Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elizabeth Adam Crump Health And Rehab during CMS and state inspections, most recent first.
Facility staff did not ensure a safe, clean, and homelike environment for two residents, as evidenced by dirty and damaged shower rooms, resident rooms with broken furniture, dirty sinks and toilets, sticky floors, and a lack of personal items. Multiple residents reported avoiding showers due to unclean conditions, and maintenance staffing was found to be insufficient to address ongoing repairs and cleaning needs.
A resident with multiple psychiatric and medical conditions received duplicate drug therapy and was exposed to unaddressed drug-to-drug interactions due to staff failing to communicate pharmacy alerts to the prescribing practitioner. Incorrect medication dosages were administered, and required notifications to the physician and pharmacist were not made, contrary to facility protocol.
A resident with multiple complex medical conditions was given double the prescribed dose of quetiapine on two occasions due to a transcription error, and staff failed to notify the physician or consult the pharmacy when severe drug interaction alerts appeared in the system. Interviews confirmed that staff did not follow protocols for provider notification, and the issue was identified during the survey.
Staff failed to ensure that several residents had access to their call bells, with repeated observations showing call bells placed on the floor and out of reach. Interviews with nursing staff, including RNs, LPNs, and CNAs, confirmed that ensuring call bell accessibility is a shared responsibility, but the facility lacked a written policy on this practice. Leadership acknowledged the expectation for call bell placement, but no supporting documentation was provided.
A resident who was alert, oriented, and dependent on staff for daily care was subjected to verbal abuse and neglect when a CNA repeatedly refused to provide milk at lunch in a loud and dismissive manner, despite milk being readily available. The resident became fearful of retaliation and reported that such treatment was common among staff. The dietary manager confirmed that milk could be provided upon request, highlighting the CNA's failure to meet the resident's needs.
Surveyors observed that staff failed to administer medications according to physician orders and facility policy, leaving medication cups at the bedsides of three residents without proper assessment or authorization for self-administration. In each case, medications were documented as given, but residents either did not take them as prescribed or were left to self-administer without oversight, and expired medications were also found at bedside.
A resident with multiple comorbidities and pre-existing wounds did not consistently receive ordered wound assessments, treatments, or nutritional supplements, and there were gaps in documentation and implementation of turning and repositioning interventions. These failures led to the development of new Stage 2 and Stage 3 pressure injuries and deterioration of existing wounds.
Staff did not consistently follow infection prevention protocols, as an LPN entered the kitchen without a required hairnet. The dietary manager confirmed that hair coverings are mandatory for all kitchen entrants, but the LPN only retrieved a hairnet after being observed without one.
A resident with severe cognitive impairment and exit-seeking behavior managed to exit through a window while under 1:1 supervision. The facility staff failed to update the care plan following this incident, despite the resident's known risk for elopement. The care plan, which included interventions like elopement risk assessment and 1:1 monitoring, was not revised after the event, indicating a deficiency in care plan management.
A resident with severe cognitive impairment managed to exit through a window while on 1:1 supervision due to inadequate supervision and communication barriers. The resident, who had a history of exit-seeking behavior, manipulated the window off its track and exited the building. The incident occurred during a shift change, and the CNA responsible for supervision was unable to prevent the elopement.
Two residents experienced significant medication errors due to the facility staff's failure to administer insulin and Trulicity according to physician orders. Insulin was administered late on multiple occasions, and Trulicity was not administered as prescribed. The Unit Manager emphasized the importance of following physician orders and contacting providers if there are delays.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment for residents on two of three nursing units. Multiple residents reported that their rooms were dirty and in disrepair, and that shower areas were so unclean that they avoided using them. Direct observations by surveyors confirmed that the shower room was dirty, mildewed, foul-smelling, and littered with trash and debris. The tile was chipped, grout was black in places, and a white crusted substance was present on the floor and walls. Resident rooms were found with broken window blinds, damaged furniture, dirty sinks and toilets, clogged drains, sticky and dirty floors, peeling baseboards, and stained bed divider curtains. Some rooms lacked basic personal items such as televisions, clocks, telephones, or radios, and had holes in the walls with unfinished repairs. Two residents were specifically identified as being affected by these conditions. One resident, with a history of femur fracture, asthma, pneumonia, anxiety, depression, and Hepatitis C, required assistance with activities of daily living and was alert with mild cognitive impairment. Another resident, with a history of stroke, anemia, gout, heart attack, diabetes, asthma, and atrial fibrillation, required extensive assistance and was alert and oriented. Both residents' living environments were found to be unsafe, unclean, and not homelike. Interviews with the new Director of Maintenance revealed that maintenance staffing had been insufficient, with only three employees responsible for repairs and upkeep across two large buildings, contributing to the ongoing issues.
