Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Navigator Homes Of Martha's Vineyard during CMS and state inspections, most recent first.
Unsecured sharps, chemicals, and hot ovens left accessible in resident areas. The facility left chef knives, scissors, peelers, and a personal knife pouch unsecured in open kitchen areas, with some drawers and cabinets broken or unlocked. Staff also left ovens on and unattended in accessible kitchen spaces, and cleaning chemicals and other hazardous items were found in unlocked under-sink cabinets, closets, and clean utility rooms across multiple houses.
The facility failed to designate a qualified FSD. The Administrator said there was no FSD, the dietitian worked only 20 hours per week and did not run the kitchen, and the Regional Chef was overseeing food service but did not have the required credentials. Staff interviews showed the senior cook was only filling in while the Regional Chef was on vacation, and no additional certifications were provided for the staff identified during the survey.
Staff failed to follow food safety and sanitation practices during meal prep and service. Multiple employees prepared, plated, sliced, peeled, and served food without beard restraints, and a CNA handled a resident’s meal, fruit, ice cream, and utensils with the same gloves after touching a trash bin and other surfaces without changing gloves or performing hand hygiene. Other staff used the same gloves across tasks, touched a cell phone, trash can, door handles, and pantry/refrigerator surfaces, and continued food handling without hand hygiene.
Missing Water Management Program: The facility failed to maintain an infection prevention and control program because it did not have a water management program in place for the current location. The DON/Environmental Services leadership stated the prior location had a comprehensive program, but the new site did not, and the only document provided was an unsigned/incomplete contract with a water management company.
Failure to maintain monthly pharmacy MRRs and document physician review of consultant recommendations for multiple residents. A resident with DM, chronic pain, and depression continued receiving several meds despite pharmacist suggestions to deprescribe, adjust basal insulin, and reassess pain control; another resident on aspirin and Eliquis had a prompt clinical recommendation with no documented prescriber response; and a third resident with dementia, allergies, and chronic pain had missing MRRs and no documented action on recommendations for acetaminophen, Seroquel, and loratadine.
Unsecured topical medications and supplies were found in unlocked clean utility rooms and residents’ rooms. The clean utility rooms in two houses contained unlocked cabinets with items such as wound cleanser, Bacitracin, triple antibiotic ointment, hydrocortisone cream, Calmoseptine, hydrogen peroxide, and anti-itch cream. In addition, a resident room had two bottles of Nystatin powder in an unlocked med cabinet, another had triple antibiotic ointment left unsecured, and a third had multiple packets of skin prep wipes in an unlocked cabinet compartment; the DON observed these items and stated chemicals and dressing supplies are not to be kept where other residents could access them.
Failure to Timely Notify HCP of Resident’s Decline: A resident on hospice with acute respiratory failure, COPD, and PVD had multiple documented changes in condition, including weakness, respiratory decline, nausea/vomiting, poor appetite, COPD exacerbation, shallow respirations, and mottling. The record did not show timely notification of the activated HCP or family about these changes or related plan-of-care updates, and staff interviews confirmed the notifications were not documented and could not be verified.
Missing Wandering/Elopement Care Plan: A resident with dementia and severe cognitive impairment had repeated exit-seeking and wandering behaviors, including leaving the unit, using the elevator, and being found looking for family. Staff observed the resident gravitating toward the front doors and asking to go home, but the record did not include a care plan with interventions for wandering or elopement, and the elopement risk assessment documented no contributing factors or need for interventions.
Care Plan Not Updated After HCP Revocation: A resident with adjustment disorder and a history of falls was assessed as cognitively intact on MDS reviews, and a physician later documented that the resident had capacity to make healthcare decisions and revoked the HCP activation. Even so, the care plan still listed cognitive loss/dementia and an activated HCP, and the DON and ADON could not find documentation that the IDT reviewed or revised the plan to reflect the change.
Pantry refrigerator not maintained in safe operating condition. Staff observed a House 4 pantry refrigerator door being held shut with a bin of oranges and tape because it would not close properly, while it stored meat products, butter, and prepared desserts. An LPN/cook reported the issue had been known since the prior day, but the senior cook had not assessed it, and the Corporate Executive Chef had only just entered a work order. The refrigerator temperature was later observed at 52 F and 53 F, above the stated 41 F standard.
The facility failed to ensure ophthalmic medications were labeled, dated, and stored properly, leading to potential infection risks. Multiple eye medications were found with dates indicating they had been open for more than four weeks, and one bottle was not labeled with an opening date. The DON acknowledged the concern, and the facility's policy was not followed.
