Crenshaw Nursing Home: Missing Oxygen Care Plan - CA
Inspectors cited the facility following a March 21, 2025 survey after reviewing records and interviewing staff about Resident 105, a patient who had been admitted to the facility twice and whose health conditions placed her among the most medically complex residents a nursing home can serve.
End-stage renal disease means the kidneys have failed permanently. Diabetes complicates wound healing and blood sugar control. Dementia, in Resident 105's case, had progressed to the point where her cognition was rated as moderately impaired, according to a resident assessment completed just days before inspectors arrived. She depended on staff to shower her and dress her. She was also receiving oxygen therapy, meaning she required supplemental oxygen beyond what she could take in from the air on her own.
There was no care plan for any of it. Not for the oxygen.
A licensed vocational nurse on staff confirmed it directly. During an interview on March 19, 2025, LVN 2 told inspectors there was no care plan addressing Resident 105's oxygen use. She said developing one mattered because it would show staff what services they needed to provide, help them track the interventions they were using, and document the outcomes of those interventions over time. A care plan, she said, would also show whether the oxygen therapy was actually helping.
The nurse knew exactly what was missing. The document just didn't exist.
Care plans in nursing homes are not administrative paperwork. For a resident like Resident 105, who cannot reliably communicate her own needs and depends on staff for basic daily tasks, a care plan is the mechanism that connects her medical conditions to the people responsible for managing them on any given shift. Without one for her oxygen therapy, there was no written record of her goals, no documented interventions, no timeframe for reassessment, and no way for staff coming onto a shift to know what progress, if any, had been made.
The facility's own policy, last updated in March 2022, described care plans as documents that must include measurable objectives, timeframes, resident goals, and desired outcomes. The policy said care plans should reflect current standards of practice for a resident's conditions and problem areas.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, and found it affected few residents in their sample of six. The citation fell under the federal tag governing care planning.
That classification does not mean the gap was trivial. Oxygen therapy in a patient with end-stage renal disease and dementia is not a routine intervention. Kidney failure affects nearly every system in the body, including how the lungs manage fluid and how the blood carries oxygen. A patient in that condition, receiving supplemental oxygen, requires monitoring. Someone needs to know what the target is, what the response has been, and what to do if the situation changes.
Crenshaw Nursing Home is located at 1900 S. Longwood Avenue in Los Angeles.
Inspectors found no care plan for Resident 105's oxygen therapy. A nurse on staff confirmed it was missing and explained, without apparent disagreement, why it mattered. The facility's own written policy described exactly what should have been there.
Resident 105, moderately cognitively impaired and dependent on staff for her most basic needs, had no documented plan for the treatment keeping her breathing.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 5, 2026 · Our methodology
CRENSHAW NURSING HOME in LOS ANGELES, CA was cited for violations during a health inspection on March 21, 2025.
End-stage renal disease means the kidneys have failed permanently.
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.