Crenshaw Nursing Home

Inspectors wroteBased on interviews and records review, the facility failed to ensure one of three sampled residents (Resident 1), did not elope (left the facility unsupervised) from the facility on 7/17/2026. The facility failed to: 1. Ensure Resident 1's elopement evaluation dated 11/21/2025 was completed, to accurately determine Resident 1's elopement risk. 2. Ensure Resident 1's care plan titled, Risk for Wandering/Elopement Identified, had intervention to minimize the resident's tendency to leave the facility unsupervised, as indicated in its Policy and Procedure (P&P) titled, Wandering and Elopements, which indicated, if a resident was identified at risk for wandering, elopement or other safety issues, the resident's care plan should include strategies and interventions to maintain resident's safety. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Change In a Resident's Condition, which indicated the facility will notify the Resident's representative (RP) of changes in the resident's medical condition and/or status for one of three sampled resident's (Resident 1), when Resident 1's Public Guardian (PG) was not notified of the Resident's transfer to the General Acute Care Hospital (GACH) on 4/4/2026. This failure had the potential to violate Resident 1's RP to be informed regarding the patient's condition and result in the inability for the RP to make informed decisions regarding the Resident's care.

Inspectors wroteBased on observation and interview, the facility failed to:Ensure the Annex medication storage refrigerator temperature was below 40 degrees Fahrenheit. This deficient practice had the potential to result in the loss of potency and expired medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained and an interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) meeting was conducted before the initiation of a psychotropic drug (any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 26) who had diagnosis of dementia (a progressive state of decline in mental abilities). This deficient practice placed Resident 26 at risk for sustaining adverse effects (undesired effect of a drug) from psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] - a federally mandated resident assessment tool) for two of 14 sampled residents (Residents 2 and 32) reflected an accurate assessment, by failing to:A. Ensure Resident 2's Gabapentin (a medication used primarily used as anticonvulsant and for treatment of certain types of nerve pain) medication was encoded as anti-convulsant medication in the MDS assessment Section N0415 (High-Risk Drug Classes) K1(Anticonvulsant). B. Ensure Resident 32's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment was encoded in the MDS assessment Section O (Special Treatments, Procedures, and Programs) 0110 (J1 - Dialysis). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level 1 screening (a federally required preliminary screening for individuals seeking admission to a Medicaid-certified nursing facility) was completed and resubmitted for one of two sampled residents (Resident 7), who had diagnoses of mental illness (abnormal behavior or disturbing feelings, thoughts, or actions that interfere with every day functioning) and was receiving psychotropic medications (any drug that affects brain activities associated with mental process and behavior). This deficient practice had the potential to result in Resident 5 not appropriately evaluated and not provided the necessary specialized services for mental illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to:1). Conduct a Level 2 Pre-admission Screening and Record Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for one of 8 sampled residents (Resident 5). This deficient practice had the potential to result in a delay of necessary care and mental health services.

