Navigator Homes of Martha's Vineyard

Inspectors wroteBased 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. potentially hazardous substances and items were not left unlocked and easily accessible to residents in the clean utility room and in one resident's room (#303). 3. House 4a. secured and/or supervised kitchen sharps including chef knives,b. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly medication regimen reviews were maintained as part of the permanent medical record and failed to ensure recommendations made by the pharmacy consultant were addressed timely for three Residents (#4, #7, and #3), out of a total sample of 12 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to:1. Ensure the clean utility room, which contained topical treatments, was locked when not in direct supervision of a licensed nurse in two (#3 and #4) of three Houses; and2. Ensure for rooms #302, #303 and #306, that topical treatments were not left unsecured and unattended in the residents' rooms.

Inspectors wroteBased on document review and interview, the facility failed to notify Resident #35's Healthcare proxy (HCP) timely of ongoing changes to the Resident's care and condition for one of two discharged records reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for one Resident (#21), out of a sample of 12 residents. Specifically, the facility failed for Resident #21, to develop and implement a care plan related to a history of leaving the residential area and expressing a desire to leave the facility.

Inspectors wroteBased on records reviewed and interviews, for one Resident (#1) from a sample of 12 residents, the facility failed to ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly assessments to reflect the Resident's needs as required.

Inspectors wroteBased on observation and interview, the facility failed to ensure mechanical equipment, specifically a refrigerator, in one of three pantry kitchens was maintained in safe operating condition.

Inspectors wroteBased on review of the online Health Care Facility Reporting System (HCFRS: web-based system that health care facilities must use to report incidents and allegations of abuse, neglect, and misappropriation) and staff interview, the facility failed to ensure staff reported/reported timely to the Department of Public Health (DPH), bruises of unknown origin on two occasions for one Resident (#29), out of a total sample of 12 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial and functional needs for one Resident (#29), out of a total sample of 12 residents. Specifically, the facility failed to ensure a comprehensive care plan was developed to address the use of psychotropic medications that identified Resident specific target behaviors, non-pharmacological interventions, and measurable goals of treatment.

Inspectors wroteBased on document review, observation, and interview, the facility failed to maintain professional standards of practice for one Resident (#8), out of a total sample of 12 residents. Specifically, the facility failed to ensure physician's orders for compression stockings/edema care were clear and implemented as prescribed.

Inspectors wroteBased on record review and interview, the facility failed to ensure for one Resident (#133), out of a total sample of 12 residents, that the resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the Resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure targeted behaviors and signs and symptoms of potential adverse consequences were monitored for the use of the antipsychotic medication Quetiapine.

Inspectors wroteBased on observation, staff interview, and review of the manufacturers' recommendations for use, the facility failed to ensure that ophthalmic medications were labeled, dated, and stored to ensure the efficacy of the medication and prevent the potential for infection in 1 of 2 medication carts on 1 of 2 units inspected.

Inspectors wroteBased on observation, document review, record review, and interviews, the facility failed to ensure hot beverages were served at a safe temperature for one Resident (#24), which resulted in a burn, from a total sample of 12 residents.