Crenshaw Nursing Home: Medication Oversight Failures - CA
When federal inspectors arrived at Crenshaw Nursing Home on March 21, 2025, they found that staff had failed to act on a consultant pharmacist's written warnings about two residents receiving lorazepam, a sedative used to treat anxiety, without the documentation required to justify continued use. The drug had no stop date. The prescribing rationale had not been recorded. And licensed nursing staff had never followed up with the residents' physicians to address any of it.
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See the Derila PillowLorazepam belongs to a class of drugs that carry particular risks for elderly patients, including sedation, confusion, and falls. One of the residents, identified in inspection records as Resident 41, had been prescribed 0.25 milliliters by mouth every four hours as needed for anxiety described as restlessness causing shortness of breath. The order was dated February 25, 2025. The pharmacist's review, conducted February 15, had already flagged an existing lorazepam order for the same resident, noting it lacked a stop date and that, under federal rules in effect since November 2017, any as-needed psychotropic drug order extending beyond 14 days requires documented rationale and a defined duration of use.
Neither existed in the record.
Inspectors reviewed the clinical files of both Resident 41 and a second resident, Resident 16, alongside the facility's Director of Nursing during a concurrent interview on March 20 at 2:41 p.m. The Director of Nursing confirmed that neither resident's record showed any documentation that licensed staff had followed up with the physicians to address the pharmacist's recommendations. She said the facility's expected timeline for acting on such recommendations was one month, or before the pharmacist's next scheduled visit.
That window had closed. Nothing had been done.
The Director of Nursing acknowledged it was important for licensed staff to discuss pharmacist recommendations with physicians, both for resident safety and to prevent residents from receiving unnecessary medication. The facility's own written policy, dating to August 2014, states that pharmacist recommendations must be acted upon and documented, and that if a physician disagrees with a recommendation, they must provide a written explanation for rejecting it.
There was no acceptance. No rejection. No explanation. The records simply showed the recommendations sitting unanswered.
The inspection tagged the violation at a level of minimal harm or potential for actual harm, affecting a few residents. That classification reflects the lowest tier of the federal deficiency scale, but it does not mean the risk was theoretical. Lorazepam prescribed without documented clinical justification, without a defined endpoint, and without physician review of a pharmacist's concerns is a drug order that exists outside any meaningful oversight structure. If a resident's condition changed, if the dose was wrong, if the drug was no longer appropriate, there was no documented process in place to catch it.
Crenshaw Nursing Home is located at 1900 S. Longwood Avenue in Los Angeles. The inspection was completed March 21, 2025.
What the records do not show is whether Resident 41 or Resident 16 were ever told that a pharmacist had raised concerns about their medication. Whether a physician was ever reached. Whether the lorazepam orders were eventually reviewed, modified, or stopped.
The pharmacist wrote the warning in February. The nurses never made the call.
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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Last verified: November 12, 2026 · Our methodology
CRENSHAW NURSING HOME in LOS ANGELES, CA was cited for violations during a health inspection on March 21, 2025.
The prescribing rationale had not been recorded.
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.