Crenshaw Nursing Home: Care Plan Failure for Dialysis Patient - CA
The resident, identified in inspection records only as Resident 202, was admitted to the facility with end-stage renal disease, the irreversible failure of the kidneys that makes dialysis a permanent, life-sustaining necessity. The resident also had hypertension and anemia. A physician had ordered dialysis every Tuesday, Thursday, and Saturday.
The facility's own records showed the resident was mentally sharp. A clinical assessment completed March 14, 2025, found Resident 202's cognitive skills for daily decision-making were intact. The resident needed moderate help with oral hygiene, dressing, and personal hygiene, but was capable of understanding and participating in their own medical care.
None of that changed the fact that no care plan existed.
When inspectors reviewed Resident 202's clinical records on March 19, 2025, they did so alongside the facility's Minimum Data Set Nurse, the clinician responsible for resident assessments. The MDS nurse confirmed it directly: Resident 202 did not have a baseline care plan specific to dialysis. The plan should have been developed by licensed nursing staff within 48 hours of admission, the nurse said. It had not been.
The MDS nurse described what a baseline care plan is supposed to do. It sets the initial goals for a resident based on admission orders. It outlines the interventions staff need to implement to deliver care. Without one, the nurse said, staff would not be able to properly assess and manage Resident 202's dialysis needs.
That admission came from inside the facility, not from inspectors drawing inferences.
Dialysis patients in nursing homes carry a particular clinical burden. End-stage renal disease requires close attention to fluid levels, blood pressure, medication timing, and the condition of vascular access sites used during treatment. A resident going to dialysis three times a week, returning to a facility where no documented plan exists for their care, is a resident whose needs exist only in someone's memory, or not at all.
Crenshaw Nursing Home's own policy, dated March 2022, required a baseline care plan for every resident within 48 hours of admission. The policy stated the plan must include the minimum healthcare information necessary to properly care for the resident. Inspectors found the facility had not followed it.
The deficiency was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale. Inspectors identified it as affecting a single resident.
The facility is located at 1900 S. Longwood Ave. in Los Angeles.
What the inspection record does not say is how long Resident 202 had been receiving dialysis at the facility without a care plan in place, or whether any gaps in care occurred during that time. The MDS assessment was dated March 14. The order summary showing the dialysis schedule was dated March 19. The inspection was completed March 21. The admission date was redacted from the public record.
Resident 202, according to every clinical measure in the file, understood their situation fully. They had the capacity to make medical decisions. Whether anyone explained to them that the facility had not yet written down how to care for them is not recorded.
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.
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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.
The resident also had hypertension and anemia.
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.