Failure to Prevent Unnecessary Drug Therapy and Address Drug Interactions
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications, specifically related to duplicate drug therapy and unaddressed drug-to-drug interactions. The resident, who had multiple diagnoses including major depressive disorder, generalized anxiety disorder, and insomnia, was admitted with several medication orders, including escitalopram, fluoxetine, and quetiapine. Upon admission, an incorrect dosage of quetiapine was administered twice before being corrected. Additionally, a new order for buspirone was entered, which triggered pharmacy alerts for potential additive serotonergic effects and risk of serotonin syndrome due to interactions with other prescribed medications. There was no documentation that the physician or pharmacy had been consulted regarding these alerts. Interviews with facility staff revealed that nurses are expected to notify physicians and consult with pharmacists when pharmacy alerts for drug interactions occur. However, in this case, the responsible staff did not communicate the pharmacy warnings to the prescribing practitioner, and the practitioner was unaware of the interactions. The DON confirmed that it is the facility's expectation for nurses to notify physicians of such alerts, but this protocol was not followed, resulting in the resident receiving unnecessary and potentially harmful medications.
Failure to Administer Correct Medication Dose and Notify Providers of Drug Interaction Alerts
Penalty
Summary
Facility staff failed to order and administer the correct dose of quetiapine fumarate for a resident, resulting in the resident receiving double the prescribed amount on two occasions. The resident, who had multiple complex medical conditions including COPD, asthma, chronic respiratory failure, major depressive disorder, and moderate cognitive impairment, was admitted with specific medication orders from the hospital. However, discrepancies occurred during the transcription of these orders, leading to the administration of 25 mg of quetiapine instead of the intended 12.5 mg. The error was not identified until after the incorrect doses had been given. Additionally, when entering the resident's medications into the pharmacy system, multiple drug-to-drug interaction alerts were triggered, some of which were classified as severe. These included potential additive QT interval prolongation and increased risk of serotonin syndrome due to the combination of several psychotropic and other medications. Despite these alerts, there was no documentation that the physician was notified or that the pharmacy was consulted regarding the warnings. Interviews with facility staff, including an LPN and the DON, confirmed that the expectation was for nurses to notify physicians and consult with the pharmacy when such alerts occur. However, the staff did not follow these protocols, and the prescribing providers were not made aware of the medication errors or the significant drug interaction warnings. The deficiency was brought to the attention of the facility administration during the survey process.
Failure to Ensure Call Bell Accessibility for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that five residents had access to their call bells, as observed on two separate occasions. During initial and follow-up rounds, these residents were found in their beds with their call bells on the floor behind the head of the bed, making them inaccessible. Staff interviews confirmed that it is the responsibility of all nursing staff, including RNs, LPNs, and CNAs, to ensure call bells are within residents' reach before leaving the room. Despite this, the call bells remained out of reach for the identified residents during both observation periods. When questioned, the Director of Nursing and other staff members acknowledged the expectation that call bells should be accessible to residents at all times. However, the facility did not have a written policy addressing call bell placement, and staff referenced general professional standards and fall prevention guidelines that require call bells to be within easy reach, especially for residents at high risk for falls. The deficiency was communicated to facility leadership, but no additional information or documentation was provided regarding policies or procedures related to call bell accessibility.