A resident with dementia and dysphagia suffered a burn after a CNA served them hot coffee without measuring its temperature. The facility lacked policies and training on serving hot beverages safely.
Unsecured sharps, chemicals, and hot ovens left accessible in resident areas
Penalty
Summary
The facility failed to maintain an environment free from accident hazards in three occupied resident Houses by leaving kitchen sharps, hot ovens, cleaning chemicals, and other hazardous items unsecured or accessible in areas open to residents. The report identified that House 2, House 3, and House 4 each had open concept kitchens or unlocked storage areas where residents could access items that were supposed to be secured, including chef knives, scissors, peelers, cleaning chemicals, and other hazardous supplies. The facility policy stated that dangerous chemicals and sharp objects were to be secured in locked cabinets or rooms and not left unattended. In House 2, the surveyor observed an open kitchen area with a broken child-safety latch on a drawer containing two chef knives, and another drawer containing kitchen scissors, a pizza cutter, and a peeler. The lower oven was observed set at 175 degrees Fahrenheit while the kitchen remained accessible to residents and no staff were present in the kitchen or adjacent dining area. The upper oven was later observed set at 350 degrees Fahrenheit after breakfast had ended, and a CNA stated she had left it on while heating a muffin and forgot to shut it off. The cabinet below the 3-compartment sink was unsecured and contained dish sanitizers, and a hallway closet with housekeeping supplies, including glass cleaner and bleach germicidal cleaner, had no mechanism to secure the door. In House 3, the surveyor observed an unsecured kitchen drawer containing three chef knives and an unsecured drawer below it containing an unsheathed pizza cutter. The pantry door was unlocked, and a housekeeping cabinet inside contained pot and pan detergent, stainless-steel polish, and oven and fryer cleaner. The cabinet below the 3-compartment sink was also unsecured and contained dish detergent and dish sanitizer with tubing attached. In addition, the clean utility room was unlocked and contained unsecured cabinets with items such as adhesive remover wipes, creams, body wash and shampoo, and disposable razors. A plastic drinking cup with five diabetic glucometer lancets was also found in an unlocked compartment of a medication cabinet in a resident room. In House 4, the surveyor observed a personal knife pouch left on a countertop in the open kitchen area, and the pouch could be opened to access chef knives while staff were away from the kitchen. House 4 also had an unsecured cabinet below the 3-compartment sink containing housekeeping chemicals, and an unlocked clean utility room with unsecured cabinets holding adhesive remover wipes, creams, body wash and shampoo, and disposable razors. The DON and Administrator acknowledged that items in the clean utility rooms should be securely stored and not accessible to residents, that the under-sink chemicals should have been secured, and that the facility plan for knives had not been followed by staff.
No Qualified Food Service Director Designated
Penalty
Summary
The facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). During the entrance conference, the Administrator stated there was no FSD and that the dietitian worked 20 hours per week. The Administrator also said food services were contracted and overseen by a Regional Chef. During subsequent interviews, [NAME] #1 identified the Regional Chef as the FSD, but said he was on vacation and [NAME] #3 was in charge while he was gone. The Corporate Executive Chef stated he was at the facility to support the kitchen staff during the survey process and was not in charge of the kitchens, though he assisted the dietitian and Regional Chef with menu specialization. [NAME] #3 stated he was the senior cook and was filling in for the Regional Chef during his vacation, but he was not the FSD. The Administrator later brought certifications for [NAME] #2 and the Corporate Executive Chef and stated the Regional Chef oversaw the whole food service program, but also said the facility did not have an FSD at that time. The Dietitian stated she was not responsible for overseeing the kitchen staff or running the kitchen, worked only 20 hours per week, and was not responsible for the food service program. The Administrator further stated the facility had no one in charge of the food service program with a certification, and the facility did not provide additional certifications for [NAME] #1, [NAME] #3, or the Regional Chef during the survey process.
