Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Our Island Home during CMS and state inspections, most recent first.
Grievance policy lacked anonymous filing and required contact info. The facility’s policies did not tell residents or their reps that grievances could be filed anonymously and did not list the grievance official’s mailing/email address or phone number, or the contact info for outside entities such as the State agency, QIO, State Survey Agency, and LTC Ombudsman/protection and advocacy system. In a resident group, 12 of 12 residents said they were unaware of anonymous filing or who the grievance official was, and the Administrator confirmed there was no way to file a grievance without involving a staff member.
A facility failed to follow physician orders for medication administration for three residents. Two residents with cognitive impairment received opioid pain meds when their documented pain levels were mild or below the ordered threshold, and one resident with COPD was given two inhalers back-to-back without the required wait time and without being observed rinsing the mouth after Wixela. The DON and physician confirmed the orders were not followed as written.
A resident with Alzheimer's disease and bipolar disorder, severe cognitive impairment, and a legal guardian was admitted with orders for Seroquel, an antipsychotic. The record showed the medication was administered as ordered, but no Rogers Treatment Plan or Rogers Monitor was documented to authorize the antipsychotic use, and the Administrator acknowledged the facility missed this requirement at admission.
An unlocked treatment cart was left in an open nursing suite with multiple topical meds accessible, while two residents wandered nearby. A resident with COPD and moderate cognitive impairment left an albuterol inhaler unsecured on a bedside table, and another resident’s pre-poured pills were found unlabeled in a med cart. The DON said the cart and meds should have been locked or labeled appropriately.
Failure to perform hand hygiene and maintain sanitary medication handling: An RN was observed administering meds to multiple residents without hand hygiene before or after the med pass, while touching the computer, med packages, and drawer handles between residents. The RN also placed a resident's nasal spray, inhalers, and another resident's eye drop cover on resident furniture or in his uniform pocket without a protective barrier, then returned the items to the med cart. The RN and DON both acknowledged the hand hygiene and medication-handling lapses.
Nursing staff administered PRN oxycodone outside of prescribed parameters for a resident recovering from a femur fracture, providing the medication for pain ratings that did not meet the physician's orders. The resident did not request the medication and expressed concerns about unnecessary use, while staff and the DON acknowledged the medication was given inappropriately.
Staff did not use the required PPE while providing care to a resident on contact and droplet precautions for a respiratory illness. Two CNAs were observed wearing only gloves during a transfer, despite clear signage and available PPE indicating the need for gown, gloves, mask, and eye protection. The CNAs later acknowledged the oversight, and the Infection Preventionist confirmed the resident was still on precautions.
The facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per CDC recommendations and facility policy for three residents. The Infection Control Preventionist was unaware that residents vaccinated more than five years ago were eligible for PCV20, leading to the failure in offering and educating residents about the PCV20 vaccine.
A resident with an indwelling catheter was observed lying in bed with a leg bag, contrary to the facility's policy and care plan, which required the drainage bag to be below bladder level to prevent urinary tract infections. Staff confirmed the resident should not have had a leg bag on while in bed, leading to potential complications.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a tracheostomy stoma, who is at high risk for infection. Despite the facility's policy requiring EBP for residents with indwelling medical devices, there was no EBP signage or personal protective equipment available, and the resident's medical records did not indicate EBP was in place. The Director of Nurses acknowledged the oversight.
The facility failed to provide effective infection control training for laundry staff. A laundry staff member reported only using gloves and not being educated on other PPE. The Maintenance/Housekeeping Director confirmed the lack of education, and the Infection Preventionist admitted to not providing the necessary training.
Grievance policy lacked anonymous filing and required contact information
Penalty
Summary
The facility failed to ensure that residents were fully aware of the grievance process. Review of the Grievance/Concerns Procedures policy, last revised 2/20/26, showed that residents, representatives, family members, or advocates could file grievances and that forms were available in several locations, but the policy did not include notification that residents and their representatives had the right to file grievances anonymously. It also did not include the contact information for the grievance official, including business mailing and email address and business phone number, or the contact information for independent entities such as the State agency, Quality Improvement Organization, State Survey Agency, and State Long-Term Care Ombudsman program or protection and advocacy system. Review of the Freedom from Abuse, Neglect, and Exploitation policy, last revised 3/4/22, showed that resident grievances were to be initiated through staff and passed to supervisory personnel, with the Social Worker or designee identified as the contact person for grievances/complaints. During a resident group meeting with 12 residents, all 12 stated they were not aware of their right to file a grievance anonymously or who the grievance official was, and said they had to go to the Resident Council President or a staff member if they had an issue. During an interview, the Administrator confirmed that the policies did not include anonymous filing or the required contact information for the grievance official and independent entities, and stated there was no way for residents or representatives to file a grievance without involving a staff member.
