Crenshaw Nursing Home: Medication Safety Failures - CA
Crenshaw Nursing Home failed to follow up on the pharmacist's recommendations for Residents 16 and 41, both prescribed lorazepam despite having cognitive skills so impaired they "never or rarely made decisions," according to federal inspection records from March.
Resident 16 had been prescribed lorazepam 0.5 milligrams every 12 hours as needed for restlessness. The consultant pharmacist noted in a February review that this dosing could exceed the recommended maximum daily dose of 2 milligrams for elderly patients. The pharmacist recommended the physician re-evaluate the order or document the risks and benefits.
Nobody followed up.
Resident 41 faced a different problem with the same medication. The resident received lorazepam 0.25 milliliters every four hours as needed for anxiety causing shortness of breath. Federal regulations require doctors to document their reasoning for prescribing as-needed psychiatric medications beyond 14 days.
The prescription had no stop date and no documented rationale.
Both residents suffered from conditions that made them particularly vulnerable to medication errors. Resident 16 lived with anxiety disorder, chronic obstructive pulmonary disease, and dementia. Staff helped with all oral hygiene, dressing, and personal care.
Resident 41 also had anxiety disorder, plus anemia and protein calorie malnutrition. This resident required maximum assistance with eating, dressing, and hygiene.
The Director of Nursing admitted during the March inspection that licensed staff never contacted either resident's physician about the pharmacist's concerns. The DON said the facility should have followed up within one month of the pharmacist's review.
"It was important for the licensed staff to address and discuss pharmacist consultant's recommendations with the resident's physician for residents' safety and to avoid the residents receive unnecessary medication," the DON told inspectors.
The facility's own policy required action on pharmacist recommendations. The August 2014 policy stated that recommendations "should be acted upon and documented by the facility staff and or the prescriber." If a physician disagreed with a suggestion, they had to provide an explanation.
The consultant pharmacist had flagged both cases by February 15. When inspectors arrived March 20, more than a month later, the clinical records showed no evidence anyone had contacted the physicians.
Lorazepam belongs to a class of medications called benzodiazepines, which federal regulators have identified as particularly risky for elderly nursing home residents. The drugs can increase fall risk and worsen cognitive problems in people with dementia.
For Resident 16, the pharmacist specifically noted the potential to exceed safe dosing limits. The 0.5-milligram dose every 12 hours as needed could theoretically be given multiple times per day, pushing the total above the 2-milligram daily maximum recommended for elderly patients.
Resident 41's situation violated a different safety rule. Since November 2017, federal regulations have required prescribers to document both the rationale and expected duration for any as-needed psychiatric medication used beyond two weeks.
The resident's lorazepam order, written February 25, had neither.
During the inspection, the DON acknowledged the timeline problem. Pharmacist consultant visits were scheduled monthly, meaning staff had roughly 30 days to address recommendations before the next review.
Both residents had been readmitted to the facility after previous stays, suggesting ongoing health complications that could make medication management even more critical.
Resident 16's order specified the lorazepam was for "anxiety manifested by restlessness" and inability to stay still in bed. Resident 41's prescription targeted "anxiety manifested by restlessness causing shortness of breath."
The facility received citations for failing to implement required medication reviews and for not ensuring proper oversight of psychiatric drugs. Inspectors found the deficient practices placed both residents at risk for unnecessary medication administration.
The violations occurred despite clear facility policies requiring staff action on pharmacist recommendations. The 2014 policy specifically outlined the process: recommendations should be acted upon and documented, with physician explanations required for any rejections.
Neither happened for either resident.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few residents. But the cases highlighted broader medication safety concerns at facilities caring for vulnerable populations with severe cognitive impairment.
Both residents depended entirely on staff for basic care decisions. Resident 16 never or rarely made decisions independently. Resident 41 also had severely impaired cognitive skills for daily decision-making.
The inspection found that licensed nursing staff simply failed to follow through on the pharmacist's safety recommendations, leaving two cognitively impaired residents on potentially problematic medication regimens without required physician oversight.
The facility's medication management failures extended beyond simple oversight. Staff had clear policies, specific pharmacist recommendations, and regulatory requirements—but failed to act on any of them for more than a month.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CRENSHAW NURSING HOME in LOS ANGELES, CA was cited for violations during a health inspection on March 21, 2025.
Resident 16 had been prescribed lorazepam 0.5 milligrams every 12 hours as needed for restlessness.
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.