Food Safety and Hand Hygiene Lapses During Meal Preparation and Service
Penalty
Summary
The facility failed to follow professional standards of practice for food safety and sanitation in the main kitchen and house kitchens by not ensuring staff wore beard restraints during food preparation and service. Survey observations showed multiple staff members preparing, plating, peeling, slicing, placing food into ovens, and handling dishware without beard coverings in House 4, House 3, and House 2. The Corporate Executive Chef stated that beard coverings and hairnets should be worn at all times during preparation and serving of food items. The facility also failed to prevent cross contamination when handling ready-to-eat food and other kitchen items. A CNA delivered a resident’s meal with gloved hands, left the resident, returned, and resumed assisting with feeding without changing gloves or performing hand hygiene. The same CNA moved a trash bin with gloved hands, then placed fruit into a dish, served it to a resident, retrieved ice cream and a spoon from the kitchen, and later removed gloves without performing hand hygiene. The CNA stated hand hygiene should be performed each time gloves are removed. Additional observations showed staff using gloves and kitchen items in ways that crossed tasks and surfaces without changing gloves or cleaning hands. One staff member cleaned a thermometer with a dishcloth, used the same cloth to wipe the countertop, used it as a potholder, touched his face and hat with gloved hands, and continued food preparation without changing gloves or performing hand hygiene. Other staff entered and exited between houses with gloved hands while touching door handles, opened refrigerators and pantry areas with the same gloves, touched a cell phone and trash can while peeling potatoes, and continued food handling without glove changes or hand hygiene. The Corporate Executive Chef stated gloves should be changed when moving between tasks and staff should not touch drawers, pantry areas, multiple surfaces, or go between houses with gloved hands, and should perform hand hygiene between glove changes.
Missing Water Management Program
Penalty
Summary
Provide and implement an infection prevention and control program. 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 that included an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and failed to implement measures to prevent the growth of opportunistic waterborne pathogens and monitor them. During the entrance conference, the Administrator stated the new facility had five separated Houses and residents had moved into Houses 2, 3, and 4 on 2/4/26. During interview, the Director of Environmental Services stated the previous location had a comprehensive water management program, but the water management program for the new current location was not currently in place. He said there had previously been a contract with a water management company for the prior location, and that the current facility location did not have any water management program in place. He provided a contract dated 12/22/25 that the Administrator had signed, with no date of signature and a blank signature section for the water management company. No additional information was provided prior to exit.
Failure to Maintain and Address Monthly Pharmacy MRRs
Penalty
Summary
The facility failed to maintain monthly medication regimen review (MRR) reports as part of the permanent medical record and failed to ensure consultant pharmacist recommendations were addressed in a timely manner for three residents. The facility policy stated that the consultant pharmacist would provide MRRs to designated facility personnel, that physician/prescriber review and documentation of any action taken were required, and that consultant pharmacy reports were to be maintained in the resident’s permanent health record. During interviews, the Administrator and DON stated the facility was trying to obtain pharmacy recommendations that had been made before the move to a new location, and the DON said he could not locate the original pharmacy recommendations in the record. For one resident with diagnoses including type II diabetes, chronic pain, and depression, the consultant pharmacist made recommendations to discontinue MVI, Ocuvite, and Coenzyme Q10, to change Lantus from twice daily to once daily, and to evaluate pain control with consideration of scheduled acetaminophen. The medical record did not show that the attending physician reviewed these recommendations or documented any action taken, and the resident continued to receive the medications as ordered. The DON stated there was no documentation showing the physician specifically addressed these recommendations. For another resident with diagnoses including pulmonary embolism, hypertension, and heart failure, the consultant pharmacist issued a clinical priority recommendation regarding concurrent aspirin and Eliquis use and advised documentation of risk versus benefit and ongoing monitoring if therapy continued. The medical record did not show physician review or action, and the resident continued receiving both medications. The DON stated there was no documentation that the physician specifically addressed the recommendation, and the consultant pharmacist stated that a prompt clinical recommendation should have a response within 30 days. For a third resident with diagnoses including dementia with agitation, allergies, and chronic pain, the medical record did not contain the pharmacist recommendations from two monthly reviews. The consultant pharmacist recommended documenting the maximum daily acetaminophen dose and reducing acetaminophen if needed, considering a trial dose reduction of Seroquel, and reducing loratadine to every other day or discontinuing it. The medical record did not show physician review or action for these recommendations, and the resident continued receiving acetaminophen 1000 mg every six hours, Seroquel 37.5 mg daily, and loratadine 10 mg daily. The DON stated there was no documentation that the physician had addressed these recommendations.
