Harbor's Edge — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Harbor's Edge was inspected 8 times between July 28, 2021 and September 3, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 39 violations under 30 distinct standards.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

08/15/2027

Administrator

Senece Midgett

Licensing inspector

Tiffany Jefferson

Inspector phone

(804) 317-0413

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

September 3, 2025Inspection4 violations

Inspection dates

09/03/2025, 09/09/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE

Technical assistance

22VAC40-73-310- Admission and retention of residents 22VAC40-73-450- Individualized service plans

Comments

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

Violations

22VAC40-73-260-A

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

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.
Staff # 1 acknowledged the record for Staff # 6, did not contain documentation of the staff person having certification in first aid.

Plan of correction

Staff #6 scheduled with the clinic to obtain first aid certification per regulatory requirement. An additional audit was completed on all new hires. No other staff identified.

22VAC40-73-450-E

Based on staff interview and review of resident records the facility failed to ensure that each resident’s individualized service plan (ISP) contained a signature and date of the resident or their legal representative.

Evidence

The ISPs for Resident # 3 (ISP dated 12/30/2024), Resident # 6 (ISP dated 6/152/2025), and Resident # 8 (ISP dated 9/26/2025), did not contain a resident or legal representative signature.
Staff # 2 acknowledged the ISPs in the residents files did not contain a resident or legal representative signature.

Plan of correction

ISP meetings have been scheduled for Resident #3, Resident #6, and Resident #8. All signatures will be obtained by the completion date. Additionally, all residents will be added to a tracking sheet that will include ISP due dates, dates for scheduled meetings, and checked off once signatures obtained. Signature sheets will be scanned into the EMR once meetings occur and will be noted on the tracking sheet.

22VAC40-73-430-H-2

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

The record for Resident # 7 did not contain a discharge statement.
Staff #1 and #2 acknowledged the resident file did not contain the discharge statement.

Plan of correction

The chart for Resident #7 will be updated with the appropriate written discharge statement per AL regulations and scanned into the EMR.

22VAC40-73-325-B

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.

Plan of correction

The fall risk assessment for Resident #5 was updated. An audit of all falls within the last 30 days will be completed to ensure that all fall risk assessments complied. Nurses were educated on this expectation.

July 22, 2024Inspection10 violations

Inspection dates

07/22/2024; 07/24/2024

Areas reviewed

Comments

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.

Violations

22VAC40-73-250-C

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

Staff #1 and Staff #2’s record does not include verification that the staff person has received a copy of their current job description.

Plan of correction

Staff #1 and Staff #2 will be instructed to go into Paylocity and sign the job descriptions that were sent to them by Human Resources. An audit will be completed on all new staff hired within the last six months to ensure a signed job description is signed in the system.

22VAC40-73-450-E

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

The ISPs for Resident #4 (dated 03/13/2024), Resident #5 (dated 03/07/2024), and Resident #7 (dated 09/30/2023) were not signed and dated by the resident or his legal representative.

Plan of correction

ISPs for Resident #4, Resident #5, and Resident #7 were corrected. ISPs were signed by their responsible parties prior to the submission of this plan of correction.

22VAC40-73-1140-B

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

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.

Plan of correction

A review of all Relias courses assigned to assisted living staff will be completed to ensure there are sufficient hours of cognitive training assigned and completed per standard.

22VAC40-73-680-D

Based on observation, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

During a medication observation with Staff #4 on 07/22/2024, a Reduced Sugar Mighty Shake was not available for administration to Resident #7.
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.

Plan of correction

The Dietary Manager notified, and the appropriate Mighty Shake was made available to the staff for the resident’s med pass. The Dietary Manager will make weekly rounds to ensure that the resident has the correct supplement available. It was identified during the inspection that the Prilosec order for Resident #2 was discontinued in error which resulted in the missed dose. The order was corrected by the end of the inspection.

22VAC40-73-450-F

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

Resident #5 admitted to the safe, secure environment on 11/16/2023; however, Resident #5’s ISP was not reviewed and updated to reflect this significant change.

Plan of correction

Corrected – Resident #5 ISP updated with significant change of condition as of 8/1/2024.

22VAC40-73-640-A

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

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.

