Inspection Reports for Edgeworth Park at New Town
5501 Discovery Park Boulevard, VA, 23188
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
64 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Aug 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-18 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related to allegations in Personnel and Resident Care and Related Services; the complaint was not substantiated.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Aug 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on July 18, 2025, regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated based on the investigation.
Report Facts
Number of residents present: 64
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Jul 16, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-08 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint related to Resident Care and Related Services received on 2025-05-08; investigation did not substantiate the allegations.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 3
Resident interviews conducted: 0
Inspection Report
Monitoring
Census: 76
Deficiencies: 1
Jul 16, 2025
Visit Reason
The inspection was a monitoring visit conducted on July 16, 2025, following a self-reported incident received on May 9, 2025, regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found non-compliance with applicable standards related to supervision of resident schedules, care, and activities, specifically regarding attention to specialized needs such as wandering from the premises. A violation was documented due to a resident with dementia exiting the secure unit, triggering the elopement protocol.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Number of residents present: 76
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Named as the current inspector conducting the inspection |
Inspection Report
Renewal
Census: 73
Deficiencies: 1
Apr 21, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards or laws related to medication administration timing, resulting in documented violations and a violation notice issued to the facility.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered within one hour before or after the standard dosing schedule, except for drugs ordered for specific times. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 8
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector who conducted the inspection and is contact for questions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 7, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 6/26/2024 and 7/1/2024 regarding allegations in the area of Resident Care and Related Service.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt of the inspection summary.
Complaint Details
Complaint related to allegations in Resident Care and Related Service; the allegations were not substantiated.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
Mar 7, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-28 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations, but violations unrelated to the complaint were identified, including failure to obtain proper documentation for private duty personnel and failure to update individualized service plans for significant changes in resident conditions.
Complaint Details
Complaint related to Resident Care and Related Services received on 2024-10-28. The evidence gathered did not support the allegation(s) of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to obtain proper documentation for private duty personnel from a licensed home care organization, including missing TB screenings and facility orientation. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for a significant change in a resident's condition. |
Report Facts
Number of residents present: 72
Number of resident records reviewed: 1
Number of staff/private duty records reviewed: 8
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the complaint investigation and inspection |
Inspection Report
Renewal
Census: 71
Deficiencies: 6
May 2, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection found non-compliance with several standards related to assessment instruments, individualized service plans, and medication administration. Violations were documented and a violation notice was issued to the facility.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure the uniform assessment instrument (UAI) was completed by qualified assessors and signed by the administrator or designee. |
| Facility failed to develop Individualized Service Plans (ISPs) containing all required elements. |
| Facility failed to have ISPs signed and dated by the licensee, administrator, or designee and by the resident or legal representative. |
| Facility failed to ensure ISPs contained descriptions of all needs and services identified. |
| Facility failed to ensure medications were administered within one hour before or after the scheduled dosing time. |
| Facility failed to administer medications in accordance with physician's or prescriber's instructions. |
Report Facts
Residents present: 71
Resident records reviewed: 16
Staff records reviewed: 6
Resident interviews: 4
Staff interviews: 4
Residents needing medication administration: 15
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Mar 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-02-12 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to follow their medication management plan, leading to missed medication dosages for a resident.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation. The complaint was related to Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| Facility failed to follow their medication management plan to ensure each resident's prescription and over-the-counter medications are filled and refilled timely to avoid missed dosages. |
Report Facts
Medication refill misses: 81
Residents present: 69
Resident records reviewed: 3
Staff interviews conducted: 2
Resident interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Mar 26, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-07 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance related to failure to provide supervision of a resident's schedule and specialized needs, specifically regarding assistance with APAP therapy for a resident with Moderate Obstructive Sleep Apnea.
Complaint Details
Complaint related: Yes. The evidence supported the allegation(s) of non-compliance with standards or law. Violations were issued related to failure to provide supervision of resident schedule and specialized needs.
Deficiencies (1)
| Description |
|---|
| The facility failed to provide supervision of the resident schedule and specialized needs, including ensuring compliance with APAP therapy for a resident during a one month trial. |
Report Facts
Number of residents present: 69
Resident records reviewed: 3
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Days resident received assistance: 14
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 4
Dec 6, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-11-25 regarding allegations related to personnel and resident care and related services at the facility.
Findings
The investigation found multiple violations including failure to ensure timely medication refills, improper storage of medications and dietary supplements, failure to properly label medical supplies, and incomplete documentation on the Medication Administration Record (MAR). Violations were substantiated and corrective plans were required.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting allegations of non-compliance with standards or law related to personnel and resident care.
