Public Google reviewers rate this highly and often mention exceptional dining and food variety. Schedule a visit to confirm the fit.
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Public Google reviewers rate Harbor's Edge highly. Reviewers highlight: exceptional dining and food variety, spectacular waterfront and city views. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Harbor's Edge is highly regarded by long-term residents for its luxurious amenities, spectacular waterfront views, and exceptional dining options. While many praise the community for its social engagement and high-quality fitness programs, some visitors and families have expressed significant frustration regarding parking difficulties and the attitude of front-desk staff.
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Key Review Excerpts
“The dining is outstanding, there are so many great fitness and wellness opportunities, and the programs always keep life interesting and engaging.”
“As a resident for 18 years, my husband and I have been filled with new friendships, adventure & a strong sense of safety & well-being. My husband Bob passed away recently, and the health care staff helped him to pass with dignity & grace.”
“Living at Harbor's Edge the last 4 years has been like being on vacation! The building and our apartments are beautiful, the views of the Elizabeth River and the city of Norfolk are spectacular.”
Source: VA State Licensing Agency
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/3/2025 9:00 am- 1:00 pm; 9/9/2025 8:40 am- 6:03 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector conducted water temperature readings, call bells response time, and observed activities and meals. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Based on staff interview and review of resident records the facility failed to ensure that each resident?s individualized service plan ( ISP
Based on documentation review and interview, the facility failed to ensure that a copy of a written discharge statement signed by the administrator was retained in resident records. Evidence: 1. The record for Resident # 7 did not contain a discharge statement. 2. Staff #1 and #2 acknowledged the resident file did not contain the discharge statement.
Based on the record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated annually. Evidence: The record for Resident # 5 did not contain a recent fall risk assessment. The last fall risk assessment was dated 8/22/2024.
Based on a review of staff records, the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. Evidence: 1. The record for Staff # 6 (date of hire 6/11/2025), did not contain documentation of the staff member having first aid certification within the first 60 days of employment. 2. Staff # 1 acknowledged the record for Staff # 6, did not contain documentation of the staff person having certification in first aid.
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/22/2024 from 8:45 am to 4:45 pm and 07/24/2024 from 12:45 pm to 2:55 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, emergency preparedness drills, and medication carts. Water temperature was measured, and the call bell system was monitored. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of their current job description. Evidence: 1. Staff #1 and Staff #2?s record does not include verification that the staff person has received a copy of their current job description.
Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative when reviews and updates of the plan have been made. Evidence: 1. The ISP
Based on record review, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section. Evidence: 1. Staff #1 (hired 12/05/2023) did not have at least 10 hours of training in cognitive impairment within four months of their hire date.
Based on observation, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. During a medication observation with Staff #4 on 07/22/2024, a Reduced Sugar Mighty Shake was not available for administration to Resident #7. 2. During a medication observation with Staff #2 on 07/22/2024, it was documented Resident #2?s Prilosec 20 mg tablet was not administered at 7 am.
Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents are assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. The serious cognitive assessments for Resident #3 (dated 05/13/2024) and Resident #5 (dated 11/13/2023) indicate the resident is able to recognize danger or protect their own safety and welfare and the residents reside in a safe, secure environment.
Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #1 (hire date 12/05/2023) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #5 admitted to the safe, secure environment on 11/16/2023; however, Resident #5?s ISP
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: Senexon 8.6 mg-50 mg tablets expired 07/17/2024 and Prochlorperazine 10 mg tablets expired 07/20/2024 for Resident #5 and Calcium Citrate 630 mg tablets expired 07/2022 for Resident #10.
Based on interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. From 7/2023 to 7/2024, documentation provided by Staff #5 shows fire drills were conducted on 4 occasions within the assisted living: 12/29/2023, 02/22/2024, 03/14/2024, and 04/05/2024.