Unsecured topical medications and supplies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles. The report states that the clean utility rooms in House #3 and House #4 were left unlocked when not under the direct supervision of a licensed nurse, even though they contained topical medications and related products. In House #3, the unlocked clean utility room contained unlocked cabinets with Vasche wound cleanser, Bacitracin Ointment USP, triple antibiotic ointment, hydrocortisone cream 1%, Calmoseptine ointment, and silicone skin guard skin protectant. In House #4, the unlocked clean utility room contained unlocked cabinets with Bacitracin Ointment USP, hydrogen peroxide 3%, hydrocortisone cream, anti-itch cream, and wound cleanser. The report also found unsecured topical treatments in residents’ rooms. In one room, two bottles of Nystatin powder were observed unsecured and easily accessible in an unlocked medication cabinet compartment with the door wide open. In another room, a packet of triple antibiotic ointment was observed in an unlocked medication cabinet compartment with the door wide open. In a third room, a box containing multiple packets of skin prep wipes was observed in an unlocked medication cabinet compartment. During observation with the DON, the unlocked clean utility room and the residents’ rooms were again observed with the items unsecured, and the DON stated that chemicals and dressing supplies are not to be kept in residents’ rooms or in areas where other residents could access them.
Failure to Timely Notify HCP of Resident’s Decline
Penalty
Summary
The facility failed to notify Resident #35’s healthcare proxy and family in a timely manner of ongoing changes in the resident’s condition and plan of care. The facility’s policy required timely notification of the resident, legal representative, and family member when there was a significant change in status, including physical, mental, psychosocial, life-threatening, or clinical changes, and required documentation of the date, time, person notified, and details of the notification. Resident #35 was admitted with diagnoses including acute respiratory failure, COPD, and peripheral vascular disease, was on hospice services, and later expired. The healthcare proxy activation form showed the resident no longer had capacity to make or communicate healthcare decisions. Progress notes documented multiple changes in condition, including weakness, unlabored breathing, a chest x-ray order that was later discontinued, Augmentin being started, nausea/vomiting with Compazine administration, wet cough, poor appetite, a COPD exacerbation treated with Morphine and Ativan, shallow respirations, left flank pain, hospice notification, and mottling of the feet. The medical record did not show that the healthcare proxy or family were notified of these ongoing changes or changes in the plan of care in a timely manner. During interviews, the DON said the resident’s activated healthcare proxy was a different daughter who lived out of state, and he believed she was informed of changes to the best of his knowledge, but he also stated that if notification was not documented, he would assume it did not occur. A nurse said there were multiple opportunities to update the family and that she could not find evidence the notifications occurred, though she recalled speaking to the healthcare proxy a few times and did not document those communications. The hospice nurse said she would expect facility staff to update the family when hospice made recommendations offsite. The Administrator stated she found no documentation supporting routine and timely notification and said timely would be right away, but never more than 48 hours.
Missing Wandering/Elopement Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #21 related to wandering and elopement risk. Resident #21 was admitted in June 2023 with dementia and had a Minimum Data Set assessment dated 3/3/26 showing a Brief Interview for Mental Status score of 0 out of 15, indicating severe cognitive impairment. The facility’s policy titled Elopement, revised on 1/8/26, stated that residents with any history of wandering or confusion with associated wandering, especially those with a history of elopement, would be identified and would have a care plan developed and implemented with specific approaches and time-measured goals. The medical record showed multiple events consistent with wandering or exit-seeking behavior, including a 1/9/26 progress note documenting increased confusion and anxiety about catching a person because his/her mother was waiting, and a 1/19/26 note stating the resident exited the unit, went through another unit, entered the elevator, and was found in the employee lounge while looking for his/her mom. After the resident moved to the new facility location on 2/4/26, the record did not include a care plan with interventions for wandering or elopement. An elopement risk assessment dated 3/6/26 indicated no contributing factors, no prior elopement attempts, no verbalizing statements about leaving, and no recent move, room change, or wandering, with no interventions deemed necessary. During survey observations on 3/10/26 and 3/11/26, the resident was seen self-propelling toward the front door and sitting by the window framed around the front door, and staff interviews confirmed the resident often asked to go home, gravitated toward the front doors, and had previously required a wander guard at the prior facility.
