A, despite clear signage indicating the required PPE. These deficiencies highlight a lack of adherence to established infection control policies and procedures, which are critical for preventing the spread of infections within the facility. The failure to maintain accurate surveillance data and ensure proper PPE usage compromises the safety and well-being of both residents and staff, as it increases the risk of infection transmission.
Failure to Assess Resident's Ability to Self-Administer Oxygen
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer and manage supplemental oxygen independently, as required by their policy. The resident, who was admitted with diagnoses including pneumonia, chronic respiratory failure, asthma, and COPD, was observed managing their oxygen therapy without a formal assessment or physician's order. The resident was cognitively intact and independent in ambulation and transfer tasks, requiring only setup assistance for activities of daily living. Despite this, the facility did not document any assessment of the resident's ability to self-administer oxygen until after the surveyor's observation. During the surveyor's observation, the resident was seen sitting on the bed with the nasal cannula oxygen tubing connected to an oxygen concentrator that was not turned on. The resident reported using oxygen for several years and managing the nasal cannula tubing independently when leaving the room. The resident also mentioned typically turning off the oxygen concentrator when leaving the room and turning it back on upon return. However, during the observation, the concentrator was off, and the resident's oxygen saturation was measured at 91% by the charge nurse, who then educated the resident on the importance of turning the concentrator back on. Interviews with nursing staff revealed a lack of understanding regarding the need for a formal assessment for self-administration of oxygen, with one charge nurse incorrectly stating that supplemental oxygen was not considered a medication. The Director of Nursing confirmed that an assessment should have been completed to ensure the resident's safety in managing their oxygen independently. The comprehensive care plan was also found to lack documentation of the resident's independence in managing oxygen therapy until after the surveyor's observation.
Failure to Develop Individualized Care Plan for Resident with Chronic Pain and Psychiatric Issues
Penalty
Summary
The facility failed to develop and implement a person-centered individualized comprehensive care plan for a resident with chronic pain and psychiatric issues. The resident, who was admitted in September 2022, has a history of pain in the right shoulder, lower back pain, Alzheimer's disease, and various psychiatric disorders. Despite the resident's expressed goal of achieving zero pain on a 0-10 scale, the care plan did not reflect the resident's actual chronic pain or include non-medicinal interventions that had been attempted and failed. Interviews with staff revealed that numerous interventions had been tried, but these were not documented in the care plan, which appeared generic and not tailored to the resident's needs. Additionally, the facility did not develop a person-centered care plan to manage the resident's psychiatric issues, including anxiety, delusions, and weepiness. The resident exhibited various behaviors such as wandering, verbal outbursts, and anxiety, but the care plans lacked specific targeted behaviors for medication use and non-medicinal interventions. Staff interviews indicated that the resident responded well to certain interventions, such as sitting by the window in the dayroom, but these preferences were not documented in the care plan. The care plans reviewed were found to be templated and not reflective of the resident's individual needs. The Director of Nurses acknowledged that the care plans were generic and did not tell the full story of the resident's pain and psychiatric needs. The lack of individualized care plans failed to provide clear guidance for staff, particularly those unfamiliar with the resident, to effectively manage the resident's chronic pain and psychiatric issues.
Failure to Update Dietary Care Plan for Resident
Penalty
Summary
The facility failed to update and revise the dietary care plan for a resident who was initially considered to have an inability to digest gluten. Despite being informed by the resident's family that the resident was no longer restricted from gluten, the care plan was not updated to reflect this change. The resident, who was admitted in May 2024, had diagnoses including irritable bowel syndrome with constipation, gastroesophageal reflux disease, and lactose intolerance. The comprehensive Minimum Data Set assessment indicated severe cognitive impairment and dependency for all activities of daily living. The care plan initially included a gluten-free diet to minimize gastrointestinal distress, but this was not revised after the family communicated the dietary change in July 2024. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's dietary needs. Charge Nurse #2 was unaware of the gluten intolerance and acknowledged that the care plan should have been edited or removed at the first care plan meeting. The dietitian confirmed that the health care proxy had informed her in July 2024 that the resident was not to have a gluten-restricted diet, but the care plan was not updated at that time. This oversight resulted in the care plan not accurately reflecting the resident's current dietary needs for eight months.
Failure to Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide written notice to the State agency regarding a change in the Director of Nurses (DON). During an interview, the current DON stated she began her role in July 2023. However, a review of the Health Care Facility Reporting System (HCFRS) revealed that the last notification to the State about a DON change was on June 23, 2021. Further examination of the HCFRS showed no record of the State Agency being informed about the current DON's appointment. The Administrator confirmed during an interview that the DON information had not been updated since June 2021, despite the current DON starting in July 2023 as an interim DON. The Administrator believed the update had been made, but it had not.
Failure to Implement Safety Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that nursing staff consistently implemented and followed interventions identified in a resident's Plan of Care, which led to an accident. A resident, who was recovering from a recent right hip fracture, required the use of chair and bed alarms for safety as per their Plan of Care. On a specific date, a Certified Nurse Aide (CNA) transferred the resident into bed but did not attach the alarm box to the bed alarm sensor pad. Consequently, the resident was found lying on the floor, complaining of right hip pain, and was later diagnosed with a new right non-displaced greater trochanter fracture. The facility's policy on the use of position change alarms was not adhered to, as the CNA failed to move the alarm box from the wheelchair sensor pad to the bed sensor pad when transferring the resident. Despite having a printed assignment sheet detailing the resident's safety interventions, the CNA did not follow the care directives. The CNA claimed to be unaware of the requirement for bed and chair alarms, although the assignment sheet and CNA Care Card clearly indicated this need. Interviews with other staff members revealed that the facility's process included reviewing the CNA Care Card and assignment sheet with oncoming CNAs, which should have informed the CNA of the resident's requirements. The Director of Nurses confirmed that the CNA was experienced and had been trained to review care directives before providing care. The failure to follow the resident's Plan of Care and ensure the proper use of alarms resulted in the resident's fall and subsequent injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 216 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tremont Rehabilitation & Skilled Care Center | 4.3 mi | ★★★★★ | 5 | 0 |
| Alden Court Nursing Care & Rehabilitation Center | 7.6 mi | ★★★★★ | 0 | 0 |
| Care One At New Bedford | 8.3 mi | ★★★★★ | 0 | 0 |
| Royal Of Fairhaven Nursing Center | 8.4 mi | ★★★★★ | 0 | 0 |
| Our Ladys Haven Of Fairhaven Inc | 8.5 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sippican Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.