Inspection Reports for
Commonwealth Senior Living at Leigh Hall
890 Poplar Hall Drive, NORFOLK, VA, 23502
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
63 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
An unannounced complaint inspection was conducted due to allegations regarding admission retention, staffing and supervision, discharge of residents, and resident care and related services.
Complaint Details
Complaint was received on 2025-06-27 regarding admission retention, staffing and supervision, discharge of residents, and resident care and related services. The evidence gathered did not support the allegations of non-compliance.
Findings
The investigation did not support the allegations of non-compliance with standards or law. However, a violation unrelated to the complaint was identified regarding failure to ensure required personal and social information was placed in and kept current in a resident's record.
Deficiencies (1)
Facility failed to ensure the personal and social information required in subsection A was placed in the person's record and kept current, specifically missing legal documents proving power of attorney for resident #1.
Report Facts
Number of residents present: 63
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is contact for questions |
| Staff #1 | Interviewed during inspection; unable to locate legal documents for resident #1 | |
| Staff #2 | Interviewed post-inspection; unable to locate legal documents for resident #1 |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 2
Date: Jun 12, 2025
Visit Reason
An unannounced complaint inspection was conducted on June 12, 2025, following a complaint received on June 2, 2025, regarding allegations in the area of Resident Care and Related Services.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2025-06-02 regarding allegations in Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection, including staffing deficiencies in the special care unit and unsecured medication storage.
Deficiencies (2)
Facility failed to ensure at least two direct care staff members were awake and on duty at all times in the special care unit when more than 20 residents were present.
Facility failed to ensure medications were stored in a locked area consistent with current standards of practice.
Report Facts
Number of residents present: 70
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 2
Residents in special care unit: 29
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Date: May 1, 2025
Visit Reason
An unannounced complaint inspection was conducted due to complaints received on 04/04/25, 04/14/25, and 04/29/25 regarding Staffing and Supervision, Resident Care and Related Services, and The Safe Secure Environment.
Complaint Details
The complaint investigation was substantiated in part, with violations found related to Resident Care and Related Services, specifically medication administration and documentation issues.
Findings
The investigation supported some of the allegations, identifying non-compliance in Resident Care and Related Services. Violations related to medication administration and documentation were found, including failure to administer medications as prescribed and incomplete medication administration records.
Deficiencies (2)
Facility failed to ensure medication was administered in accordance with physician's instructions, specifically Lorazepam and Trazadone were not administered as scheduled.
Medication Administration Record (MAR) did not include staff initials or reasons for omissions for Lorazepam and Trazadone on specified dates.
Report Facts
Residents present: 63
Resident records reviewed: 9
Staff records reviewed: 4
Resident interviews: 5
Staff interviews: 7
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Date: Mar 24, 2025
Visit Reason
The inspection was conducted in response to complaints received on 02/20/2025 and 03/03/2025 regarding allegations related to Staffing and Supervision and Resident Care and Related Services at the facility.
Complaint Details
Complaint related to allegations in Staffing and Supervision and Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, violations unrelated to the complaints were identified, including failure to ensure proper admission and retention of individuals with stage III dermal ulcers without physician documentation, and failure to secure medication storage areas.
Deficiencies (2)
Facility failed to ensure admission and retention policies were followed regarding residents with stage III dermal ulcers without documentation from an independent physician that the ulcer was healing.
Facility failed to ensure medications were stored in a locked area; medication cart on 2nd floor was observed unlocked and unstaffed.
Report Facts
Number of residents present: 63
Number of resident records reviewed: 2
Number of staff interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Unable to provide documentation that resident's sacral ulcer stage III was determined by an independent physician to be healing. | |
| Staff #2 | Acknowledged leaving the medication cart unlocked and unstaffed. |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: Jan 28, 2025
Visit Reason
An unannounced complaint inspection was conducted on January 28, 2025, following complaints received on January 13 and 17, 2025, regarding allegations in the areas of Staffing and Supervision and Resident Care and Related Services.