Resident Subjected to Verbal Abuse and Neglect by CNA
Penalty
Summary
A resident with multiple medical conditions, including stroke, anemia, gout, heart attack, diabetes, asthma, atrial fibrillation, and vertigo, who was alert, oriented, and required extensive assistance for all activities of daily living, experienced neglect and abuse by a Certified Nursing Assistant (CNA). During an interview, the resident requested milk at lunch, which was available on the unit, but the CNA responded in a loud, curt, and dismissive manner, refusing to provide the milk and displaying frustration and anger. This interaction caused the resident to become fearful, whispering to the surveyor and expressing concern about possible retaliation for making requests. The resident also indicated that such treatment was common from multiple staff members. The dietary manager confirmed that milk was available at all times and could be provided upon request, contradicting the CNA's refusal. The CNA's repeated withholding of readily available goods and services, combined with the angry and dismissive manner, resulted in the resident experiencing fear and reluctance to speak up. The surveyor's observations and interviews with the resident and staff established that the environment was not free from abuse and neglect, as required by facility policy and regulations.
Failure to Administer Medications per Physician Orders and Facility Policy
Penalty
Summary
Facility staff failed to ensure that medications were administered in accordance with physician orders and accepted professional standards for three residents. During surveyor rounds, multiple instances were observed where medication cups containing various pills were left at residents' bedsides, rather than being administered directly and observed by nursing staff. In each case, the residents had not been assessed or care planned for self-administration of medications, and there was no documentation authorizing self-administration or bedside storage of medications. One resident, with a complex medical history including major depressive disorder, hypertension, diabetes, and cardiac conditions, was found with two medicine cups on her bedside table containing Tylenol, calcium, and a multivitamin. She reported that she did not want all the prescribed Tylenol and would dispose of unwanted pills herself, indicating that staff routinely left medications for her to take at her discretion. Review of her Medication Administration Record (MAR) showed that nurses had documented administration of these medications, despite the resident's statements and the physical evidence that the medications had not been taken as ordered. Another resident, with diagnoses including hypertension, chronic pain, and psychosis, was found with a medicine cup containing several tablets and multiple bottles of eye drops, one of which was expired. The resident was unable to provide details about the medications or how long they had been at her bedside. A third resident, with a history of restless leg syndrome, anemia, and diabetes, was observed with a medicine cup containing many pills, which she ingested only after being prompted by the surveyor. In all cases, the facility's own medication administration policy required that medications be administered at the time they are prepared, that the nurse observe the resident swallowing the medication, and that self-administration be authorized and care planned, none of which were followed for these residents.
Failure to Provide Consistent Pressure Ulcer Prevention and Care
Penalty
Summary
Facility staff failed to provide adequate pressure ulcer care and prevention for one resident, resulting in the development of new pressure injuries and deterioration of existing wounds. The resident, who had multiple complex medical diagnoses including hypertension, diabetes, morbid obesity, hemiplegia, and pre-existing wounds, was admitted with significant risk factors for pressure injury development. Despite being assessed as moderate risk on the Braden Scale and requiring extensive assistance with mobility and ADLs, the resident did not consistently receive the ordered interventions and assessments necessary for pressure ulcer prevention and management. Clinical record review revealed missed or incomplete wound assessments on specific dates, as well as gaps in the administration of prescribed treatments and nutritional supplements intended to promote wound healing. Documentation showed that the air mattress, which was ordered to reduce pressure, lacked evidence of being in place or regularly checked for functionality. Additionally, the care plan interventions for turning and repositioning were not consistently implemented or documented, with multiple instances of missing or incomplete CNA documentation regarding repositioning and ADL care. Further review of medication and treatment administration records identified multiple days where wound care treatments and supplements such as Prostat, MVI, and Zinc were not administered as ordered, either due to being on order, not available, or left blank. The facility's own policies required weekly skin risk assessments and documentation of interventions, but these were not consistently followed. The cumulative effect of these failures led to the resident developing new Stage 2 and Stage 3 pressure injuries and a lack of timely response to changes in wound status.