Failure to Follow Medication Orders for Pain and Inhaled Treatments
Penalty
Summary
The facility failed to ensure physician orders were followed for pain medications for Resident #13, who was admitted with diagnoses including Alzheimer's disease and bipolar disorder and had severe cognitive impairment with a BIMS score of 3 out of 15. The record showed orders for acetaminophen as needed for pain/fever, scheduled acetaminophen for pain, and morphine sulfate solution as needed for pain, but the orders did not include pain severity parameters for when each medication should be used. The MAR showed acetaminophen was given for pain levels of 4 and 2, and morphine sulfate was given for pain levels of 5, 2, and 1. The DON and physician both stated the pain medication orders should have included parameters such as mild, moderate, or severe pain, and the DON stated acetaminophen should be used for mild pain rather than morphine. The facility also failed to follow physician orders for Resident #17, who was admitted with diagnoses including fractured neck of the right femur, cognitive communication deficit, and osteoarthritis, and had cognitive impairment with a BIMS score of 5 out of 15. The physician orders included scheduled acetaminophen, acetaminophen as needed for mild pain/fever, oxycodone as needed for moderate to severe pain, and pain monitoring every shift. The MAR showed oxycodone was administered when the resident’s pain level was documented as 5, 2, and 2. During interview, the nurse stated oxycodone was intended for moderate to severe pain, which he described as 6 through 10 on the pain scale, and said he should have given acetaminophen instead when the pain level was 2. The DON and physician both stated it was inappropriate to give the opioid when the resident’s pain level was mild. For Resident #25, who had COPD, the facility did not follow the physician’s order and its own medication administration policy during inhaler administration. The orders included Wixela Inhub twice daily with instruction to rinse the mouth after use, and umeclidinium bromide once daily. During observation, the nurse administered umeclidinium bromide and then immediately administered Wixela without waiting at least one minute between inhalers, and the resident was not observed rinsing the mouth after Wixela as ordered. The nurse stated he should have waited between inhaled medications and should have had the resident rinse the mouth, and the DON stated the inhalers should not have been given back-to-back and the resident should have been instructed to rinse the mouth as ordered.
Failure to Obtain Court-Approved Treatment Plan for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a Rogers Monitor was appointed and that a court-approved treatment plan was in place for Resident #13, who was admitted in March 2026 and was administered an antipsychotic medication. Resident #13 had diagnoses including Alzheimer's disease and bipolar disorder, and the MDS assessment dated 3/11/26 showed severe cognitive impairment with a BIMS score of 3 out of 15 and daily antipsychotic medication use. The medical record showed the resident had been appointed a permanent Legal Guardian by the Commonwealth of Massachusetts Probate and Family Court on 8/15/24. Review of the record did not show a Rogers Treatment Plan authorizing the administration of antipsychotic medication. March 2026 physician orders included Seroquel 25 mg in the afternoon and 50 mg at bedtime, and the March and April 2026 MARs showed the medication was administered as ordered. During interviews on 4/8/26, the Administrator stated the resident should have had a Rogers Monitor and a court-approved treatment plan for the antipsychotic medication, and acknowledged the facility was responsible for ensuring residents with legal guardians and antipsychotic medication had the required monitor and treatment plan, but this need was not identified when the resident was admitted.