Inspectors wroteBased on interview and record review, the facility failed to:1). Ensure care plan for oxygen use was initiated for two of 8 sampled residents (Resident 22 and Resident 6). This deficient practice had the potential to result in a delay in delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident's (Resident 11) blood pressure was checked prior to the administration of hydrochlorothiazide (drug used to treat high blood pressure). This deficient practice had the potential to result in severe hypotension (low blood pressure) for Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to ensure the recommendation from the Consultant Pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) for one of five sampled residents (Resident 26), was acted upon. This failure had the potential to result in Resident 26 experiencing a delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dishwasher chlorine test paper strips (used to test commercial dishwasher for proper sanitation level) were not expired. This deficient practice could result in inaccurate readings that would lead to under-sanitized dishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size measurement of 80 square feet of room space per resident in rooms with multiple residents. This deficient practice could potentially result in the residents not being able to move around freely and could potentially affect residents' health and safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 1) was treated with dignity when requesting to be cleaned by the Certified Nursing Assistant (CNA) 1. This deficient practice of not cleaning Resident upon request left Resident 1 to feel frustrated and upset.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement policies and procedures for one out of three sampled residents (Resident 1) that an abuse allegation was reported within two hours to the California Department of public Health (CDPH) and other agencies. This deficient practice of not reporting an abuse allegation within two hours caused a delay in investigating by the CDPH.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had severe cognitive impairment, was safely discharged when the facility failed to: 1. Ensure an Interdisciplinary Meeting ([IDT] gathering where healthcare professionals from different disciplines collaborate to discuss a patient's care, develop shared understandings, and coordinate treatment plans) for discharge planning was conducted for Resident 1. 2. Ensure Resident 1 ' s discharge location (house) could meet the resident ' s needs. 3. Follow up with Resident 1 after his discharge from the facility to the house, to ensure Resident 1 was safe and comfortably settled. 4. Ensure Resident 1 had a designated individual to safely administered his medications including Risperdal (medication to treat mental health conditions) and gabapentin (medication to treat nerve pain). 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administering a psychotropic medication (any drug that affects brain activities associated with mental process and behavior) for two of four sampled residents (Residents 16 and 41). This deficient practice violated the resident's right to make an informed decision regarding the use of psychotropic medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the results of the most recent survey of the facility was posted in a place readily accessible to residents. This deficient practice had the potential to violate the rights of residents to examine the survey results of the facility and could lead to residents not being fully informed of the facility's deficient practices and how they were corrected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] a mattress designed to prevent and treat pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) was set and maintained at the correct setting according to the manufacturer's setting for two of three sampled residents (Residents 16 and 41). 2. Ensure one out of six sampled residents (Resident 105) had a LALM to prevent pressure ulcer. These deficient practices placed Residents 16 and 41 at risk for discomfort and skin breakdown. and had the potential to result in the worsening of Resident 105 pressure ulcer.

Inspectors wroteBased on observation and interview, the facility failed to ensure the medication room storage refrigerator was maintained below 46 degrees as indicated in the facility's policy and procedure (P&P) titled, Medication Storage in the Facility. This deficient practice had the potential for medications be stored in improper temperature, or humidity and can alter the effectiveness of the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a privacy bag (a cover placed over the urine collection bag, so it was not visible) for one out of six sampled residents (Resident 101) who had a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential for Resident 101 to feel uncomfortable while around other residents and negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of six sampled resident's (Resident 44) call light was within reach. This deficient practice had the potential for Resident 44 not to be able to call for assistance to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one of one sampled resident (Resident 202) who was on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential for Resident 202 to not receive appropriate care and treatments specific to the resident's dialysis need.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for one of six sampled residents (Resident 105) who was receiving oxygen (O2). This deficient practice had the potential for unidentified goals and interventions for Resident 105.

Inspectors wroteBased on interview and record review, the facility failed to monitor and record the blood pressure (BP) for one of one sampled resident (Resident 202) who had a physician's order for Midodrine (a medication to treat low blood pressure) every 8 hours as needed for systolic blood pressure ([SBP] the first number in a blood pressure reading) of less than 120. This deficient practice had the potential to result in Resident 1 not receiving the medication as needed and hypotension (low blood pressure) which could lead to dizziness, falls and stroke (loss of blood flow to a part of the brain).

Inspectors wroteBased on interview and record review, the facility failed to ensure respiratory care (interventions and therapies aimed at improving or restoring lung function and addressing breathing difficulties) were provided to two of three sampled residents (Residents 12 and 16), in accordance with standards of practice, by failing to ensure: 1. Resident 12's tracheostomy (a surgical opening in the neck for an airway) site and tube were free of dried secretions (substance such as saliva or mucus). 2. Resident 16's face mask nebulizer (a medical device that uses a small machine to turn liquid medication into a mist that can be inhaled through a face mask, allowing medication to be delivered directly to the lungs) tubing was labeled with date when changed. These failures had the potential to cause respiratory infection for Resident 12 and 16.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of one sampled resident (Resident 202) by failing to: 1. Monitor and record resident's blood pressure every 8 hours who was receiving Midodrine (a medication to treat low blood pressure) as needed following parameters set by physician. This deficient practice had the potential to result in unintended consequences of Resident 202's management of low blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to act on the pharmacist consultant's (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendations timely, for two of four sampled residents (Residents 16 and 41). Cross Reference to F758. This deficient practice placed Residents 16 and 41 at risk for unnecessary medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Resident 16 and 41), who received as needed (PRN) psychotropic medication (any drug that affects brain activities associated with mental process and behavior), were reevaluated after 14 days. Cross Refer to F756. This deficient practice placed Residents 16 and 41 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Kitchen refrigerator 1 had an external thermometer (an appliance to monitor the temperature of a refrigerator) in working condition. 2. The large clear egg noodle pasta bin in the dry storage area was labeled with name and date. 3. Kitchen refrigerator 2 had proper internal temperature (40 degrees Fahrenheit or lower) maintained for the refrigerated food items. This deficient practice had the potential to cause rapid growth of bacteria that can cause foodborne illness (food poisoning).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the humidifier (a product that adds moisture to the air to help with breathing) for one of six sampled residents (Resident 105), was changed and labeled with date. This deficient practice placed Resident 105 at risk for respiratory infection (an infection affecting the nose, throat, sinuses, airways, and lungs).