Complaint Details
The complaint investigation was triggered by allegations received on 01/13/2025 and 01/17/2025 concerning Staffing and Supervision and Resident Care and Related Services. The evidence supported some allegations related to Resident Care and Related Services. A violation notice was issued, and the licensee was given the opportunity to submit a plan of correction.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Two violations were cited related to failure to provide care as specified in the individualized service plan and failure to ensure general responsibility for residents' health, safety, and well-being, specifically involving a resident fall resulting in multiple injuries.
Deficiencies (2)
Facility failed to ensure the care and services specified in the individualized service plan are provided to each resident, resulting in a resident fall causing multiple rib fractures, a skin tear, and hospitalization.
Facility failed to assume general responsibility for the health, safety, and well-being of residents, evidenced by a resident fall during transfer causing serious injuries.
Report Facts
Number of residents present: 69
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of staff interviews conducted: 3
Date of resident fall: Jan 11, 2025
Hospital stay duration: 5
Plan of correction completion date: Mar 10, 2025
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Date: Nov 22, 2024
Visit Reason
An unannounced complaint inspection was conducted due to allegations related to Personnel, Staffing and Supervision, and Resident Care and Related Services received by VDSS Division of Licensing on 2024-11-14.
Complaint Details
The complaint was substantiated in part, specifically regarding Resident Care and Related Services. The facility failed to document required two-hour rounds for residents with dementia unable to use call bell systems on multiple dates.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. A violation notice was issued regarding failure to ensure required two-hour rounds for residents unable to use signaling devices.
Deficiencies (1)
Facility failed to ensure for each resident with an inability to use the signaling device that direct care staff made rounds no less than every two hours and documented the rounds including resident name, date, time, and staff member.
Report Facts
Number of residents present: 73
Number of resident records reviewed: 3
Number of staff interviews conducted: 3
Dates missing documented rounds for resident #1: 1
Dates missing documented rounds for resident #2: 3
Dates missing documented rounds for resident #3: 4
Inspection Report
Renewal
Census: 71
Deficiencies: 8
Date: Nov 12, 2024
Visit Reason
An unannounced renewal inspection was conducted to evaluate compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to post the current on-site person in charge, incomplete sex offender screening prior to admission, missing discharge documentation, incomplete individualized service plans, medication administration errors, unlabeled over-the-counter medications, expired emergency drinking water supply, and incomplete criminal history reports for staff.
Deficiencies (8)
Failed to develop and implement a procedure for posting the name of the current on-site person in charge conspicuously.
Failed to ascertain and document whether a potential resident was a registered sex offender prior to admission.
Failed to provide a dated discharge statement signed by the licensee or administrator at time of resident discharge.
Failed to complete comprehensive individualized service plans within 30 days after admission including all identified needs.
Medications were not administered in accordance with physician orders, including incorrect dosages and medications given without orders.
Over-the-counter medication was not kept in original container labeled with resident's name.
Facility failed to maintain a 96-hour supply of emergency food and drinking water; expired water was observed.
Criminal history record reports were not obtained on or prior to the 30th day of employment for staff.
Report Facts
Number of residents present: 71
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews with residents: 2
Number of interviews with staff: 3
Expired emergency water cases: 12
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
An unannounced complaint inspection was conducted on October 10, 2024, following a complaint received on September 23, 2024, regarding allegations in the areas of Admission, Retention, and Discharge of Residents; Resident Care and Related Services; and Staffing and Supervision.
Complaint Details
Complaint related to allegations in Admission, Retention, and Discharge of Residents; Resident Care and Related Services; and Staffing and Supervision. The evidence gathered did not support the allegations of non-compliance.
Findings
The investigation did not support the allegations of non-compliance related to the complaint. However, a non-complaint related violation was identified concerning medication administration without a valid physician order.
Deficiencies (1)
The facility failed to ensure no medication was started, changed, or discontinued without a valid order from a physician or other prescriber, specifically regarding administration of Lacosamide Tab 200 mg by mouth without a valid order on 8/30/24.
Report Facts
Number of residents present: 72
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff #4 | Named in medication administration finding regarding Lacosamide Tab 200 mg |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
An unannounced complaint inspection was conducted due to allegations related to Personnel, Staffing and Supervision, and Resident Care and Related Services received on 2024-09-06.