Unsecured medications and unlabeled drugs found in nursing suite and resident room
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles. During observation, the nursing suite doors were wide open and an unlocked multi-drawer treatment cart was left inside the open Oxygen Room with no licensed staff nearby. The cart contained multiple topical medications and related products, including Skin Prep, Povidone-Iodine antiseptic pads, Bengay Cream, Adapt Stoma Powder, Diclofenac Sodium Topical Gel 1%, Tacrolimus Ointment 1%, Preparation H Ointment, Triamcinolone Acetate 0.1%, Fluorouracil Cream 5%, Collagenase Santyl Ointment, Estradiol 0.01% Cream, Geri Care Analgesic Balm, and Ketoconazole Shampoo 2%. Two residents were observed wandering by the unlocked nursing suite while the cart remained accessible. The DON stated the treatment cart was supposed to be locked when not in use and not accessible to anyone other than licensed staff. The facility also failed to secure Resident #10’s Albuterol Sulfate HFA inhaler and failed to keep Resident #25’s medications properly labeled. Resident #10 had COPD and moderate cognitive impairment with a BIMS score of 11 out of 15, and was approved to self-administer the inhaler and store medications in a secured location. The inhaler was observed on a bedside table while the resident was not in the room, and the resident stated it was left out all the time and had no way to lock it up. In a separate observation, a medicine cup in the medication cart contained 11 unlabeled pills for Resident #25, and Nurse #1 said the medications had been pre-poured because the resident was sleeping and would be given later. The DON stated the medications should not have been left unlabeled in the medication cart.
Failure to Perform Hand Hygiene and Maintain Sanitary Medication Handling
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. The cited issues involved medication handling and hand hygiene, including failure to ensure staff handled medications in a sanitary manner and failure to ensure hand hygiene was performed before and after medication administration. On 4/7/26, a surveyor observed Nurse #1 administer medications to six residents and did not observe hand hygiene before or after the medication pass. During the observations, Nurse #1 touched the computer, medication packages, and drawer handles between residents' medications. The surveyor also observed Nurse #1 place Resident #25's nasal spray and two inhalers in his uniform pocket and later remove them from his pocket and place them directly onto the medication cart without a protective barrier, and observed Nurse #1 place Resident #28's eye drop cover on the resident's dresser without a protective barrier before later placing the eye drops in his uniform pocket and returning them to the medication cart. In interview, Nurse #1 stated he should have performed hand hygiene before and after each resident's medication administration and should not have placed the medications in his uniform pocket or on resident furniture without a protective barrier. The DON also stated hand hygiene should have been performed before and after each resident's medication administration and that medications should not have been placed in the nurse's uniform pocket.
Failure to Administer PRN Pain Medication According to Physician Orders
Penalty
Summary
The facility failed to ensure that nursing staff administered pain medication according to the parameters specified in the physician's orders for one resident. The resident, who was admitted with a left femur fracture and other diagnoses, was prescribed oxycodone to be given as needed (PRN) based on specific pain ratings: a half tablet for moderate pain (rating 4-6) and a full tablet for severe pain (rating 7-10). Despite these clear parameters, review of the medication administration records (MAR) revealed that licensed nurses administered oxycodone outside of these prescribed guidelines on multiple occasions, including giving the medication when the resident reported no pain or only mild pain. Interviews with the resident indicated that they did not request the oxycodone and expressed concerns about unnecessary use and potential addiction, stating that their pain was manageable by other means. The MAR showed that the medication was given for pain ratings that did not meet the criteria for administration, such as ratings of zero, one, two, three, and four, rather than only for moderate or severe pain as ordered. Nursing staff acknowledged during interviews that the medication should only have been administered according to the resident's reported pain level and the physician's orders, and that the process was not followed. Further review of therapy and rehabilitation notes did not indicate that the resident's participation in therapy was limited by pain, and therapists confirmed that pain did not interfere with therapy sessions. The Director of Nursing also confirmed upon review that the PRN oxycodone had been administered outside of the ordered parameters, which was not in accordance with facility policy or professional standards of nursing practice.
Failure to Follow PPE Protocols for Resident on Transmission-Based Precautions
Penalty
Summary
Staff failed to follow infection prevention and control practices for a resident who was on both contact and droplet precautions due to an unknown respiratory illness. Despite clear signage at the resident's doorway indicating the need for specific personal protective equipment (PPE)—including gown, gloves, mask, and eye protection—two CNAs were observed providing care to the resident using only gloves while transferring the resident with a Hoyer lift. The required PPE was available on a cart below the precaution signs, and the signs themselves outlined the necessary steps for both contact and droplet precautions. During interviews, the CNAs stated they were unaware the resident was still on precautions and acknowledged they should have worn the full required PPE. The Infection Preventionist confirmed that the resident remained on contact and droplet precautions and that staff are expected to read and follow the posted precaution signs. The deficiency was identified through direct observation, document review, and staff interviews, revealing a failure to adhere to established infection control protocols.