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the required 80 square feet for each resident in House Station Rooms 1, 2, 3, 4, 6, 8, 9 and 10, and Annex Station room [ROOM NUMBER]. This deficient practice had the potential to result in unsafe condition when providing nursing care and treatment to the residents living in the affected rooms.

Inspectors wrote1. Report to the California Department of Public Health (CDPH- the state department responsible for public health in California) of a resident-to-resident physical altercation for two of four sampled residents (Resident 2 and Resident 3). This resulted in a delay in investigation by CDPH and placed Resident 3 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), within 24 hours, for one of three sampled residents, Resident 3, who sustained a total of three bruises (result of a direct blow or an impact, such as a fall or after trauma, such as a blow to the body) of unknown source from 6/2024 to 12/2024. This deficient practice resulted in the delay of investigation by the CDPH.

Inspectors wroteBased on interview and record review, the facility failed to investigate swelling and bruises (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) of unknown source, on 6/18/2024, 11/5/2024 and 12/24/2024, for one of three sampled residents, Resident 3. This failure resulted in Resident 3 ' s continued sustaining injuries requiring interventions. This failure placed the resident at risk for severe injuries, resulting in hospitalization and death.

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized plan of care for the safety of a resident that required to be within sight at all times of day and night for one of three sampled resident (Residents 3). This deficient practice had the potential for recurrent injuries or falls for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to: 1). Provide an environment free of accident hazards as possible and provided one of three residents ' (Resident 3), adequate supervision and assistance to prevent accidents. 2). Conduct accurate fall risk assessment to one of 3 residents, Resident 3, who had history of fall. 3). Implement its policy and procedure (P&P) titled Safety and Supervision of Residents, which indicated safety risks and environmental hazards are identified on an ongoing basis and the Quality Assurance and Performance Improvement (QAPI) review safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. [...]

Inspectors wroteBased on interview and record review, the facility's dietary staff failed to serve the correct consistency per physician's order on June 1, 2024. This deficient practice placed the resident at risk for potential aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 1) with a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was provided with low air loss mattress (small air holes in the mattress top surface continually blow out air causing the patient to float, which reduces skin interface pressure at the mattress surface and moisture is wicked away so the patient stays dry) to promote wound healing. This failure had the potential to cause residents to experience the development or deterioration of pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision during the night shift for one of 4 sample residents (Resident 4). Resident 4 was observed, going to the bathroom unsupervised on 6/14/2024 and 6/20/2024, while Certified Nurses Assistance (CNA) 2, was asleep at the nurse's station. This failure had the potential to lead to accidents, falls and injuries for Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment for residents by failing to maintain residents room walls, floors, shower rooms, and laundry area clean. These deficient practices had the potential to result in cross contamination (transfer of harmful bacteria from one person, object, or place to another), pest activity and negatively affect resident's wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure one out of three Resident (Resident 1) had a documented assessment for an injured right index finger after a notification of change of condition. This deficient practice of not having documented assessment placed Resident 1 at risk for worsening of injury of the right index finger.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse (willful infliction of injury with resulting physical harm, pain, or mental anguish) by Resident 2, by failing to: 1. Ensure Resident 1 (victim) was not subjected to a repetitive physical abuse from Resident 2 (aggressor). 2. Ensure Resident 1 and Resident 2 were separated and were not left to continue residing in the same room, after Resident 1 reported to a Licensed Vocational Nurse (LVN 1) that Resident 2 hit him on 4/1/ 2024. 3. Ensure Resident 1 and Resident 2 were separated, after Resident 2 hit Resident 1 on the right eye on 4/23/2024, causing Resident 1 to sustain a red bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact) and swelling around the right eyelid. 4. [...]