Complaint Details
The complaint was substantiated in part, specifically regarding Resident Care and Related Services. The complaint was received on 2024-09-06 and involved allegations in Personnel, Staffing and Supervision, and Resident Care and Related Services. Evidence and staff interviews confirmed failures in treatment provision and documentation.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations included failure to ensure timely physical examinations prior to admission, failure to update fall risk ratings after falls, and failure to provide and document medical treatments as ordered by physicians.
Deficiencies (3)
Facility failed to ensure a physical examination by an independent physician within 30 days preceding admission.
Facility failed to ensure fall risk rating was reviewed and updated after resident falls.
Facility failed to provide and document medical procedures or treatments ordered by a physician, including repositioning and application of foam dressing and calmoseptine ointment.
Report Facts
Residents present: 73
Resident records reviewed: 5
Staff records reviewed: 3
Resident interviews conducted: 3
Staff interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff #4 | Confirmed lack of documentation for resident #2's treatment according to physician orders |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: Aug 22, 2024
Visit Reason
An unannounced complaint inspection was conducted on August 22, 2024, following a complaint received on August 17, 2024, regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and the Safe Secure Environment.
Complaint Details
The complaint was substantiated in part, specifically in the area of Resident Care and Related Services. The complaint involved allegations about Staffing and Supervision, Resident Care and Related Services, and Safe Secure Environment, with evidence supporting non-compliance in Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations were found related to preliminary plan of care timing, missing signatures on individualized service plans, and medication administration errors.
Deficiencies (3)
Facility failed to ensure a preliminary plan of care was developed on or within 7 days prior to admission for resident #3.
Individualized service plan (ISP) for resident #1 was not signed and dated by the resident or legal representative.
Medications were not administered according to physician orders for resident #3, with insulin doses not matching blood sugar levels on specified dates.
Report Facts
Residents present: 72
Resident records reviewed: 4
Staff interviews conducted: 5
Resident interviews conducted: 6
Medication administration errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Monitoring
Census: 73
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
An unannounced monitoring inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector reviewed the facility's staffing schedule, policies for resident emergencies, and incident reporting, and completed a tour of the physical plant.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 6
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Date: Apr 3, 2024
Visit Reason
An unannounced complaint inspection was conducted due to complaints received on 2024-03-04 and 2024-03-27 regarding allegations in the areas of Admission Retention and Discharge of Residents and Resident Care and Related Services.
Complaint Details
The complaint investigation was substantiated in part, with non-compliance found in Resident Care and Related Services. The complaint was received by VDSS Division of Licensing on 2024-03-04 and 2024-03-27.
Findings
The investigation supported some, but not all, of the allegations, identifying non-compliance in Resident Care and Related Services. A violation notice was issued with deficiencies related to physical examinations, individualized service plan signatures, and medication administration records.
Deficiencies (3)
Facility failed to ensure a physical examination by an independent physician within 30 days preceding admission was on file, including a statement that the individual does not have prohibited conditions or care needs.
Facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or designee, and by the resident or legal representative.
Facility failed to ensure the Medication Administration Record (MAR) included any medication errors or omissions for medications scheduled on 03/13/24 at 9:00 p.m. and 10:00 p.m.
Report Facts
Number of residents present: 66
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 5
Inspection Report
Monitoring
Census: 62
Deficiencies: 5
Date: Dec 12, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws, including resident and staff records, emergency preparedness, medication administration, and facility conditions.
Findings
The inspection found multiple violations including failure to post the current on-site manager, incomplete uniform assessment instruments prior to admission and after significant changes, incomplete preliminary and individualized service plans, and an outdated annual fire inspection. Plans of correction were proposed for each deficiency.
Deficiencies (5)
Failed to develop and implement a procedure for posting the name of the current on-site person in charge conspicuously.
Failed to ensure the uniform assessment instrument (UAI) was completed prior to admission, annually, and after significant changes.
Failed to ensure a preliminary plan of care was developed on or within seven days prior to admission addressing basic resident needs.
Failed to ensure the individualized service plan (ISP) was completed within 30 days after admission including identified needs.