Failure to Provide Pneumococcal Vaccinations per CDC Recommendations
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per CDC recommendations and facility policy for three residents out of a sample of five. Specifically, the facility did not ensure that staff offered, assessed, and provided education on the recommended PCV20 vaccine. The facility's policy indicated that vaccines against various diseases, including pneumonia, would be available to all residents, and their immunization status would be assessed upon admission and annually thereafter. However, the facility did not follow through with these guidelines for the three residents in question. Resident #10, admitted in February 2024, had received PPSV23 in 2008 and PCV13 in 2012 but was not provided with PCV20. Resident #5, admitted in January 2010, had received PPSV23 in 2010 and PCV13 in 2015 but was also not provided with PCV20. Resident #21, admitted in May 2021, had received PPSV23 in 2014 and PCV13 in 2017 but was not provided with PCV20. The Infection Control Preventionist admitted that she was unaware that residents who had previously been vaccinated more than five years ago were eligible for PCV20, leading to the failure in offering and educating residents about the PCV20 vaccine.
Failure to Maintain Proper Catheter Drainage Bag Position
Penalty
Summary
The facility failed to maintain the catheter drainage bag below the level of the bladder for one resident, leading to potential complications. The resident, who was admitted with diagnoses including hydronephrosis and protein calorie malnutrition, was observed with a leg bag while lying in bed. This was contrary to the facility's policy and the resident's care plan, which specified that the drainage bag should be positioned below the bladder level to prevent urinary tract infections caused by urinary reflux. During multiple observations, the resident was seen lying in bed with the leg bag in place, which does not allow for proper drainage. Interviews with the nursing staff and the Director of Nurses confirmed that the resident should not have had a leg bag on while in bed, as it would prevent proper urine drainage. The care plan and standard procedures were not followed, leading to this deficiency.
Failure to Implement Enhanced Barrier Precautions for High-Risk Resident
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident with a tracheostomy stoma, who is at high risk for infection. The facility's policy on Enhanced Barrier Precautions (EBP) requires implementation for residents with indwelling medical devices, such as a tracheostomy, to prevent the transmission of communicable diseases. However, the facility did not implement EBP for the resident, as evidenced by the absence of EBP signage on the resident's door and the lack of personal protective equipment available for staff use. The resident's medical record, progress notes, orders, and care plans also did not indicate that EBP was in place. During interviews, the resident mentioned that special precautions were followed at the hospital but not at the facility, despite the high risk of infection due to the tracheostomy stoma. The Director of Nurses acknowledged that EBP should have been implemented for the resident based on the facility's policy. Observations by the surveyor on multiple occasions confirmed the absence of EBP signage and personal protective equipment, highlighting the facility's failure to adhere to its infection control policy for a high-risk resident.
Failure to Implement Effective Infection Control Training for Laundry Staff
Penalty
Summary
The facility failed to implement and maintain an effective training program for all staff, including laundry personnel, on the standards, policies, and procedures for the infection prevention and control program. During an interview, a laundry staff member stated that she only uses gloves and has never been educated to use other PPE when handling soiled linens. The Maintenance/Housekeeping Director confirmed that he does not provide education on infection control related to laundry and mentioned that masks and gloves should be worn when handling contaminated linens. The Infection Preventionist admitted that she is responsible for providing infection control education to all staff, including laundry staff, but has not done so.
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Illustrative
What surveyors actually found near you
We read the 10 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nantucket
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Navigator Homes Of Martha's Vineyard | 24.1 mi | ★★★★★ | 10 | 0 |
| Mayflower Place Nursing & Rehabilitation Center | 28.1 mi | ★★★★★ | 8 | 0 |
| Windsor Nursing & Retirement Home | 28.5 mi | ★★★★★ | 6 | 0 |
| Cape Regency Rehabilitation & Health Care Center | 29 mi | ★★★★★ | 0 | 0 |
| Pavilion , The | 29.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.