Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
57 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Renewal
Census: 57
Deficiencies: 4
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility Harbor's Edge on September 3 and September 9, 2025.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to staff first aid certification, fall risk assessment updates, retention of discharge statements, and signatures on individualized service plans.
Deficiencies (4)
Facility failed to ensure each direct care staff member had current first aid certification within 60 days of employment.
Facility failed to ensure that a fall risk assessment was reviewed and updated annually.
Facility failed to ensure that a copy of a written discharge statement signed by the administrator was retained in resident records.
Facility failed to ensure that each resident's individualized service plan contained a signature and date of the resident or their legal representative.
Report Facts
Number of residents present: 57
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of interviews with residents: 2
Number of interviews with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff #6 | Named in first aid certification deficiency | |
| Staff #1 | Acknowledged lack of first aid certification documentation for Staff #6 and discharge statement deficiency | |
| Staff #2 | Acknowledged discharge statement and individualized service plan signature deficiencies |
Inspection Report
Renewal
Census: 49
Deficiencies: 10
Date: Jul 22, 2024
Visit Reason
The inspection was a renewal type conducted on July 22 and July 24, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to cognitive impairment assessments, staff training, documentation, medication management, individualized service plans, resident safety rounds, and fire drill frequency. The facility was cited for non-compliance and required to submit plans of correction.
Deficiencies (10)
Failed to ensure residents were assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission.
Direct care staff did not attend at least 10 hours of cognitive impairment training within four months of employment.
Failed to maintain personal and social data on staff including verification of receipt of current job description.
Direct care staff lacked current certification in first aid.
Individualized service plans were not signed and dated by the licensee or resident/legal representative when updated.
Failed to review and update individualized service plans for significant changes in resident condition.
Failed to implement written medication management plan to prevent use of outdated medications.
Medications were not administered according to physician's instructions, including missed doses and unavailable supplements.
Failed to document direct care staff rounds at least every two hours for residents unable to use signaling devices.
Failed to ensure fire and emergency evacuation drill frequency and participation met state code requirements.
Report Facts
Number of residents present: 49
Number of resident records reviewed: 9
Number of staff records reviewed: 4
Number of interviews with residents: 4
Number of interviews with staff: 4
Expired medications observed: 3
Fire drills conducted: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Named in findings for lack of cognitive impairment training, missing job description verification, and lack of first aid certification | |
| Staff #2 | Named in finding for missing job description verification and medication administration observation | |
| Staff #4 | Named in medication observation where supplement was unavailable | |
| Staff #5 | Named in fire drill documentation evidence | |
| M. Tess Pittman | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 46
Deficiencies: 11
Date: Sep 12, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to resident assessments, documentation, license posting, medication management, and staff record compliance. Plans of correction were noted for each violation.
Deficiencies (11)
Failed to ensure residents are assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission.
Failed to ensure determination of appropriateness of placement in the special care unit for residents with serious cognitive impairment.
Failed to ensure the current license is posted in a place conspicuous to residents and the public.
Failed to obtain written acknowledgment of receipt of disclosure by resident or legal representative.
Failed to provide written assurance documenting the facility has appropriate license to meet care needs at admission.
Failed to ensure uniform assessment instrument (UAI) is completed and signed by administrator for private pay individuals.
Failed to review and update individualized service plans for significant changes in resident condition.
Failed to ensure menus for meals are dated and posted in an area conspicuous to residents.
Failed to implement written plan for medication management including prevention of outdated medications and proper disposal.
Failed to ensure medications are stored in a medicine cabinet or container consistent with standards of practice.
Failed to obtain criminal history record report on or prior to the 30th day of employment for an employee.
Report Facts
Number of residents present: 46
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Date of admission for Resident #3: Sep 29, 2022
Date of expired Aspirin medication: 202302
Date of expired Midodrine HCI medication: Jul 31, 2023
Date of expired Omeprazole DR medication: Jul 31, 2023
Date criminal history report obtained for Staff #2: Mar 22, 2023
Date Staff #2 hired: Jan 3, 2023
Inspection Report
Monitoring
Deficiencies: 1
Date: Jun 23, 2023
Visit Reason
The inspection was a monitoring visit conducted on June 23, 2023, following a self-reported incident received on May 24, 2023, regarding allegations related to personnel and resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to ensure all direct care staff attended the required annual training hours.
Deficiencies (1)
Facility failed to ensure all direct care staff attend at least 18 hours of training annually, with exceptions for licensed health care professionals or certified nurse aides who must attend at least 12 hours, including infection control and mental impairment-related topics.
