Cycle 1
Health 2025-05-08 · Fire 2025-05-08
2 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Nantucket, MA
Our Island Home
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
East Creek Road, Nantucket, MA
(508) 228-0462
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
37
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,720
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.11
Composite VBP score used to determine payment impact.
Payment multiplier
1.0018
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
1.38
Performance 7.42% · Measure score 1.38 · Achievement 1.38 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
8.24
Performance 30.00% · Measure score 8.24 · Achievement 8.24 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.81
Baseline 4.28 hours · Performance 4.45 hours · Measure score 4.81 · Achievement 4.81 · Improvement 0.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.14% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 17.5% · Lower 95% interval 8.09% |
| Discharge to community | 44.08% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 34.48% · Lower 95% interval 30.27% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 2.56% |
0.77%
1.8 pts worse
|
Numerator 1 · Denominator 39 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 39 · Adjusted rate 2.55% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 15.96% |
8.2%
7.8 pts better
|
Numerator 15 · Denominator 94 |
| Staff flu vaccination coverage | 27.72% |
42%
14.3 pts worse
|
Numerator 28 · Denominator 101 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48% |
25.2%
22.8 pts better
|
Numerator 12 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.9
0.1 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
92.2%
3.3 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 90.9% · Q3 100.0% · Q4 97.1% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.9% |
94.8%
6.9 pts worse
|
95.5%
7.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.5%
1.2 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 2.9% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
12.0%
9.5 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.2%
2.9 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.9% · Q4 3.1% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.1% |
19.2%
16.1 pts better
|
19.6%
16.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 2.9% · Q4 3.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
22.5%
5.4 pts better
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 21.4% · Q3 16.7% · Q4 14.3% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.1% |
17.7%
8.6 pts better
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 26.7% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
17.6%
4.3 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.4% · Q3 26.7% · Q4 18.5% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.0%
0.3 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.2% · Q3 0.0% · Q4 3.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.7% |
21.7%
17 pts better
|
19.8%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 0.0% · Q3 5.9% · Q4 0.0% · 4Q avg 4.7% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.6%
2.6 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.4% · Q3 3.6% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.0% |
77.1%
30.1 pts worse
|
81.7%
34.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 38.1% · Q3 40.9% · Q4 52.2% · 4Q avg 47.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
11.8%
0.2 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 12.1% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.9% |
77.7%
36.8 pts worse
|
79.7%
38.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
25.8%
1.8 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 24.2% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2024-05-09
4 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-26 · Fire 2023-04-26
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-05-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-22
E · Potential for more than minimal harm
2023-04-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-04-26
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-04-26
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-04-26
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-04-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-22
C · Minimal harm
2023-04-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
E · Potential for more than minimal harm
2024-05-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-09
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-05-31
E · Potential for more than minimal harm
2023-04-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-04-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-04-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-04-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-26
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-06-07
Penalties and ownership
What sits behind the stars
Ownership
Town Of Nantucket
5% Or Greater Direct Ownership Interest · Organization
Chretien, Rachel
Operational/Managerial Control · Individual
Chretien, Rachel
Corporate Director · Individual
Chretien, Rachel
W-2 Managing Employee · Individual
Dyer, Heather
W-2 Managing Employee · Individual
Gibson, C. Elizabeth
Corporate Officer · Individual
Town Of Nantucket
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Edgartown, MA
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Mayflower Place Nursing & Rehabilitation Center
West Yarmouth, MA
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Windsor Nursing & Retirement Home
South Yarmouth, MA
1-star overall rating with 2-star inspections with $12,386 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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