Crenshaw Nursing Home: Call Light Left on Floor - CA
That's what inspectors found on the morning of March 18, 2025, when they walked into the room of Resident 44 at Crenshaw Nursing Home, a facility on South Longwood Avenue in Los Angeles. The time was 9:59 a.m.
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See the Derila PillowResident 44 cannot speak. She has right-sided weakness in both her arms and legs, leaving her left side as her only functional side. She depends on staff entirely for showering, dressing, and personal hygiene. Her diagnoses include chronic obstructive pulmonary disease, epilepsy, and diabetes. When something goes wrong, she cannot call out. The call light is her only option.
It was on the floor.
Her own care plan said the call light should be within reach at all times. A licensed vocational nurse at the facility, interviewed the following day, confirmed this without hesitation. The nurse said the call light needed to always be placed within the resident's reach, and explained that because of the right-sided weakness, it had to be positioned on the left side where the resident could actually use it. The nurse said it was important so the resident could call for help when needed.
That's not a complicated instruction. It is, in fact, the entire point of a call light.
Crenshaw Nursing Home also had a written policy on call lights. The policy, which the facility left undated, said staff should ensure the call light is within the resident's reach when she is in her room. Inspectors found that policy during their review. They also found that it wasn't being followed.
The inspection, conducted on March 21, 2025, was a standard health survey. Of the six residents whose care was sampled, Resident 44 was the only one found in this situation. CMS rated the violation at the minimal harm level, meaning inspectors concluded no actual harm had occurred, though they noted the potential for Resident 44 to be unable to call for assistance to obtain necessary care and services.
That phrase, "necessary care and services," carries real weight for someone with Resident 44's conditions. Epilepsy means seizures can happen without warning. COPD means breathing can become a sudden emergency. Diabetes means a blood sugar crisis can move fast. A person who cannot speak and cannot reach the device that summons help is, in any of those moments, entirely alone.
The assessment tool completed in January 2025 noted that Resident 44 was usually able to understand. She knew what was happening around her. Whether she knew, on the morning of March 18, that the cord was somewhere behind the mattress and not in her hand is not something the inspection report addresses.
What the report does say is that her care plan identified the problem and named the solution. Staff had been told. A policy existed. And still, when inspectors arrived on a Tuesday morning, the call light was on the floor.
The facility's plan of correction was not included in the inspection materials reviewed. For information on how Crenshaw Nursing Home intends to address the deficiency, CMS directs the public to contact the facility or the California state survey agency directly.
Resident 44 was still living at Crenshaw Nursing Home at the time of the inspection. Her left hand, the one that works, had nothing to hold.
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
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.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 13, 2026 · Our methodology
CRENSHAW NURSING HOME in LOS ANGELES, CA was cited for violations during a health inspection on March 21, 2025.
She has right-sided weakness in both her arms and legs, leaving her left side as her only functional side.
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.