Inspection Report

Crenshaw Nursing Home: Blood Pressure Monitoring Failure - CA

November 14, 2026

Los Angeles, CA

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Crenshaw Nursing Home: Blood Pressure Monitoring Failure - CA

The resident, identified in inspection records as Resident 202, had a prescription for midodrine, a drug used to raise blood pressure. The order was specifically intended to keep her blood pressure stable and to prevent hypotension, a potentially serious drop in blood pressure that dialysis patients are particularly vulnerable to during treatment. Her physician had ordered blood pressure checks every eight hours. The checks were not happening.

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The Director of Nursing at Crenshaw Nursing Home, located at 1900 S. Longwood Avenue in Los Angeles, laid out the consequence plainly during an interview with federal inspectors on March 20, 2025. Without monitoring Resident 202's blood pressure every eight hours, the DON said, licensed nursing staff would not be able to determine when to give and when not to give the midodrine.

That is the point of the monitoring. Midodrine raises blood pressure. Giving it to a patient whose blood pressure is already adequate, or already elevated, creates risk. Withholding it from a patient whose pressure has dropped before dialysis creates a different risk. The every-eight-hour check is how a nurse knows which situation she is in. Without it, the decision becomes a guess.

Inspectors found the lapse during a survey completed March 21, 2025, and classified it as causing minimal harm or the potential for actual harm, affecting a small number of residents.

The facility's own internal policies made the standard clear. A policy on care for residents with end-stage renal disease, in place since 2010, stated that residents with ESRD would be cared for according to currently recognized standards of care and that staff training specifically included the timing and administration of medications, particularly those given before and after dialysis. A separate medication administration policy, dated 2008, stated that medications are administered in accordance with the written orders of the attending physician.

Resident 202's physician had written the order. The policy said follow it. The monitoring did not happen.

Dialysis is not a minor treatment. For patients with end-stage renal disease, it is what keeps them alive, typically three times a week, each session lasting several hours. The process filters waste from the blood that the kidneys can no longer clear, but it also pulls fluid from the body rapidly, and that fluid shift can cause blood pressure to fall. Midodrine is one tool physicians use to manage that risk. Its effectiveness depends entirely on it being given at the right time, which depends on knowing what the patient's blood pressure is doing.

The Director of Nursing's own words to inspectors captured the problem without ambiguity. There was no dispute about whether the monitoring had occurred, no claim that an alternative system was in place, no suggestion that the resident had been checked through some other means. The DON acknowledged directly that without the checks, staff had no way to make the call.

Crenshaw Nursing Home has been operating at the Longwood Avenue address in the West Adams neighborhood of Los Angeles. The inspection was conducted by the Centers for Medicare and Medicaid Services. For information on the facility's plan to correct the deficiency, CMS directs the public to contact the nursing home or the California state survey agency directly.

Resident 202 is a dialysis patient in a nursing home, dependent on staff to carry out orders her physician wrote to protect her. The monitoring her doctor ordered was not being done. Whether her blood pressure dropped before anyone noticed is not something the inspection report says.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Crenshaw Nursing Home from 2025-03-21 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards & Data Disclosure

Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.

Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.

Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.

Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.

Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: November 14, 2026 · Our methodology

Quick Answer

CRENSHAW NURSING HOME in LOS ANGELES, CA was cited for violations during a health inspection on March 21, 2025.

The resident, identified in inspection records as Resident 202, had a prescription for midodrine, a drug used to raise blood pressure.

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.

Frequently Asked Questions

What happened at CRENSHAW NURSING HOME?

The resident, identified in inspection records as Resident 202, had a prescription for midodrine, a drug used to raise blood pressure.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in LOS ANGELES, CA, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from CRENSHAW NURSING HOME or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 055525.

Has this facility had violations before?

To check CRENSHAW NURSING HOME's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.