Failed to comply with the Virginia Statewide Fire Prevention Code by not having an annual fire inspection completed within the last year.
Report Facts
Number of residents present: 62
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 3
Date of last annual fire inspection: Feb 21, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is contact for questions |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 3
Date: Sep 19, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations regarding Admission Retention and Discharge of Residents and Resident Care and Related Services.
Complaint Details
The complaint was received on 2023-09-06 regarding allegations in Admission Retention and Discharge of Residents and Resident Care and Related Services. The evidence supported some allegations related to Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations were found related to failure to complete Uniform Assessment Instruments (UAI) and Individualized Service Plans (ISP) timely and upon significant changes in resident condition.
Deficiencies (3)
Facility failed to ensure the Uniform Assessment Instrument (UAI) was completed whenever there was a significant change in the resident's condition.
Facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission.
Facility failed to ensure the ISP was reviewed and updated as needed for a significant change in the resident's condition.
Report Facts
Number of residents present: 60
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 56
Deficiencies: 5
Date: Nov 14, 2022
Visit Reason
An unannounced renewal inspection was conducted on November 14 and November 17, 2022, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure proper assessments for residents with serious cognitive impairment, lack of written approval for placement in secure units, incomplete individualized service plans, insufficient emergency food and water supplies, and employment of a staff member with disqualifying criminal convictions. Plans of correction were proposed for each violation.
Deficiencies (5)
Failed to ensure prior to admission to a safe, secure environment, the resident was assessed by an independent clinical psychologist or physician for serious cognitive impairment due to dementia.
Failed to obtain written approval prior to placing a resident with serious cognitive impairment in a safe, secure environment.
Failed to ensure the comprehensive individualized service plan included a description of identified needs based upon the uniform assessment instrument.
Failed to ensure availability of a 96-hour supply of emergency food and drinking water.
Failed to ensure any person required to obtain a criminal history report was ineligible for employment if the report contained convictions of barrier crimes.
Report Facts
Number of residents present: 56
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Cases of water purchased: 30
Staff member hired date: Mar 21, 2022
Staff member termination date: Dec 2, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is contact for questions |
Inspection Report
Monitoring
Census: 58
Deficiencies: 8
Date: Dec 16, 2021
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with administrative, personnel, resident care, emergency preparedness, and other regulatory standards.
Findings
The facility was found to have multiple deficiencies including failure to implement infection control procedures, improper posting of required documents, incomplete individualized service plans, and noncompliance with fire safety inspection requirements.
Deficiencies (8)
Failed to ensure infection control procedures were implemented; resident glucometer mislabeled.
Facility failed to ensure required documents were posted in at least 12-point font size.
Failed to post listing of staff with current first aid or CPR certification.
Failed to post name of current on-site person in charge in a conspicuous place.
Failed to ensure all assessed needs were addressed on residents' individualized service plans (ISP).
Failed to comply with Virginia Statewide Fire Prevention code due to outdated fire inspection.
Fire and emergency evacuation drawings did not contain all required information.
Failed to post emergency telephone numbers by each telephone on fire and emergency evacuation plans.
Report Facts
Inspection dates: 2
Deficiency due date: Jan 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Named as current inspector conducting the inspection |
Inspection Report
Renewal
Census: 53
Deficiencies: 1
Date: Dec 4, 2020
Visit Reason
A renewal inspection was initiated on December 4, 2020 and concluded on December 11, 2020 to assess compliance with applicable standards and laws at Commonwealth Senior Living at Leigh Hall.
Findings
The inspection identified non-compliances with applicable standards, including a violation related to the facility's failure to ensure potentially harmful ordinary materials or objects were inaccessible to a resident with serious cognitive impairment. Consultation was provided on various care and documentation requirements.
Deficiencies (1)
Facility failed to ensure that ordinary materials or objects that may be harmful to a resident with serious cognitive impairment were inaccessible except under staff supervision.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Current Inspector | Named as the inspector conducting the inspection. |
| Staff #1 | Confirmed during discussion that the belt was an ordinary object that could be harmful to a resident. |
Viewing
Loading inspection reports...