Deficiencies (4)
| Description |
|---|
| Facility failed to implement a written plan ensuring residents' prescription medications and supplements are filled and refilled timely to avoid missed dosages. |
| Facility failed to ensure all medications and dietary supplements were stored consistent with current standards of practice. |
| Facility failed to properly label single-use and dedicated medical supplies. |
| Facility failed to have all required items on the Medication Administration Record (MAR), including diagnosis, condition, or specific indications, and failed to document effectiveness of PRN medications. |
Report Facts
Number of residents present: 78
Number of resident records reviewed: 9
Number of staff records reviewed: 4
Number of staff interviews conducted: 5
Medication missed dates for Resident #5: 3
Medication missed dates for Resident #9: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff #3 | Acknowledged that a bottle of Boost was unsecured during inspection | |
| Executive Director | Involved in corrective actions including audits and staff in-service trainings | |
| Director of Health Services | Responsible for audits and approving medications in electronic record system |
Inspection Report
Renewal
Census: 73
Deficiencies: 9
Apr 12, 2023
Visit Reason
The inspection was a renewal inspection conducted over multiple days (April 12, 13, and 21, 2023) to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including failure to perform required reviews for residents in the special care unit, incomplete tuberculosis risk assessments, missing fall risk assessments after falls, incomplete discharge statements, unsigned uniform assessment instruments, incomplete individualized service plans, lack of annual health inspection report, unlocked medication storage, and medication administration outside the facility's dosing schedule.
Deficiencies (9)
| Description |
|---|
| Failed to ensure six-month and annual reviews of appropriateness of resident placement in the special care unit. |
| Failed to ensure annual tuberculosis risk assessments were completed for residents. |
| Failed to ensure fall risk assessments were reviewed and updated after every fall. |
| Failed to ensure discharge statements included all required information. |
| Failed to ensure uniform assessment instrument forms were approved and signed by administrator or designee. |
| Failed to ensure individualized service plans contained descriptions of all identified needs/services. |
| Failed to obtain an annual inspection report from the Virginia Department of Health. |
| Failed to ensure medication storage cabinet or compartment was locked. |
| Failed to ensure medications were administered within one hour before or after the facility's standard dosing schedule. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 11
Number of staff records reviewed: 5
Number of resident interviews conducted: 4
Number of staff interviews conducted: 4
Dates of inspection: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the inspection |
| Executive Director | Named in multiple plans of correction addressing deficiencies | |
| Staff #1 | Acknowledged missing documents and medication cart issues during inspection | |
| Staff #6 | Acknowledged missing fall risk assessments | |
| Staff #3 | Observed administering medications outside dosing schedule | |
| Director of Health Services | L.P.N. | Responsible for audits and ensuring compliance with health-related plans of correction |
| Memory Care Director | Involved in medication cart audits and medication administration compliance |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Apr 12, 2023
Visit Reason
The inspection was conducted as a self-report complaint-related investigation to review compliance with staffing, supervision, resident care, and additional requirements for adults with serious cognitive impairments.
Findings
The inspection found non-compliance with applicable standards related to failure to provide adequate supervision for a resident with wandering behavior, including incomplete incident reporting and failure to follow the facility's Missing Resident Policy.
Complaint Details
The complaint was related to a resident elopement incident on 2/6/23 where the resident was found outside the facility. The facility did not follow its Missing Resident Policy and the incident report lacked a complete detailed account. The complaint was not substantiated as per the violation notice.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Named as the current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 6
Oct 3, 2022
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 9/14/2022 and 9/22/2022 regarding allegations in the areas of Staffing and Supervision, Resident Care, and Buildings and Grounds.
Findings
The investigation supported some but not all allegations, with non-compliance found in Resident Care. Multiple violations were cited related to tuberculosis risk assessments, fall risk assessments, individualized service plans, resident rights documentation, and medication management.
Complaint Details
Complaints were received regarding Staffing and Supervision, Resident Care, and Buildings and Grounds. The evidence supported some allegations related to Resident Care.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident. |
| Facility failed to ensure a fall risk rating was updated after a fall. |
| Facility failed to have the Individualized Service Plan (ISP) signed by the resident or legal representative. |
| Facility failed to ensure each resident's ISP contained a description of all needs/services identified. |
| Facility failed to ensure that the annual review of resident rights and responsibilities is filed in the resident's record. |
| Facility failed to implement a written plan for medication management. |
Report Facts
Number of residents present: 18
Number of resident records reviewed: 5
Number of staff records reviewed: 0
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Medications refused by Resident #2: 135
Medications/treatments refused by Resident #4: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 87
Deficiencies: 2
Jun 7, 2022
Visit Reason
The inspection was a renewal type conducted on June 7 and June 10, 2022, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations. Two specific violations were noted: failure to post a listing of staff with current first aid or CPR certification, and failure to prevent use of outdated, damaged, or contaminated medications.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a listing of all staff who have current certification in first aid or CPR is posted in the facility. |
| Facility failed to implement methods to prevent the use of outdated, damaged, or contaminated medications. |
Report Facts
Number of residents present: 87
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Inspection Report
Routine
Deficiencies: 0
Oct 28, 2021
Visit Reason
An initial inspection was initiated and concluded on 10/28/2021 to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection determined compliance with applicable standards or law, and no violations were documented.
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