Federal inspectors found the 1900 S Longwood Ave facility failed to follow its own policies for psychotropic medication management during a March inspection. Both residents had dementia and couldn't make daily decisions for themselves.
Resident 16, who had anxiety disorder, chronic lung disease and dementia, started receiving lorazepam every 12 hours as needed for restlessness in February. The medication order had no end date. Resident 41, diagnosed with anxiety disorder, anemia and malnutrition, began getting lorazepam every four hours as needed for anxiety causing shortness of breath, also with no stop date.
The facility's Director of Nursing told inspectors both residents were on lorazepam "with no duration of therapy." She acknowledged all PRN psychotropic medications should have stop dates and that physicians should assess and reevaluate continued use to comply with regulations.
"The physician should assess and reevaluate the continued use of the lorazepam," the director said. She explained the facility should have documentation justifying any extension beyond 14 days. "The risk of not putting a stop date for a PRN psychotropic medication could result in a resident receiving unnecessary medication."
The facility's own policy, dated July 2022, required physicians to document rationale for extending PRN psychotropic orders beyond 14 days and include duration for the order.
In the medication room, inspectors discovered a more immediate problem. The storage refrigerator temperature read 48 degrees Fahrenheit when it should have been maintained between 36 and 46 degrees. Inside sat unopened insulin vials, insulin pens, and tuberculosis injection vials.
Licensed Vocational Nurse 1 confirmed the policy required temperatures between 36-46 degrees. "The refrigerator temperature was 48 degrees," the nurse said, acknowledging the risk of out-of-range temperatures could result in medications expiring.
The facility's medication storage policy from April 2008 specified that refrigerated medications requiring temperatures between 36-46 degrees should be kept in a refrigerator with a thermometer for temperature monitoring.
Kitchen problems compounded the temperature control issues. Refrigerator 1's external thermometer malfunctioned, counting upward in seconds and minutes from zero instead of displaying temperature. Dietary Aide 1 didn't know why the thermometer was malfunctioning. "The risk of having a malfunctioned external thermometer on a refrigerator could result in spoiled food," the aide said.
Kitchen refrigerator 2 ran at 42 degrees, two degrees above the required 40 degrees or below for food safety. The Dietary Supervisor confirmed the temperature violation. "The risk of a refrigerator with internal temperature of 42 degrees could result in expired food," the supervisor said.
In dry storage, inspectors found a large clear container of uncooked egg noodle pasta without required name and date labels. The Dietary Coordinator explained the unlabeled container posed risks. "The risk of not labeling food in the dry storage container could result in not knowing what food contents are in the bin and until when it was good for."
For Resident 105, who had end-stage kidney disease, diabetes and dementia, infection control failures created additional risks. The resident required oxygen therapy and had a humidifier attached to the oxygen concentrator. But the humidifier carried no date label indicating when it was last changed.
Licensed Vocational Nurse 2 said the undated humidifier prevented staff from knowing if it had been changed. Policy required weekly humidifier changes. "If the humidifier was not changed weekly, it placed the resident at risk for developing a respiratory infection," the nurse said.
The facility's oxygen administration policy required humidifiers to be changed weekly and as needed.
Space constraints affected multiple residents. Nine rooms failed to meet federal requirements of 80 square feet per resident in shared rooms and 100 square feet for single occupancy. The Director of Nursing acknowledged some rooms were smaller than required but said no harm had occurred.
Room measurements revealed the extent of the space violations. A four-bed room in the House Station measured 252 square feet, providing just 63 square feet per resident. Another four-bed room measured 260 square feet, giving residents 65 square feet each. Even single-occupancy rooms fell short, with two rooms measuring 99 square feet instead of the required 100.
The director explained the facility had submitted a waiver request on March 18. "The risk for not meeting the required square footage for each resident could result in residents' not being able to move around freely," she said, though she maintained the cramped conditions hadn't harmed residents.
An Annex Station room housing four residents measured 312 square feet, providing 78 square feet per person. A House Station room with two beds measured 144 square feet, giving each resident 72 square feet.
The violations affected residents already dependent on staff for basic care. Resident 16 required help with oral hygiene, dressing and personal hygiene. Resident 41 needed maximal assistance with eating, dressing and hygiene. Resident 105 was dependent on staff for showering, dressing and transferring from bed to chair.
Both residents receiving lorazepam had severely impaired cognitive skills for daily decision-making, with assessments indicating they "never/rarely made decisions." Their vulnerability made proper medication monitoring more critical.
The facility's request for a room size waiver remained pending with state regulators. Inspectors noted the undersized rooms didn't adversely affect residents' health or safety during their visit, recommending approval of the waiver despite the space violations.
Crenshaw Nursing Home's multiple system failures stretched from medication management to food safety to infection control, affecting some of its most vulnerable residents who couldn't advocate for themselves.
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.