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 August 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.
Call bells were left out of reach for multiple residents, including bells tangled with a roommate’s bell, lying on the floor under beds, clipped out of reach, or tied behind a headboard. Staff interviews confirmed the bells should have been accessible for residents to summon help, and one resident with intact cognition, another with autistic disorder, and others with significant physical impairments were all observed without usable access to their call lights.
Unsafe and Unhomelike Resident Environment: Surveyors observed multiple resident rooms and bathrooms with leaking sinks, broken bed equipment, exposed wall damage, missing baseboards, rust, peeling paint, and sewage-like odor in a bathtub area. Several rooms had dirty floors with debris and food remains, and residents on one unit reported excessive heat while temperatures in rooms, the hallway, and the dining room remained in the 80s. The maintenance director acknowledged several areas needed repair or renovation and that the unit’s A/C had been broken.
Failure to Provide Required ADL and Hygiene Care: Staff failed to provide dependent residents with needed bathing/showering, dressing, and incontinence care. One resident with CHF and DM had no showers documented for several months despite being dependent for bathing, another resident was observed visibly soiled with a saturated brief and call bell out of reach, and a third resident with CVA, hemiplegia, DM, and PTSD had multiple missed showers/baths and was observed with dirty, oily hair. Staff interviews and record review showed bathing was expected at least twice weekly, but the care was not consistently provided or documented.
A facility failed to promptly notify the physician and/or responsible party in two cases. One resident with hypothyroidism did not receive levothyroxine at the scheduled time because the medication was unavailable, and there was no documented physician or RP notification. Another resident with ESRD, DM, PVD, and gout developed left great toe pain, swelling, and bloody drainage that progressed to suspected cellulitis, but staff did not notify the physician when the change in condition first occurred.
A resident was repeatedly observed lying in bed with O2 tubing around the ears and no ear protectors in place. An LPN later confirmed the resident should have had the protectors, but they were still not being used after the issue was brought to her attention. Facility guidance stated that evidence-based pressure injury prevention interventions should be implemented and communicated to relevant staff.
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.
Call bells left inaccessible to residents
Penalty
Summary
The facility failed to ensure that resident call bells were accessible and within reach for six residents. Surveyors observed multiple call bells lying on the floor, tangled with a roommate’s call bell, clipped out of reach, or placed behind a headboard and tied around a fall mat. In several instances, staff interviews confirmed that the call bells were not positioned so the residents could use them to summon assistance. For one resident with chronic kidney disease, type 2 diabetes, morbid obesity, osteoarthritis, hemiplegia, muscle weakness, contracture of the left hand, cognitive communication deficit, anxiety, and hypertension, the call bell was observed intertwined with a roommate’s call bell and lying on the floor under the bed. The resident’s BIMS score was 15 out of 15, indicating intact cognition. A CNA stated the call bell was used so residents could call for help, but the bell remained inaccessible during repeated observations. For another resident with autistic disorder, the call bell was also intertwined with a roommate’s call bell and lying on the floor under the roommate’s bed. When asked how help would be summoned after a fall, the resident pointed toward the middle of the room and attempted to reach the bell but could not. A CNA confirmed the resident would not have been able to use the call light because it was tangled under the roommate’s bed. A third resident, who used a manual wheelchair and required substantial to maximal assistance for toileting and toilet transfers, had a bathroom call bell that could be activated by pulling a lever, but there was no pull cord accessible from the floor. The button was mounted above the toilet paper dispenser near the grab bar, approximately six feet from the bathroom entrance. The resident stated she used the bathroom when needed and pressed the button for staff assistance, but was unsure whether she could reach it if she fell. Staff interviews indicated the call bell should have a string long enough to reach from the floor. Additional residents were observed with call bells out of reach in their rooms. One resident with malignant neoplasm of the mouth, respiratory failure with hypoxia, repeated falls, dysphagia, cognitive communication deficit, and traumatic brain injury had the call light clipped to the bed out of reach while sitting in a wheelchair eating breakfast. Another resident who was blind had the call bell lying on the floor under the bed and stated she preferred it clipped to her pillow so she could reach it. A final resident had the call bell behind the headboard and tied around a fall mat, and an LPN stated it should not have been positioned that way and should have been in reach of the resident.
Unsafe and Unhomelike Resident Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for multiple residents across resident rooms, bathrooms, common areas, and one bathroom tub area. Surveyors observed a leaking sink with a nonfunctioning cold-water handle in one resident’s room, a bathroom sink running freely for another resident over multiple observations, and several bathrooms with visible wall damage, exposed sheetrock, peeling paint, missing baseboards, water damage, and basins placed under sinks to catch leaks. One resident’s bed was observed broken, with the foot board coming apart and the mattress unable to lower flat at one point. In another room, the bathroom showed significant visible damage around the toilet and sink, and the maintenance director stated some rooms still had issues that required renovation and were not homelike. Several residents were also observed in rooms with unclean floors or excessive heat. In two resident rooms, the floors had scattered dirt, debris, clumps of fuzzy black material, smeared brown material, and even a partially eaten orange, with conditions remaining unchanged over repeated observations across several days. On Unit C, residents and staff reported the air conditioning had been out or not working correctly, and residents stated the rooms were too hot and they were unable to sleep well. Temperatures taken in resident rooms, the hallway, and the dining room on Unit C were in the low to upper 80s, including a dining room ceiling temperature of 89.9 degrees while residents were eating breakfast. The maintenance director stated he was unaware of a maximum allowable temperature and that the unit had been broken since he began work. Surveyors also observed a bathroom in one room with a baseboard heater covered in rust, missing baseboards, wall damage, cracked and peeling paint, and missing flooring near the toilet. In another bathroom, a dry, crusty brownish-black substance was observed covering the bottom of the bathtub, along with an odor consistent with sewage. A CNA stated the bedroom bathtubs were not in use and that everyone used the shower room. Across these observations, the facility staff did not maintain several resident areas in a clean, sanitary, comfortable, or homelike condition, and the maintenance director repeatedly described the affected areas as needing repair or renovation.
