Crenshaw Nursing Home: Tracheostomy Care Missed - CA
The Director of Nursing sat with inspectors on March 19 and walked through Resident 12's Treatment Administration Record, which covered March 1 through March 19. The record showed tracheostomy care was not performed on March 2 or March 9. Both were missed by licensed nursing staff.
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See the Derila PillowThe Director of Nursing did not dispute it. She told inspectors that tracheostomy care should be done every day, and as needed beyond that. She explained that the site needs daily cleaning to prevent skin irritation and infection. She said the tube itself needs daily cleaning to reduce the risk of blockage, because a blocked tracheostomy tube obstructs the airway.
The facility's own written policy, last updated in October 2011, goes further than once daily. It calls for tracheostomy care every shift, not just once a day, to keep the airway open and minimize infection risk. On two days in a nine-day stretch, it wasn't done at all.
Inspectors also flagged a second resident's breathing equipment.
Resident 16 has COPD, anxiety disorder, and dementia. Her cognitive abilities for daily decision-making were documented as severely impaired. She depends on staff for oral hygiene, dressing, and personal hygiene. She has a standing order for albuterol sulfate, administered by nebulizer every six hours as needed for shortness of breath or respiratory distress.
On the morning of March 18, an inspector stood in Resident 16's room with Licensed Vocational Nurse 3. The nurse looked at the face mask nebulizer tubing and said it was not dated. She said she didn't know when it had last been changed, because nothing on the equipment indicated when it was replaced or by whom. She said the tubing should be changed once a week for resident safety and infection control.
The facility's policy on oxygen administration, which covers masks, cannulas, and nebulizer equipment, requires weekly changes. There was no way to tell whether that had happened for Resident 16. The tubing carried no date. The nurse who used it every day couldn't say.
For a resident with COPD who depends on that nebulizer when she can't breathe, the condition of the equipment is not a paperwork question.
Crenshaw Nursing Home is located at 1900 S. Longwood Avenue in Los Angeles. The inspection was completed March 21, 2025. CMS assigned the tracheostomy finding a harm level of minimal harm or potential for actual harm, affecting few residents.
That classification sits alongside what the Director of Nursing described in plain terms: a tracheostomy tube that isn't cleaned can become blocked. A blocked tracheostomy tube obstructs the airway.
Resident 12's tracheostomy went uncleaned on a Sunday and again the following Sunday. What happened on those two days, and whether anyone noticed, the inspection record does not say.
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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Last verified: November 12, 2026 · Our methodology
CRENSHAW NURSING HOME in LOS ANGELES, CA was cited for violations during a health inspection on March 21, 2025.
The record showed tracheostomy care was not performed on March 2 or March 9.
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.