Failure to Ensure Staff Use Hair Coverings in Kitchen
Penalty
Summary
Facility staff failed to ensure adherence to infection prevention protocols in the kitchen, specifically regarding the use of hair coverings. On the observed date, an LPN was seen entering the kitchen area without wearing a hairnet, despite facility policy requiring all individuals in the kitchen to wear hair coverings. The LPN walked through the kitchen and out of the surveyor's view before later retrieving a hairnet, stating she had forgotten to put it on. Dietary staff and the dietary manager confirmed that hairnets are mandatory for anyone entering the kitchen. The deficiency was identified through direct observation, staff interviews, and review of facility documentation. No information was provided regarding any residents directly involved or affected at the time of the deficiency.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility staff failed to review and revise the care plan for a resident who exhibited exit-seeking behavior, resulting in the resident exiting through a window while under 1:1 supervision. The resident, who was admitted with severe cognitive impairment and a history of dementia, mood disorder, and anxiety, was placed on 1:1 supervision due to exit-seeking behaviors. Despite this, the resident managed to manipulate the window in their room and exit the facility, indicating a lapse in the effectiveness of the care plan and supervision. The care plan for the resident, which included interventions such as elopement risk assessment, use of a personal wander prevention device, and 1:1 monitoring, was not updated following the incident. The Assistant Director of Nursing (ADON) believed the care plan had been updated, but a review of the clinical record showed that the care plan had not been revised after the incident. The care plan was only revised on a later date, which did not address the immediate need for changes following the resident's elopement.
Resident Elopes Through Window Despite 1:1 Supervision
Penalty
Summary
The facility staff failed to provide adequate supervision for Resident #2, who was on 1:1 supervision due to exit-seeking behaviors. Despite being under direct supervision, Resident #2 managed to exit through a window in his room. The resident, who has severe cognitive impairment with a BIMS score of 1/15, was able to manipulate the window off its track and remove the screen, allowing him to exit the building. This incident occurred while the CNA assigned to 1:1 supervision was reportedly unable to communicate effectively due to a language barrier, which contributed to the failure in preventing the resident's elopement. Resident #2 was admitted with diagnoses including dementia, mood disorder, and anxiety, and had been placed on 1:1 supervision since May due to his exit-seeking behavior. On the day of the incident, the resident was observed to be agitated, and the CNA left the room momentarily to seek help, during which time the resident exited through the window. The window, which was designed to open only 5-6 inches as a safety measure, was manipulated by the resident, who had prior experience as a custodial worker, allowing him to remove it from the track without breaking it. Interviews with staff revealed that the incident occurred during a shift change, and the CNA responsible for 1:1 supervision was suspended pending investigation. The facility's policy on resident safety checks and 1:1 supervision was not effectively implemented, as evidenced by the resident's ability to exit the building. The incident highlighted a lapse in supervision and communication among staff, which allowed the resident to elope despite being under direct observation.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility staff failed to ensure that two residents were free from significant medication errors. For one resident, the staff did not administer insulin according to physician orders. The resident had orders for both long-acting and short-acting insulin, which were not administered at the prescribed times on multiple occasions in August and September 2024. The long-acting insulin was supposed to be given twice daily, but there were several instances where it was administered late. Similarly, the short-acting insulin, which was to be given before meals, was also administered late on numerous occasions. The Unit Manager confirmed that nurses should follow physician orders and contact the provider if there is a delay in medication administration. For another resident, the facility staff failed to administer Trulicity, a diabetes medication, as per physician orders. The medication was supposed to be given once a week, but the Medication Administration Record indicated that it was marked as "on order" without any notes of physician or resident notification. The Unit Manager reiterated the importance of following physician orders and reaching out to the provider if there is a delay in medication administration. The Administrator was informed of these findings, but no further information was provided.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 203 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glen Allen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parham Health Care & Rehab Center | 2.9 mi | ★★★★★ | 57 | 3 |
| The Laurels Of University Park | 4 mi | ★★★★★ | 1 | 0 |
| Cedarfield Pinnacle Living | 4.4 mi | — | 0 | 0 |
| Lakeside Health & Rehabilitation | 4.8 mi | ★★★★★ | 0 | 0 |
| Westport Rehabilitation And Nursing Center | 4.8 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.