Failure to Provide Required ADL and Hygiene Care
Penalty
Summary
Facility staff failed to provide ADL care to dependent residents, including bathing/showering, bathing assistance, dressing assistance, incontinence care, and access to needed hygiene support. The report identified three residents affected. Facility records, observations, interviews, and policy review showed that the required care was not consistently provided or documented as provided, and in some cases the residents were observed in conditions indicating unmet personal care needs. For one resident with morbid obesity, CHF, and diabetes, the record showed dependence for bathing/showering and no showers documented during January, February, and March 2025. The care plan noted refusals of skin checks, showers, ADL care, and meds, but the progress notes did not document refusals for showers during those months. Staff stated showers were offered twice weekly and documented if refused, yet the record showed bed baths instead of showers and only one refusal documented. For another resident who required assistance with all ADLs and was incontinent of bowel and bladder, surveyors observed the resident lying in bed visibly soiled with a saturated incontinent brief, leakage onto the sheets, and the call bell on the floor out of reach. The resident was only wearing a shirt and was not covered by a sheet or blanket. For the third resident, who had cerebral infarction, hemiplegia/hemiparesis, heart failure, diabetes, autistic disorder, anxiety disorder, and PTSD, the MDS showed dependence for showering/bathing. The clinical record showed multiple date ranges when no shower or bath was provided, and the record was marked not applicable for shower/bath. During observation, the resident’s hair was described as dull, dingy, and oily, and the resident stated staff had not given a shower in a long time and that fear of being transferred after a prior fall had affected willingness to shower. Staff interviews confirmed the resident used a shower lift, that the shower schedule called for bathing twice weekly, and that staff were unsure when the last shower had occurred.
Failure to Notify Physician and Responsible Party of Medication Unavailability and Change in Condition
Penalty
Summary
The facility failed to notify the physician and/or responsible party when a resident’s medication was not available at the scheduled administration time. One resident was admitted with hypothyroidism and had an order for levothyroxine 50 mcg by mouth each morning. The September 2024 MAR documented that the medication was not available at the scheduled 6:00 a.m. administration time, and a nurse’s note stated the new admit was waiting on pharmacy. The backup pharmacy contents reviewed by the surveyor did not list levothyroxine, and there was no documentation that the physician or responsible party was notified of the missed medication availability issue. The facility also failed to notify the physician of a change in condition for another resident who developed left great toe pain, swelling, and bloody drainage. The resident had diagnoses including ESRD, diabetes mellitus, PVD, and gout, and the most recent MDS indicated cognitive intactness with no skin concerns. On 9/14/2024, nursing documented complaints of left great toe pain and a small amount of bloody drainage, with a note placed in the MD communication book and standing order treatment initiated. The next day, the resident continued to have toe pain and drainage, and on 9/16/2024 the toe was still swollen and painful, with the nurse practitioner later ordering Keflex for cellulitis and the physician documenting suspected cellulitis with bloody drainage and tenderness. The record and staff interviews showed that the resident’s ongoing toe symptoms were managed with local care and documentation, but the physician was not notified at the time the change in condition first occurred. An LPN stated that if there was no change or no relief, the on-call physician would have been contacted, and another LPN stated she was unsure about standing treatment orders and believed staff would clean and dress the wound, document it, and notify the wound nurse. The facility policy stated that the facility promptly informs the resident, consults the resident’s physician/physician extender, and notifies the legal representative when there is a change requiring notification.
Failure to Provide Ear Protectors for Oxygen Tubing
Penalty
Summary
Facility staff failed to ensure a pressure relieving device was in place for Resident #112 to prevent pressure ulcers. The resident was observed on 06/22/2026, 06/23/2026, and 06/24/2026 lying in bed with oxygen tubing around her ears and no ear protectors in place on the tubing. During the observations, the resident remained without ear protectors despite the repeated findings over multiple days. On 06/24/2026, an LPN entered the resident’s room, observed that the ear protectors were not being used, and reviewed the resident’s orders at the nurses’ station. The LPN stated that the resident should have the ear protectors and said she would see if the facility had them and correct the issue. Facility documentation titled Pressure Injury Prevention Guidelines stated that evidence-based interventions are to be implemented for residents at risk or with a pressure injury and documented in the care plan and communicated to relevant employees, but the resident was still observed without the ear protectors after the concern was brought to the nurse’s attention. On 06/26/2026, the resident was observed with ear protectors being provided.
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 169 citations issued within 25 miles in the last 12 months — including the 12 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 | ★★★★★ | 52 | 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
Built specifically for Elizabeth Adam Crump Health And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.