Our Island Home

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 their grievance policy included notification that residents and their representatives have the right to file grievances anonymously, should they choose not to alert a staff member of their concern(s), and failed to include the contact information of the grievance official with whom a grievance can be filed, that is, business address (mailing and email) and business phone number, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system.Findings include:Review of the facility's policy titled Grievance/Concerns Procedures, last revised 2/20/26, indicated:-Any resident, his or her representative, interested family member, or advocate may file a grievance or complaint concerning his or treatment, medical care,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide services that met professional standards of practice for three Residents (#13, #17, and #25), out of a total sample of 33 residents. Specifically, the facility failed: 1. For Resident #13, to ensure physician's orders for opioid administration were followed; and2. For Resident #17 to ensure physician's orders for opioid administration were followed; and3. For Resident #25, to ensure physician's orders for inhaled medication were followed. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that a [NAME] Monitor was appointed, and treatment plan approved by the court for one Resident (#13) who was admitted to the facility and administered an antipsychotic medication, from a total sample of 12 residents. Findings include:In a [NAME] guardianship hearing, the court is being asked to authorize extraordinary treatment or care, such as administering antipsychotic medications, admitting an adult to a nursing home facility, and other medical care. This procedure was established by the Supreme Judicial Court in a decision entitled [NAME] v. Commissioner of the Department of Mental Health, 390 Mass. 489 (1983) - Massachusetts Guardianship Association (massguardianshipassociation.org).Resident #13 was admitted to the facility in March 2026 and had diagnoses including Alzheimer's disease and bipolar disorder.Review of the Minimum Data Set (MDS) assessment, with a reference date of 3/11/26, indicated that Resident #13 had severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure medications were accurately labeled and stored in accordance with acceptable professional standards. Specifically, the facility failed to:1. Ensure a treatment cart was locked when not in direct supervision of a licensed nurse;2. Ensure Resident #10's Albuterol Sulfate HFA inhaler (used to treat shortness of breath) was stored securely; and3. Ensure Resident #25's medications were stored in their original packaging.Findings include: 1. On [DATE] at 5:08 P.M., the surveyor observed two entry doors to the nursing suite (nursing station, medication room, oxygen room) wide open with no licensed staff in the vicinity of the nursing suite. The door labeled Oxygen Room was wide open and had an unlocked multi-drawer treatment cart inside that was easily accessible to all residents residing in the facility. The treatment cart contained the following items: -Multiple packets of Skin Prep (forms a protective film or barrier on the skin)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review, 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. Specifically, the facility failed to:-Ensure staff handled medications in a sanitary manner to prevent potential transmission of infections; and-Ensure staff followed hand hygiene procedures prior to handling medication(s) and after administering medication(s).Findings include:Review of the facility's policy titled Hand Hygiene Procedures, revised 9/2020, indicated but was not limited to the following:-hand hygiene should be performed between providing care for residents, after hand contact with unclean equipment or work surfacesReview of the facility's policy titled Medication Administration Policy, revised 9/2020, indicated but was not limited to the following:-wash your hands before beginning and before contact with each residentOn 4/7/26 from 11:38 A.M. through 1:26 P.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for one Resident (#6), out of a total sample of 12 residents. Specifically, for Resident #6, the facility failed to ensure pain medication was not administered outside of parameters identified in the Physician's orders. Findings include: Review of [NAME], Manual of Nursing Practice 11ed, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber's that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, document review, and interviews, the facility failed to follow infection control prevention practices to prevent the transmission of communicable diseases and infections for one Resident (#13) out of one resident on transmission-based precautions, out of a total sample of 13 residents. Specifically, the facility failed to ensure staff wore the appropriate PPE (personal protective equipment) while providing care for Resident #13, who was on droplet and contact precautions. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions, dated 4/3/24, indicated but was not limited to: -Contact Precautions: Use of PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning (putting on) PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. -Droplet Precautions: Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#10, #5 and #21), out of a sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended Pneumococcal vaccine 20-valent (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria). Findings include: Review of the facility's policy titled Resident Immunization Policy, dated as last revised on 1/17/23, indicated but was not limited to the following: -Vaccines against tetanus and diphtheria, influenza, pneumonia, COVID-19 will be available to all residents. Residents and their Responsible Party will be educated and encouraged to consent to receiving immunizations as recommended by the Massachusetts Immunization Program…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed for one Resident (#12), of 12 sampled residents, to maintain their catheter drainage bag below the level of the bladder at all times to prevent potential complications. Findings include: Review of the facility's policy titled Indwelling Urinary Catheter: insertion, routine care and removal, dated as effective 9/21/22, indicated but was not limited to the following: - always keep the drainage bag below the level of the individual's bladder, to prevent urinary tract infections caused by urinary reflux (urine flowing back up into the bladder) Resident #12 was admitted to the facility in August 2022 with diagnoses including: hydronephrosis (a condition in which urine cannot drain from the kidneys resulting in kidney swelling) and protein calorie malnutrition. Review of the most recent Brief Interview for Mental Status (BIMS), dated 3/12/24, indicated the Resident was cognitively intact with a score of 15 out of 15. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to 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 within the facility for one Resident (#17), out of a total sample of 12 residents. Specifically, the facility failed to implement enhanced barrier precautions for a Resident who has a tracheostomy stoma and is at high risk for infection. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, dated as reviewed 4/26/24, indicated but was not limited to the following: - enhanced barrier precautions (EBP) will be implemented for residents with wounds and indwelling medical devices at especially high risk for both the acquisition of and colonization with multi-drug resistant organisms (MDRO) - the decision to implement EBP will be made by the infection control nurse and healthcare leadership team - compliance with EBP will be monitored by the infection control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, the facility failed to implement and maintain an effective training program for all staff, which included laundry personnel, training on standards, policies, and procedures for the facility's infection prevention and control program as it relates to handling contaminated laundry. Findings include: According to the Centers for Disease Control and Prevention (2024), best practices for personal protective equipment (PPE) for laundry staff include but are not limited to: -If there is risk of splashing, for example, if laundry is washed by hand, laundry staff should always wear gowns or aprons and face protection (e.g., face shield, goggles) when laundering soiled linens. According to the American Healthcare Association (2023), Tips for Meeting the Linen Requirements in Skilled Nursing Facilities include but are not limited to: Linen and Laundry Handling: Staff should handle all used laundry as potentially contaminated and use standard precautions (e.g. gloves, gowns when sorting and rinsing). During an interview on 5/8/24 at 11:20 A.M., Laundry Staff #1 said she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.