Based on interview, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility. Evidence: 1. Staff were unable to provide documentation of rounds no less often than every two hours for each resident with an inability to use the signaling device within the safe, secure environment.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/12/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 2 residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, and the staff schedule. Water temperature was measured, and the call bell system was monitored. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1. Resident #3 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs at the time of admission. Evidence: 1. There was no evidence of written assurance to Resident #3 or their legal representative documenting that the facility has the appropriate license to meet their care needs at the time of admission.
Based on observation, the facility failed to ensure that the current license is posted in the facility in a place conspicuous to the residents and the public. Evidence: 1. During a tour of the facility, the current license was not posted in the facility in a place conspicuous to the residents and the public.
Based on record review, the facility failed to ensure that the uniform assessment instrument is completed as required by 22VAC30-110 for private pay individuals. Evidence: 1. The UAI
Based on record review, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee. Evidence: 1. The criminal history record report for Staff #2 (hired 01/03/2023) was obtained on 03/22/2023.
Based on observation, the facility failed to ensure a medicine cabinet, container, or compartment be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice. Evidence: 1. During a medication observation with Staff #1 in the safe, secure environment, a cup with medications (3 tablets and 1 capsule) were noted on top of the medication cart. Staff #1 left the medications on top of the medication cart in the dining area unattended to administer medications to Resident #5 in their apartment.
Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. During a tour of the facility, the menu for the meals for the current week were not posted in an area conspicuous to residents.
Based on record review, the facility failed to ensure prior to admission to a safe, secure environment, residents are assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. The serious cognitive assessments for Resident #3 (dated 09/01/22) and Resident #4 (dated 06/28/21) indicate the resident is able to recognize danger or protect their own safety and welfare and the residents reside in a safe, secure environment.
Based on record review, the facility failed to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative. Evidence: 1. Resident #3 (admitted 09/29/2022) did not have written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative in their resident record.
Based on record review, the facility failed to review and update individualized service plans as needed for a significant change of a resident?s condition. Evidence: 1. Resident #3 admitted to hospice on 11/28/2022; however, Resident #3?s ISP
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. The following expired medications were observed in the medication carts at the facility: an unlabeled bottle of Aspirin 81 mg tablets expired 02/2023, Midodrine HCI 10 mg tablets expired 07/31/2023 for Resident #6, and Omeprazole DR 20 mg capsules expired 07/31/2023 for Resident #7.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/23/2023 from 10:20 am to 11:00 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/24/2023 regarding allegations in the area(s) of: Part III Personnel and Part VI Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to ensure all direct care staff attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Training also should include at least two of the required hours on infection control and prevention and when adults with mental impairments reside in the facility, at least four of the required hours on topics related to residents' impairments. Evidence: 1. Staff #3 (hire date 7/12/2021) worked as an RMA/CNA; however, Staff #3 did not have at least 12 hours of annual training in their record.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/23/2023 from 10:20 am to 12:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/14/2023 regarding allegations in the area(s) of: Part III Personnel and Part VI Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review and interview, the facility failed to meet the requirements listed under subdivisions A 2 through A 6 of this section in addition to the requirements under subdivision B when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents. Evidence: 1. Resident #1 admitted to the facility on 01/24/2023 with Staff #3 providing private duty services; however, the direct care or companion services provided by Staff #3 is not reflected on the Resident #1's individualized service plan. 2. Staff #2 acknowledged Staff #3 is not an employee of a licensed home care organization and was unable to provide in writing information on the type and frequency of the services to be delivered to Resident #1 by Staff #3. 3. The record for Staff #3 did not contain documentation of Staff #3?s qualifications for the types of direct care or companion services they are responsible for providing to Resident #1. Additionally, the TB evaluation in Staff #3?s record was completed on 07/16/2019 and is not consistent with the requirements of 22VAC40-73-250 D 1 through D 4 regarding tuberculosis that apply to private duty personnel.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/23/2023 from 10:20 am to 12:00 pm and 05/10/2023 from 8:35 am to 8:45 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Additional Comments/Discussion: LI and LA inspected the newly renovated safe, secure environment. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/25/2022 from 8:27 am to 4:30 pm and 07/26/2022 from 8:25 am to 10:20 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Observations by licensing inspector: medication pass, breakfast and lunch meal service and required postings. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description. Evidence: 1. The record for Staff #1 and Staff #2 did not include verification that the staff person has received a copy of their current job descriptions.
Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #1 (admitted 02/28/2022) did not have a copy of a mental health screen in their record.
Based on record review, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment. Evidence: 1. Resident #1 admitted to the special care unit on 03/02/2022; however, Resident #1 did not have documentation of approval for placement in a special care unit in the resident record.
Based on record review and interview, the facility failed to complete resident?s UAI
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. Resident #2 admitted into assisted living on 03/29/2022; however, the sex offender screening was completed on 7/25/2022. 2. Resident #4 admitted into the facility on 08/05/2021; however, the sex offender screening was completed on 08/30/2021.
Based on record review, the facility failed to ensure that the uniform assessment instrument is completed as required by 22VAC30-110 for private pay individuals. Evidence: 1. The UAI
Based on record review, the facility failed to ensure all direct care staff shall attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Evidence: 1. Staff #4 (hire date 2/13/2007) works as a RMA/CNA and does not have any documentation for training completed over the past year.
Based on record review, the facility failed to ensure a fall risk rating is completed after a fall. Evidence: 1. Upon review of the resident?s record, Resident #5 has falls documented in progress notes on 02/05/22, 03/01/2022, and 04/17/2022; however, there is no documentation of a fall risk rating being completed after each fall in the resident?s record. 2. Upon review of the resident?s record, Resident #6 had a fall documented in progress notes on 03/14/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident?s record.
Based on record review, the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The last inspection by the appropriate fire official was completed on 11/20/2019.
Based on record review, the facility failed to annually review the rights and responsibilities of residents with each staff person. Evidence: 1. The records of Staff #1, Staff #2, and Staff #4 do not include written acknowledgement of having been so informed of the review of the rights and responsibilities of residents.
A renewal inspection was initiated on 07-28-2021 and concluded on 10-14-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 33. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, activity calendar, fire and emergency drills, and menus submitted by the facility to ensure documentation was complete. One inspector and LA conducted the on-site portion of the inspection on 10-14-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. A new addition was inspected on 10-14-2021.
Description: Based on resident record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed in writing by an independent physician as having an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #2?s ?Interdisciplinary Notes? dated 01-22-2021 documented the resident transferred to memory support; and ?resident tolerating being in memory support locked unit?? 2. Resident #2?s ?Assessment of Serious Cognitive Impairment? form was signed and dated by an independent physician on 03-31-2021. The form was also checked ?no? documenting the resident is unable to recognize danger and protect his/her own safety and welfare. 3. Staff #1 confirmed resident #2 transferred to the safe, secure unit on 01-22-2021 and could not provide additional documentation of Resident #2 being assessed in writing by an independent physician as having an inability to recognize danger or protect his own safety and welfare prior to admitting to the safe, secure environment on 01-22-2021. 4. Staff #1 acknowledged Resident #2 was placed on the safe, secure environment prior to the resident being assessed in writing by an independent physician.
Description: Based on observation, the facility failed to ensure hot water at taps available to residents are maintained within a range of 105?F to 120?F. Evidence: 1. On 10-14-2021, during an inspection of the facility with Staff #7, the hot water taps sampled were not within the required range in the following areas in the safe, secure environment: Room 419 measured 121.5?F and Room 428 measured 120.5?F. 2. Additionally, a sink located within the new addition in Apartment 323 also was assessed at reaching 122.5?F 3. Staff #1 acknowledged the aforementioned temperatures from the hot water taps in rooms #419, #428, and #323.
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