Cycle 1
Health 2022-08-11 · Fire 2022-08-11
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Norfolk, VA
Harbor's Edge
5-star overall rating with 4-star inspections with 3 recent health deficiencies
One Colley Avenue, Norfolk, VA
(757) 233-0475
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
33
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-03-14
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.73
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.41
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
6.34
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.93
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.95
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
1.05
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.75
CMS adjusted RN staffing hours
Adjusted total hours
6.41
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
849
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63
Composite VBP score used to determine payment impact.
Payment multiplier
1.0178
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.33
Baseline 21.15% · Performance 18.04% · Measure score 7.33 · Achievement 7.33 · Improvement 7.06
Healthcare-associated infections
4.52
Baseline 5.63% · Performance 6.48% · Measure score 4.52 · Achievement 4.52 · Improvement 0
Total nurse turnover
3.35
Baseline 51.16% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
10
Baseline 6.42 hours · Performance 6.79 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 306 · Observed rate 7.19% · Lower 95% interval 7.22% |
| Discharge to community | 70.85% |
50.57%
20.3 pts better
|
Better than the National Rate · Eligible stays 331 · Observed rate 68.88% · Lower 95% interval 65.33% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.43% |
95.27%
4.2 pts better
|
Numerator 175 · Denominator 176 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 176 |
| Discharge self-care score | 58.99% |
53.69%
5.3 pts better
|
Numerator 82 · Denominator 139 |
| Discharge mobility score | 64.03% |
50.94%
13.1 pts better
|
Numerator 89 · Denominator 139 |
| Pressure ulcers or injuries, new or worsened | 1.14% |
2.29%
1.2 pts better
|
Numerator 2 · Denominator 176 · Adjusted rate 1.48% |
| Healthcare-associated infections requiring hospitalization | 6.48% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 180 · Observed rate 4.44% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 7.69% |
8.2%
0.5 pts worse
|
Numerator 4 · Denominator 52 |
| Staff flu vaccination coverage | 41.02% |
42%
1 pts worse
|
Numerator 105 · Denominator 256 |
| Discharge function score | 56.12% |
56.45%
0.3 pts worse
|
Numerator 78 · Denominator 139 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 163 · Denominator 163 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 34.04% |
25.2%
8.8 pts better
|
Numerator 32 · Denominator 94 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
91.2%
1.7 pts better
|
93.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 12.5% |
3.6%
8.9 pts worse
|
3.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 13.7% |
5.7%
8 pts worse
|
5.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
20.2%
7.2 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
15.0%
3.9 pts worse
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
15.7%
7.6 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.5%
0.8 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.5% |
1.6%
5.9 pts worse
|
1.7%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
22.2%
0.1 pts better
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 13.4% |
5.2%
8.2 pts worse
|
5.1%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
74.6%
17.1 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.3% · Q2 92.5% · Q3 95.0% · Q4 93.9% · 4Q avg 91.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
11.7%
3.5 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 7.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.0% |
73.6%
15.4 pts better
|
79.7%
9.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
22.0%
2.8 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 19.5% · Expected 18.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-10 · Fire 2019-09-10
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-04-11 · Fire 2018-04-11
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-09-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-15
F · Potential for more than minimal harm
2019-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-15
F · Potential for more than minimal harm
2019-09-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-12-23
E · Potential for more than minimal harm
2019-09-10
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-12-23
E · Potential for more than minimal harm
2019-09-10
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2019-12-23
E · Potential for more than minimal harm
2019-09-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-09-10
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-09-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-09-10
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2019-11-15
D · Potential for more than minimal harm
2018-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-05-30
D · Potential for more than minimal harm
2018-04-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-05-30
D · Potential for more than minimal harm
2018-04-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2018-05-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-03-14
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-28
D · Potential for more than minimal harm
2022-08-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-11
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-09-16
E · Potential for more than minimal harm
2019-09-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-10-25
E · Potential for more than minimal harm
2019-09-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-10
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-10
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-10
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-25
E · Potential for more than minimal harm
2018-04-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-05-21
E · Potential for more than minimal harm
2018-04-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-05-21
D · Potential for more than minimal harm
2018-04-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2018-05-21
D · Potential for more than minimal harm
2018-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-05-21
D · Potential for more than minimal harm
2018-04-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-05-21
D · Potential for more than minimal harm
2018-04-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2018-05-21
D · Potential for more than minimal harm
2018-04-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2018-05-21
D · Potential for more than minimal harm
2018-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-05-21
Penalties and ownership
What sits behind the stars
Ownership
L'heureux, Cathy
Corporate Director · Individual
Smith, Linda
Contracted Managing Employee · Individual
Torres, Dayanara
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Norfolk Health Care Center
Norfolk, VA
1-star overall rating with 2-star inspections with $157,300 in total fines with 23 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Signature Healthcare Of Norfolk
Norfolk, VA
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Portsmouth Health And Rehab
Portsmouth, VA
1-star overall rating with 1-star inspections with $156,213 in total fines with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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