Care Plan Not Updated After HCP Revocation
Penalty
Summary
The facility failed to ensure the Comprehensive Care Plan for one resident was reviewed and revised by the interdisciplinary team after assessments, including the comprehensive and quarterly assessments, to reflect the resident’s current needs. The resident was admitted in July 2025 with diagnoses including adjustment disorder and a history of falls. An MDS assessment dated 10/7/25 showed the resident was cognitively intact with a BIMS score of 15/15 and had an invoked HCP. A physician progress note dated 12/16/25 stated the resident demonstrated capacity to make healthcare decisions and the HCP activation was revoked. A subsequent MDS assessment dated 1/6/26 showed the resident remained cognitively intact with a BIMS score of 13/15 and did not have an invoked HCP. However, the comprehensive care plan still listed a problem of cognitive loss/dementia with impaired decision making, an activated HCP, and a goal dated 1/1/26, and it did not show that the IDT reviewed or revised the plan after the revocation of the HCP activation. The DON and ADON both reviewed the record and stated they could not find documentation that the care plan had been reviewed or revised by the IDT after the last MDS assessment to reflect the change.
Pantry Refrigerator Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure mechanical equipment, specifically the refrigerator in House 4’s kitchen pantry, was maintained in safe operating condition. Surveyors observed the pantry refrigerator door being held shut by a plastic bin of oranges placed on the floor in front of the door, and tape was also placed on the top and sides of the refrigerator in an attempt to keep it closed. The refrigerator contained honeydew melons, salted butter, prepared desserts dated 3/10/26 and 3/11/26, and packages of meat products. During interviews, staff stated the refrigerator had not been closing properly since the prior day, but no immediate assessment had been completed when the issue was first reported. The senior cook said he had been told about the problem that morning but had not yet assessed or addressed it, and the Corporate Executive Chef later confirmed he had only just entered a work order and had not yet gone to House 4 to inspect the refrigerator. At the time of the later observations, the internal thermometer in the refrigerator read 52 degrees F and then 53 degrees F, while the Corporate Executive Chef stated refrigerator temperatures should be 41 degrees F or below and that all food items in the pantry refrigerator would need to be discarded.
Failure to Properly Label and Store Ophthalmic Medications
Penalty
Summary
The facility failed to ensure that ophthalmic medications were labeled, dated, and stored properly to maintain their efficacy and prevent potential infections. During an inspection of the Unit 3 Medication Cart, multiple boxes containing eye medications were found with handwritten dates ranging from November 2023 to January 2024. Specifically, bottles of Artificial Tears for several residents were labeled with dates indicating they had been opened for more than four weeks, and a bottle of Timolol 0.5% ophthalmic solution was not labeled with the date it was opened. Nurse #5, who was present during the inspection, was unaware of the recommended discard period for these medications and the associated risk of infection when used past their expiration date after opening. The Director of Nursing (DON) acknowledged the concern regarding the potential for infection from using eye drops beyond the recommended four-week period after opening. The facility's policy required staff to enter the date opened on the label of medications with shortened expiration dates, but this was not adhered to in this instance. The manufacturer's instructions for both Tears Naturale and Timolol 0.5% ophthalmic solution indicated that the medications should be discarded four weeks after opening to prevent infections, a guideline that was not followed, leading to the deficiency noted in the report.
Failure to Ensure Safe Temperature of Hot Beverages
Penalty
Summary
The facility failed to ensure hot beverages were served at a safe temperature, resulting in a burn injury to a resident. Resident #24, who had dementia, dysphagia, and muscle weakness, was unable to complete the Brief Interview for Mental Status and required set-up assistance for eating and drinking. On 2/2/24, the resident requested a cup of coffee from a CNA, who brewed the coffee using a single-serve hot beverage brewing system in the staff break room. The CNA did not measure the temperature of the coffee before serving it to the resident, who subsequently spilled the hot coffee on themselves, causing a burn on their abdomen. The burn area was described as a strip of redness that became darker and raised over the week following the incident. The surveyor's inspection of the unit's staff break room revealed the presence of the single-serve hot beverage brewing system but no thermometers or instructions for ensuring safe beverage temperatures. During interviews, the Director of Nursing confirmed that there was no policy or procedure in place to ensure hot beverages were served at safe temperatures, and the CNA involved in the incident stated that they had not received any education regarding serving hot liquids to residents. This lack of policy and training contributed to the incident and the resulting injury to the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 38 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
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 Edgartown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Nursing Center, Llc | 12.4 mi | ★★★★★ | 19 | 0 |
| Jml Care Center Inc | 13.1 mi | ★★★★★ | 0 | 0 |
| Royal Of Cotuit | 16.8 mi | ★★★★★ | 11 | 0 |
| Royal Megansett Nursing & Rehabilitation | 18.5 mi | ★★★★★ | 0 | 0 |
| Cape Regency Rehabilitation & Health Care Center | 20.3 mi | ★★★★★ | 0 | 0 |
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