Plan of correction

All identified medications were immediately removed from the carts during the inspection and will be audited weekly – This will be ongoing.

22VAC40-73-1090-A

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

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.

Plan of correction

A 100% audit was completed on all serious cognitive assessments to ensure the documentation was correctly completed. The Medical Director was notified of the deficient documentation from the inspection. The serious cognitive assessments for Resident #3 and Resident #5 will be corrected to reflect that the residents are unable to recognize danger or protect their own safety and welfare. All serious cognitive assessment forms will be checked by the Administrator, or designee upon admission to ensure they are completed correctly prior to being scanned into the resident’s EMR.

22VAC40-73-930-D

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

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.

Plan of correction

Staff will now document rounds in the POC charting in MatrixCare. Assistant Administrator updated the CNA charting to include documentation on their rounding. Education was provided on the expectation and importance of completing these rounds.

22VAC40-73-970-A

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

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.

Plan of correction

It was identified that the facility was deficient in the amount of fire drills for the year. Education was provided to the Director of Life Safety and Security on this standard during the inspection. The schedule for fire drills has been updated to reflect the appropriate shifts and unit to receive credit for compliance. Staff education will be ongoing.

22VAC40-73-260-A

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

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.

Plan of correction

Staff #1 will be scheduled for the next first aid class in the onsite clinic to bring them into compliance with this standard. A 100% audit of all new hires assigned to assisted living that provide direct care will be completed to ensure all follow this regulation. Any staff out of compliance will be scheduled and complete a first aid course within 30 days.

September 12, 2023Inspection11 violations

Inspection dates

09/12/2023

Areas reviewed

Technical assistance

22VAC40-73-450 22VAC40-73-1140

Comments

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.

Violations

22VAC40-90-40-B

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

The criminal history record report for Staff #2 (hired 01/03/2023) was obtained on 03/22/2023.

Plan of correction

A 100% audit has been conducted by Human Resources on all criminal history reports after the assisted living mock survey. Although this employee was identified at that time, the violation still exists due to the date obtained.

22VAC40-73-610-B

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

During a tour of the facility, the menu for the meals for the current week were not posted in an area conspicuous to residents.

Plan of correction

Corrected immediately – All dining menus are hanging in a conspicuous area in the dining room. We will be going towards the digital signage in the next few months.

22VAC40-73-40-B-8

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

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.

Plan of correction

Current licensure is now hanging up in a common area visible to the residents and the public.

22VAC40-73-310-D

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

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.

Plan of correction

Corrected immediately – All written assurances in place for the special care unit.

22VAC40-73-660-A

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

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.

Plan of correction

Corrected immediately – Staff involved were immediately educated on correct procedures. All staff will be educated on correct procedures when walking away from the medication cart during med pass by 10/6/2023.

22VAC40-73-1110-A

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

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.

Plan of correction

Documentation for Resident #3 completed and placed in chart.

22VAC40-73-50-B

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

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.

Plan of correction

Awaiting family response to have documents signed. Goal completion date to have documents signed and in the medical record is 10/6/2023.

22VAC40-73-640-A

Evidence

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.

Plan of correction

All expired medications removed immediately. Staff/supervisor education with implementation of ensuring medication cart checks are being completed timely, to include the assurance of expired medications being discarded – Will be completed by 10/6/2023.

22VAC40-73-1090-A

Evidence

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.

Plan of correction

Corrected immediately and placed in the charts.

22VAC40-73-440-B

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

The UAIs for Resident #3 (dated 09/01/2022) and Resident #4 (dated 12/16/2022) were not signed for approval by the administrator or designee.

Plan of correction

Corrected 9/29/2023 – Administrator’s approval signature obtained on the UAIs for Resident’s 3 and 4. 100% review to be completed on all updated UAIs for Administrator’s signature by 10/6/2023.

22VAC40-73-450-F

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

Resident #3 admitted to hospice on 11/28/2022; however, Resident #3’s ISP (dated 09/01/2022) did not indicate the resident began hospice services or reflect this significant change.

Plan of correction

100% audit completed on ISPs to reflect any significant changes to resident’s care including, but not limited to hospice care.

June 23, 2023Inspection1 violation

Inspection dates

06/23/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

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.

