Crenshaw Nursing Home: Medication Safety Failures - CA
Federal inspectors flagged the problem during a March 2025 survey of the facility at 1900 S. Longwood Avenue. What they found was not a paperwork technicality. Lorazepam is a benzodiazepine, a class of drugs associated with falls, sedation, and dependence in elderly patients. Giving it to nursing home residents indefinitely, without reassessment, is exactly the kind of prescribing the oversight system is designed to catch.
It didn't catch it here. Not until inspectors arrived.
Resident 41 had been placed on lorazepam on February 25, 2025, by telephone order. The prescription was for 0.25 milliliters by mouth every four hours as needed, written for anxiety and restlessness causing shortness of breath. Resident 16 was on the same drug, also on an as-needed basis, also for anxiety. When inspectors reviewed both residents' clinical records on March 19 alongside the Director of Nursing, neither order had a duration attached to it.
The Director of Nursing did not dispute what the records showed. She said both residents were on lorazepam with no duration of therapy. She said all as-needed psychotropic medications should have a stop date. She said the physician should assess and reevaluate the continued use of the drug. She said the provider should have documentation explaining why lorazepam was still appropriate after 14 days. And she said the risk of leaving a psychotropic prescription open-ended was that a resident could end up receiving medication they no longer needed.
She said all of this during the inspection. The orders still had no stop dates.
The facility's own written policy, dated July 2022, addressed this directly. For psychotropic medications that are not antipsychotics, if a physician believed it was appropriate to keep an as-needed order active beyond 14 days, the physician was required to document the rationale and specify how long the order would run. No such documentation existed for either resident.
That policy had been on the books for nearly three years.
Lorazepam is not a medication that nursing homes are prohibited from using. There are residents for whom it is appropriate, carefully dosed and monitored. The concern here is not that two residents were prescribed an anti-anxiety drug. The concern is that once a prescription like this is written with no end date and no reassessment requirement, it can continue indefinitely, refilled and administered, without anyone formally asking whether the resident still needs it or whether the risks have changed.
For an elderly person in a nursing home, those risks are not abstract. Benzodiazepines are linked to increased fall risk, cognitive impairment, and physical dependence. The shorter the prescription window and the more frequent the reassessment, the more likely problems are caught before they compound.
Inspectors rated the level of harm as minimal, with potential for actual harm. Few residents were affected.
What the inspection record does not contain is any indication of when, or whether, either resident's lorazepam order was reviewed before inspectors walked in.
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 3, 2026 · Our methodology
CRENSHAW NURSING HOME in LOS ANGELES, CA was cited for violations during a health inspection on March 21, 2025.
Federal inspectors flagged the problem during a March 2025 survey of the facility at 1900 S.
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.