Inspectors wroteBased on interview and record review, for two of two sampled residents (Resident 1 and Resident 2), the facility failed to implement its policy and procedure titled, Abuse & Mistreatment of Residents, which indicated the following: 1. When incidents involving the health, welfare, or safety of residents are reported, the involved resident(s) shall be removed from the environment that threatened resident's health, welfare, or safety. 2. The Charge Nurse and/or nursing supervisor shall conduct an immediate resident assessment to identify any injuries or extent of injuries, if any, shall notify the attending physician of incident for necessary interventions and notify family members and or legal agents of incident. 3. The Charge Nurse and/or Nursing Supervisor shall initiate resident care plan to reflect current conditions and measures taken to prevent recurrence of event.

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH) within two hours, the alleged abuse reported on 4/1/2024 and 4/23/2024 for two out of three sampled residents (Resident 1 and Resident 2). This violation delayed the investigation by the CDPH.

Inspectors wroteBased on record review and interview, the facility failed to investigate a resident-to-resident altercation on 4/1/2024 between two of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted in Resident 2 hitting Resident 1 in the face on 4/23/2024, that resulted in a red bruise and swelling on right eyelid. This also placed Resident 1 at risk for repeated physical abuse by Resident 2, which had the potential for more serious injuries requiring hospitalization, possible coma, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive and resident-centered abuse care plan, on two alleged physical abuse incidents on 4/1/2024 and 4/23/2024, for two out of three sampled residents (Resident 1 and Resident 2). This deficient practice resulted in a repeated physical abuse to Resident 1 by Resident 2 on 4/23/2024, that resulted in a red bruise and swelling on right eyelid. This also placed Resident 1 at risk for repeated physical abuse by Resident 2, which had the potential for more serious injuries requiring hospitalization, possible coma, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure an oxygen sign was posted and extension cord was free from hazards for two out of two sampled residents (Resident 11 and 34). This deficient practice had the potential for an unsafe environment with a fire hazard risk and placing Resident 34 at risk for a fall and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure medications were properly labeled with open dates in medication cart 1 for five out of 23 residents (Resident 45, Resident 46, Resident 11, Resident 47, and Resident 29). This deficient practice had the potential to result in unintentional medication administration of possibly expired medications.

Inspectors wroteThe facility failed to: 1. Ensure refrigerator temperatures were at or below 40 F. 2. Ensure food items were labeled with open and used by dates in the reach-in refrigerators, reach-in freezers, seasoning rack and dry storage room of the kitchen. These deficient practices had the potential to cause food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Have a written Quality Assurance and Performance Improvement (QAPI) program in place for a census of 42. This deficient practice had the potential to affect how the facility ensures care and services are delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress toward correction or improvement is achieved and sustained.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Use a dignity bag (blue nonwoven material that conceals fluid in the drainage bag to improve resident dignity) for a foley catheter drainage bag (device that holds the urine that drains from the resident's body) for one of one sampled resident (Resident 40). This deficient practice had the potential to negatively affect Resident 40's self-esteem and self-worth and to cause psychosocial harm or decline to the resident and violates resident's right to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure the overhead room light was in working condition for one of 12 sampled residents (Resident 21). This deficient practice had the potential for an unsafe environment with placing Resident 21 at risk for a fall and injury.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of six Residents (Resident 35) had a change of condition (COC) assessment after an altercation. This failure had the potential to result in Residents 35 receiving inadequate and inappropriate care and services necessary to reach their highest practical physical, mental, and psychosocial well being.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 11) had a physician order for the use of oxygen. This deficient practice of not having a physician order for oxygen usage placed Resident 11 at risk for incorrect oxygen usage.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label and date the humidifiers (a device that adds moisture to a space) and nasal cannula (a device that gives you additional oxygen) for one out of six Residents (Resident 11). This deficient practice placed Resident 11 at risk for respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic medications administered were documented accurately in the medication administration record (MAR) and the controlled drug record sheets (drugs or other substance tightly controlled by the government that may be abused or cause addiction) for one of four sampled residents (Resident 1). This deficient practice had the potential for medication errors and can result in overdosage of narcotic medication and/or hospitalization.