Report Facts
Staff records reviewed: 1
Resident interviews conducted: 2
Staff interviews conducted: 2
Training hours required: 18
Training hours required: 12
Hire date: Jul 12, 2021
Inspection Report
Monitoring
Census: 42
Deficiencies: 1
Date: Mar 23, 2023
Visit Reason
The inspection was a monitoring visit conducted on March 23, 2023, following a self-reported incident received on March 14, 2023, regarding allegations in personnel and resident care areas.
Findings
The investigation supported the self-report of non-compliance with regulations related to private duty personnel not employed by a licensed home care organization providing direct care or companion services. Violations were issued regarding failure to document services in individualized service plans and staff qualifications, including outdated tuberculosis evaluations.
Deficiencies (1)
Facility failed to meet requirements for private duty personnel not employed by a licensed home care organization providing direct care or companion services, including lack of documentation in individualized service plans and staff qualifications.
Report Facts
Number of residents present: 42
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Date of admission for Resident #1: Jan 24, 2023
Date of TB evaluation for Staff #3: Jul 16, 2019
Date of updated ISP correction for Resident #1: Mar 24, 2023
Date of updated TB for Staff #3: Mar 28, 2023
Deadline for correction of additional ISPs and private duty staff information: Apr 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
The inspection was a monitoring visit conducted on March 23, 2023 and May 10, 2023 to review the physical plant including the building and grounds of the assisted living facility Harbor's Edge.
Findings
The inspection found no violations of applicable standards or laws. The newly renovated safe, secure environment was inspected and deemed compliant.
Inspection Report
Renewal
Census: 36
Deficiencies: 10
Date: Jul 25, 2022
Visit Reason
The inspection was a renewal type conducted on July 25 and 26, 2022, to assess compliance with applicable standards and laws for the assisted living facility Harbor's Edge.
Findings
The inspection found multiple violations related to resident placement approvals, staff training, documentation of job descriptions, fall risk assessments, mental health screenings, sex offender screenings, completion of uniform assessment instruments, annual resident rights reviews, and fire safety inspections. Plans of correction were submitted for all deficiencies.
Deficiencies (10)
Failed to obtain written approval for placement of a resident with serious cognitive impairment in a special care unit.
Failed to ensure all direct care staff attended required annual training hours.
Failed to maintain personal and social data on staff including verification of receipt of current job descriptions.
Failed to ensure fall risk rating was completed after resident falls.
Failed to conduct mental health screening prior to admission when indicated.
Failed to ascertain and document sex offender status prior to admission.
Failed to complete resident Uniform Assessment Instrument (UAI) at least annually.
Failed to ensure UAI was signed for approval by administrator or designee for private pay individuals.
Failed to annually review rights and responsibilities of residents with each staff person.
Failed to comply with Virginia Statewide Fire Prevention Code due to lack of annual fire inspection.
Report Facts
Number of residents present: 36
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Dates of inspection: Inspection conducted on 07/25/2022 and 07/26/2022
Last fire inspection date: Nov 20, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Named in deficiencies related to job description verification and resident rights training | |
| Staff #2 | Named in deficiencies related to job description verification and resident rights training | |
| Staff #4 | Named in deficiencies related to training documentation and resident rights training | |
| Staff #8 | Acknowledged missing annual UAI completion for residents | |
| Resident #1 | Named in deficiencies related to placement approval and mental health screening | |
| Resident #2 | Named in deficiencies related to sex offender screening and UAI signature | |
| Resident #3 | Named in deficiency related to UAI signature | |
| Resident #4 | Named in deficiency related to sex offender screening and UAI signature | |
| Resident #5 | Named in deficiencies related to fall risk rating and UAI completion | |
| Resident #6 | Named in deficiencies related to fall risk rating and UAI signature | |
| Resident #7 | Named in deficiency related to UAI completion |
Inspection Report
Renewal
Census: 33
Deficiencies: 2
Date: Jul 28, 2021
Visit Reason
A renewal inspection was initiated on 07-28-2021 and concluded on 10-14-2021 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified non-compliance with standards including failure to ensure a resident was assessed in writing by an independent physician prior to admission to a safe, secure environment, and failure to maintain hot water temperatures within the required range at taps available to residents.
Deficiencies (2)
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.
Facility failed to ensure hot water at taps available to residents are maintained within a range of 105°F to 120°F.
Report Facts
Resident census: 33
Water temperature: 121.5
Water temperature: 120.5
Water temperature: 122.5
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