Violations

22VAC40-73-210-B

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

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.

Plan of correction

1. Review of all AL/MS education completed by the AL Manager. 2. Notifications sent out to AL/MS staff by the Manager with overdue courses for completion. 3. Manager will be notified monthly via Outlook calendar to audit Relias courses due for completion prior to the end of month. 4. Staff will be made aware of any courses overdue and will be given Time during their shift to complete courses with an expectation that if courses not completed timely, they may be removed from the schedule. 5. This process will occur monthly with reporting to Director of Nursing of the need for any process changes.

March 23, 2023Inspection0 violations

Inspection dates

03/23/2023, 05/10/2023

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 23, 2023Inspection1 violation

Inspection dates

03/23/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

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.

Violations

22VAC40-73-220-B

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

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.
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.
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.

Plan of correction

Individualized service plan for Resident #1 updated to reflect private duty services being provided by Staff #3. Audit of ISPs done for residents with private duty services to ensure they are updated with services provided. ISP for Resident #1 was corrected on 3/24/2023. Audits and correction of additional ISPs to be corrected by 4/17/2023. Record for Staff #3 corrected to reflect type and frequency of private duty services provided. Clinic staff will conduct 100% audit of all private caregivers for AL/MS residents to ensure records reflect the required information for compliance. The record for Staff #3 was updated with the type of services being provided to Resident #1 by Clinic Manager. Additionally, Staff #3 received an updated TB on 3/28/2023 provided by the Harbor's Edge Clinic nurse. A 100% audit was conducted on all private duty staff providing care for Assisted Living and Memory Support residents to identify any deficiencies in requirements in their records, if applicable. Private duty staff have been notified to report to the clinic to provide updated documents and/or receive an updated TB, if needed. Staff #3 received an updated PPD on 3/28/2023. Additional private duty staff information to be corrected by 4/17/2023.

July 25, 2022Inspection10 violations

Inspection dates

07/25/2022, 07/26/2022

Areas reviewed

Comments

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.

Violations

22VAC40-73-210-A

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

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.

Plan of correction

Staff #4 will receive the required training and documented completion. An audit will be conducted of all staff training to ensure completion and documentation in place. The Assisted Living manager/designee will conduct monthly audits of training to ensure compliance and report any findings and/or trends to the Quality Assurance committee.

22VAC40-73-440-B

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

The UAIs for Resident #2 (dated 03/25/2022 and 03/30/2022), Resident #3 (dated 12/23/2021), Resident #4 (dated 12/24/2021), and Resident #6 (dated 01/07/2022) were not signed for approval by the administrator or designee.

Plan of correction

All UAIs have been updated with appropriate signatures. All parties responsible for review and approval of UAIs were in-serviced on completion and approval in a timely manner. The Assisted Living manager/ designee will conduct audits for the next eight weeks to ensure compliance and report any findings and/or trends to the Quality Assurance committee.

22VAC40-73-330-A

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

Resident #1 (admitted 02/28/2022) did not have a copy of a mental health screen in their record.

Plan of correction

A mental health screening has been completed and included in the record for Resident # 1. The Assisted Living manager conducted an audit of all current residents to ensure a completed mental health screening was performed and included in the resident record. The Assisted Living manger/ designee will conduct audits for the next eight weeks of all new admissions to ensure completion, inclusion in the resident record and report any findings and/or trends to the Quality Assurance committee.

22VAC40-73-550-G

Based on record review, the facility failed to annually review the rights and responsibilities of residents with each staff person.

Evidence

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.

Plan of correction

An in-service was conducted with Staff #1, #2 and #4 to review and acknowledge resident rights and responsibilities of residents. All staff records will be audited to identify records not in compliance. The Human Resource Director/designee will ensure annual training reviewing and acknowledging resident rights and responsibilities of residents is complete and report any findings and/or trends to the Quality Assurance committee.

22VAC40-73-350-B

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

Resident #2 admitted into assisted living on 03/29/2022; however, the sex offender screening was completed on 7/25/2022.
Resident #4 admitted into the facility on 08/05/2021; however, the sex offender screening was completed on 08/30/2021.

