Navigator Homes of Martha's Vineyard

In the surveyor’s words

From the most serious findings on record at Navigator Homes of Martha's Vineyard, in the surveyor’s own words.

• Actual harm, patternF689Oct 20, 2022

  Based on observation and interview, the facility failed to ensure staff provided residents with adequate supervision for four Residents (#22, #26, #1, and #8), out of 16 sampled residents, and an environment free from accident hazards on two of two units in the facility. Specifically, the facility failed to ensure: 1. For Resident #22, that effective care plan interventions were developed and implemented to prevent a fall with major injury; 2. For Resident #26, that effective care plan interventions were developed and implemented to prevent seven falls; 3. For Resident #1, that effective care plan interventions were developed and implemented to prevent three falls; 4. For Resident #8, that effective care plan interventions were developed and implemented to prevent four falls ; 5. […]

• No harm, potential for more than minimal, widespreadF689Mar 12, 2026

  Based on observations and interviews the facility failed to maintain an environment free from accident hazards in 3 out of 3 occupied resident Houses. Specifically, the facility failed to ensure: 1. House 2a. secured and/or supervised kitchen sharps including chef knives (an all-purpose, versatile kitchen knife with a broad, 8 to 10-inch blade that curves toward a point, designed for chopping, slicing, dicing, and mincing), scissors and peelers,b. supervised accessible hot ovens, andc. secured cleaning chemicals. 2. House 3a. kitchen sharps including chef knives were secured and/or supervised, b. cleaning chemicals were secured, and c. […]

• No harm, potential for more than minimal, widespreadF801Mar 12, 2026

  Based on record review and interview, the facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Specifically, the facility did not employ a full-time dietitian or have a qualified dietary employee who met the minimum qualifications to serve as the FSD. Findings include:During an interview at the entrance conference on 3/10/26 at 12:16 P.M., the Administrator said there was not a FSD and the dietitian worked 20 hours per week at the facility. The Administrator said food services for the facility were contracted and overseen by a Regional Chef. During an interview on 3/11/26 at 10:45 A.M., [NAME] #1 said the FSD for the facility was the Regional Chef and he was on vacation. [NAME] #3 was in charge while he was gone. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based on observations and interviews, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure staff wore beard restraints in the main kitchen during meal preparation and service; and2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another).Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to:-2-402 Hair Restraints 2-402.11 Effectiveness. […]

• No harm, potential for more than minimal, widespreadF880Mar 12, 2026

  Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program which included an assessment to identify where Legionella (a type of bacteria naturally found in water and soil that causes serious, sometimes fatal, pneumonia known as Legionnaires' Disease) and other opportunistic waterborne pathogens could grow and spread and failed to implement measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. […]