Elizabeth Adam Crump: 8 Deficiencies, No Fix Plan - VA
Federal inspectors found that Elizabeth Adam Crump Health and Rehab failed to protect Resident #2 from unnecessary medications during a complaint investigation completed October 30. The resident, who scored 11 out of 15 on a cognitive assessment indicating moderate impairment, had been admitted with multiple serious conditions including a fractured left femur, chronic respiratory failure, major depressive disorder, and generalized anxiety disorder.
The medication errors began immediately upon admission in early September. Hospital discharge orders specified that the resident should receive half a tablet of quetiapine fumarate, an antipsychotic medication, each evening for mood. The discharge summary clearly stated "take 0.5 tab" of the 25-milligram tablets, which equals 12.5 milligrams.
Instead, facility staff wrote the admission order as "give 1 tablet by mouth in the evening for mood." The resident received the incorrect 25-milligram dose on September 6 and September 7 before staff corrected the error to the proper 12.5-milligram amount.
Ten days later, a psychiatric nurse practitioner ordered buspirone, an anti-anxiety medication, for the same resident's depression. The pharmacy system immediately flagged a serious warning about drug interactions.
"Drug to Drug interaction," the alert read. "Additive serotonergic effects may occur during coadministration of buspirone and escitalopram oxalate 20 mg tramadol HCl and trazadone and the risk of developing serotonin syndrome may be increased."
Serotonin syndrome can cause confusion, agitation, rapid heart rate, and in severe cases, death.
The pharmacy system raised the same alert again on September 15 when the psychiatric nurse practitioner finalized the buspirone order. No documentation showed that any physician had been notified or that pharmacy staff had been consulted about the dangerous interaction warnings.
More than six weeks passed without action.
When inspectors interviewed the psychiatric nurse practitioner on October 30, he said facility staff never contacted him about the pharmacy warnings. "He stated that the facility staff did not contact him regarding pharmacy warnings of drug-to-drug interactions," the inspection report states.
The nurse practitioner told inspectors he had only ordered the buspirone for depression, not the other medications involved in the interaction. "He stated that he did not order the other medications, so he was not aware of any issues with them."
LPN B, interviewed the same day, confirmed that pharmacy alerts appear when conflicting orders are entered or when drug interactions are detected. She told inspectors that nurses are supposed to notify physicians when these warnings appear "to see if the physician wants to keep the medicine or change it to something else."
The nurse also said staff should consult with pharmacists about the alerts.
The Director of Nursing acknowledged the facility's failure during her interview. She told inspectors it was her expectation that nurses contact physicians when pharmacy alerts flag drug interactions or allergies. Such notification "allows the physician to decide whether the benefit of taking the drug outweighs the risks," she explained.
When asked whether physicians had access to progress notes where pharmacy alerts are documented, the Director of Nursing confirmed they did.
The inspection revealed a systematic breakdown in medication safety protocols. Despite having multiple safeguards in place, including automated pharmacy warnings and written policies requiring physician notification, staff failed to act on clear alerts about potentially life-threatening drug combinations.
The resident involved in the medication errors had complex medical needs requiring careful coordination. Beyond the fractured femur and mental health conditions, the person also suffered from chronic obstructive pulmonary disease, asthma, lung abscess, acute hepatitis C, and insomnia.
Federal regulations require nursing homes to ensure each resident's drug regimen is free from unnecessary medications. The rule exists specifically to prevent the kind of medication mismanagement that occurred at Elizabeth Adam Crump Health and Rehab.
During the end-of-day meeting on October 30, inspectors informed the facility administrator about their findings. The inspection report notes that "no further information was provided."
The violation affected multiple residents beyond the specific case documented, with inspectors noting that "some" residents were impacted by the facility's failure to maintain proper medication safety protocols.
Elizabeth Adam Crump Health and Rehab's medication management failures put vulnerable residents at risk during a time when they needed careful medical oversight. The resident who received double doses of antipsychotic medication and experienced the ignored drug interaction warnings continues to live with the consequences of a system designed to protect but failing to act when alerts demanded immediate attention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elizabeth Adam Crump Health and Rehab from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
ELIZABETH ADAM CRUMP HEALTH AND REHAB in GLEN ALLEN, VA was cited for violations during a health inspection on October 30, 2025.
The medication errors began immediately upon admission in early September.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.