Plan of correction

All current residents have sex offender screenings completed and documented. The Admissions Coordinator has been in-serviced regarding sex offender checks being performed and documented prior to admission. The Assisted Living manger/ designee will conduct audits for the next eight weeks for all new admissions to ensure compliance and report any findings and/or trends to the Quality Assurance committee.

22VAC40-73-940-A

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

The last inspection by the appropriate fire official was completed on 11/20/2019.

Plan of correction

The Norfolk Fire Department was contacted previously to schedule and annual fire inspection. The Life Safety Coordinator will contact the local fire department annually to schedule an inspection to ensure compliance with the standard.

22VAC40-73-325-B

Based on record review, the facility failed to ensure a fall risk rating is completed after a fall.

Evidence

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.
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.

Plan of correction

A fall risk rating assessment has been completed on resident #5 and #6. The Assisted Living manager/designee conducted audits to ensure that fall risk rating assessments have been completed on all current residents who have experienced a fall to date. The Assisted Living manager/ designee will in-service those responsible for completing the assessments to include frequency and required documentation. Audits will be conducted for the next eight weeks to ensure timely completion and report any findings and/or trends to the Quality Assurance committee.

22VAC40-73-440-A

Based on record review and interview, the facility failed to complete resident’s UAI at least annually.

Evidence

Two of the seven resident records reviewed did not have an updated UAI: Resident #5’s last UAI completed 03/17/2021 and Resident #7’s last UAI completed on 01/04/2021.
Staff #8 acknowledged the UAIs for Resident #5 and Resident #7 were not completed at least annually.

Plan of correction

Updated UAIs for residents #5 and #7 were completed on 7/25/2022. All current resident records were reviewed to identify any UAI’s not updated timely. The Assisted Living manager/designee conducted in-services for staff responsible for UAI completion. Audits will be conducted for the next eight weeks to ensure compliance and report any findings and/ or trends to the Quality Assurance committee.

22VAC40-73-250-C

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

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.

Plan of correction

Staff #1 and #2 employment records have been updated to include verification that a current job description has been provided to those staff members. The Human Resource manager/ designee will ensure that all employees are provided with and acknowledge receipt of their job description. The Human Resource manager/ designee will audit all new employee files for the next eight weeks to ensure that verification of a current job description is included in their employee record and report any findings and/or trends to the Quality Assurance committee.

22VAC40-73-1100-A

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

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.

Plan of correction

The approval for placement in a special care unit form has been signed with a summary of acknowledgement that the approval was received at the time of placement. It is now included in the resident record. An audit of required forms was conducted for all residents in the special care unit to ensure compliance. The Assisted Living manager/designee will ensure that all residents in need of special care unit placement has the appropriate paperwork completed and included in the resident record.

July 28, 2021Inspection2 violations

Inspection dates

07/28/2021

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 The Criminal History Record Report

Technical assistance

ISP dates were reviewed.

Comments

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.

Violations

22VAC40-73-1090-A

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

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…”
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.
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.
Staff #1 acknowledged Resident #2 was placed on the safe, secure environment prior to the resident being assessed in writing by an independent physician.

Plan of correction

An audit was conducted for all memory support residents to ensure an assessment was present by an independent physician regarding the need for a safe, secure environment prior to admission. Staff responsible for the admission process was in-serviced regarding paperwork requirements to the memory support unit prior to admission. All new admissions will be audited weekly for a period of 8 weeks to ensure required documents have been completed timely and included in the resident record. The audit results and any trends will be report to the Quality Assurance Committee.

22VAC40-73-860-G

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

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.
Additionally, a sink located within the new addition in Apartment 323 also was assessed at reaching 122.5°F
Staff #1 acknowledged the aforementioned temperatures from the hot water taps in rooms #419, #428, and #323.

Plan of correction

Maintenance personnel were immediately notified regarding water temperatures registering out of the appropriate degree range. Water temperatures were adjusted and rechecked by maintenance personnel as well as the Assisted Living Manager and Administrator. All water temperatures were reassessed and found to be in compliance. All residents were assessed and there were no negative outcomes due to the increased water temperatures. Maintenance personnel was in-serviced regarding the appropriate temperature range for the assisted living and memory care unit. Water temperatures will be checked routinely. Any variations will be reported to the Safety Committee.