Inspection Reports for
Commonwealth Senior Living at Leigh Hall
890 Poplar Hall Drive, NORFOLK, VA, 23502
Back to Facility Profile1 Inspection Summary
Inspection Reports Summary
Covers 30 inspections · Dec 2020 – Jun 2026Visit Reason
The page covers 30 inspections of Commonwealth Senior Living at Leigh Hall from December 4, 2020 to June 16, 2026, including complaint and routine inspections with areas reviewed, comments, violations, and plans of correction.
Complaint Details
21 inspections were prompted by complaints alleging issues in Resident Care and Related Services, Staffing and Supervision, and Safe Secure Environment. Some complaints were substantiated with violations issued; others were not supported by evidence.
Findings
Across that history VDSS cited 70 violations under 41 distinct standards. 23 of 30 visits ended with violations cited and 7 with none. 21 inspections were prompted by a complaint.
Deficiencies (262)
22VAC40-73-570-D: Facility failed to ensure emergency personnel received correct resident information during transport.
22VAC40-73-680-I: MAR did not document symptoms for PRN medications given to resident #1.
22VAC40-73-680-D: Medication administered contrary to physician's orders; Lorazepam given after discontinuation.
22VAC40-73-450-A: Preliminary plan of care not signed by resident or legal guardian.
22VAC40-73-450-C: Comprehensive ISP not completed within 30 days after admission.
22VAC40-73-260-A: Staff #3 and #4 lacked current first aid certification.
22VAC40-90-40-C: Staff #2 employed despite criminal record with barrier crime conviction.
22VAC40-90-40-B: Criminal history report for staff #3 not obtained within 30 days of employment.
22VAC40-73-660-A-1: Medication cart found unlocked and unstaffed during inspection.
22VAC40-73-640-A: Facility failed to implement written medication management plan ensuring timely refills.
22VAC40-73-1090-A: Resident admitted to safe secure environment without proper assessment of serious cognitive impairment.
22VAC40-73-1100-A: Facility failed to obtain required written approval prior to placing resident in safe secure environment.
22VAC40-73-110-1: Staff failed to be considerate and respectful; verbal abuse incident substantiated.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-450-E: ISP not signed by preparer nor resident or legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures not provided or documented as ordered by physician.
22VAC40-73-200-B: Direct care staff provided services beyond scope of practice and training.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-380-B: Personal and social information not current; legal representative documentation missing.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-980-H: Facility failed to maintain 96-hour supply of emergency food and drinking water.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-90-40-B: Criminal history report not obtained on or before 30th day of employment for staff #3.
22VAC40-73-680-G: Over-the-counter medication not kept in original container labeled with resident’s name.
22VAC40-73-680-D: Medications administered not in accordance with physician’s orders; unapproved medications given.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-380-B: Personal and social information not current; legal representative documentation missing.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-980-H: Facility failed to maintain 96-hour supply of emergency food and drinking water.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-90-40-B: Criminal history report not obtained on or before 30th day of employment for staff #3.
22VAC40-73-680-G: Over-the-counter medication not kept in original container labeled with resident’s name.
22VAC40-73-680-D: Medications administered not in accordance with physician’s orders; unapproved medications given.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-380-B: Personal and social information not current; legal representative documentation missing.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-980-H: Facility failed to maintain 96-hour supply of emergency food and drinking water.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-90-40-B: Criminal history report not obtained on or before 30th day of employment for staff #3.
22VAC40-73-680-G: Over-the-counter medication not kept in original container labeled with resident’s name.
22VAC40-73-680-D: Medications administered not in accordance with physician’s orders; unapproved medications given.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-380-B: Personal and social information not current; legal representative documentation missing.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-980-H: Facility failed to maintain 96-hour supply of emergency food and drinking water.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-90-40-B: Criminal history report not obtained on or before 30th day of employment for staff #3.
22VAC40-73-680-G: Over-the-counter medication not kept in original container labeled with resident’s name.
22VAC40-73-680-D: Medications administered not in accordance with physician’s orders; unapproved medications given.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-380-B: Personal and social information not current; legal representative documentation missing.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-980-H: Facility failed to maintain 96-hour supply of emergency food and drinking water.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-90-40-B: Criminal history report not obtained on or before 30th day of employment for staff #3.
22VAC40-73-680-G: Over-the-counter medication not kept in original container labeled with resident’s name.
22VAC40-73-680-D: Medications administered not in accordance with physician’s orders; unapproved medications given.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-380-B: Personal and social information not current; legal representative documentation missing.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-980-H: Facility failed to maintain 96-hour supply of emergency food and drinking water.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-90-40-B: Criminal history report not obtained on or before 30th day of employment for staff #3.
22VAC40-73-680-G: Over-the-counter medication not kept in original container labeled with resident’s name.
22VAC40-73-680-D: Medications administered not in accordance with physician’s orders; unapproved medications given.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-380-B: Personal and social information not current; legal representative documentation missing.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-980-H: Facility failed to maintain 96-hour supply of emergency food and drinking water.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-90-40-B: Criminal history report not obtained on or before 30th day of employment for staff #3.
22VAC40-73-680-G: Over-the-counter medication not kept in original container labeled with resident’s name.
22VAC40-73-680-D: Medications administered not in accordance with physician’s orders; unapproved medications given.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-450-E: ISP not signed by preparer or resident/legal guardian.
22VAC40-73-450-F: ISP not reviewed and updated for significant changes in resident condition.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered.
22VAC40-73-200-B: Staff provided care beyond scope; CPR given without certification.
22VAC40-73-70-D: Facility failed to submit amended incident report including resident death.
22VAC40-73-320-A: Physical exam did not contain required statement about prohibited conditions.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-380-B: Personal and social information not current; legal representative documentation missing.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-980-H: Facility failed to maintain 96-hour supply of emergency food and drinking water.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-90-40-B: Criminal history report not obtained on or before 30th day of employment for staff #3.
22VAC40-73-680-G: Over-the-counter medication not kept in original container labeled with resident’s name.
22VAC40-73-680-D: Medications administered not in accordance with physician’s orders; unapproved medications given.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission.
22VAC40-73-680-I: MAR did not include medication errors or omissions, date/time given, or staff initials.
22VAC40-73-680-D: Medication administered not in accordance with physician’s instructions.
22VAC40-73-660-A: Medication cart unlocked and unstaffed during inspection.
22VAC40-73-1130-A: Safe secure unit understaffed with only two awake direct care staff for 29 residents.
Report Facts
Violations cited: 70
Distinct standards: 41
Inspections on page: 30
Inspections with violations: 23
Complaint visits: 21
Loading inspection reports...
