Crenshaw Nursing Home

During a review of the facility's policy and procedure (P&P) titled, Informing Residents of Health, Medical Condition and Treatment Options dated 2/2021, the P&P indicated, Each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on an ongoing basis. If a resident has an appointed representative, the representative is also informed.

During a review of the facility's P&P titled, Use of Psychotropic Medication dated 7/2022, the P&P indicated, Resident and/or representative have the right to decline treatment with psychotropic medications and the staff and physician will review the risks related to not taking the medications as well as appropriate alternatives.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 44's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), epilepsy (a chronic brain disorder that sends the wrong signals in the brain and cause seizures), and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 44's Minimum Data Set ([MDS] a resident assessment tool), dated 1/3/2025, the MDS indicated Resident 44 was usually able to understand.

The MDS indicated Resident 44' had no speech (absence of spoken words) and was dependent on staff for showering, dressing, and personal hygiene.

During an observation on 3/18/2025 at 9:59 a.m. in Resident 44's room, the call light was not within reach and was on the floor behind the resident's bed.

During a review of Resident 44's care plan titled, Resident has self-care deficits for activities of daily living ([ADL] - routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves), the care plan indicated the intervention was to have the call light within reach and attend to needs promptly.

During an interview on 3/19/2025 at 11:58 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, the call light needed to always be placed within the resident's reach. LVN 2 stated Resident 44 had right sided weakness to her extremities (arms and legs) and her functional arm/hand was on the left side. LVN 2 stated it was important to place the call light within reach so the resident could call for help from staff when needed.

During a review of facility's undated policy and procedure (P&P) titled, Call Lights, the P&P indicated to assure residents receive prompt assistance.

The P&P indicated to ensure that the call light is within the resident's reach when in his/her room.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During an observation, on 3/20/2025 at 9:00 a.m., at the Annex Station, a signage was observed posted on the wall, inside of the nursing station indicating, CDPH survey information available upon request.

During a concurrent observation and interview on 3/20/2025 at 9:47 a.m., with the Director of Nursing (DON), the DON stated all recertification survey results should have been in a folder at the nursing station, freely accessible to all residents.

The DON stated the survey binder was not placed near the signage or around the nurse's station.

The DON stated the risk of not providing free access to the facility's survey binder could result in residents not being informed of the facility's previous survey information and if any corrections were made.

A review of the facility's policy and procedures (P&P) titled, CDPH 327- Attachment F: Resident [NAME] of Rights dated 5/2011, indicated A resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.

The P&P indicated, The facility must make the results available for examination in a place readily accesible to residents and must post a notice of their availability.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of Resident 202's admission Record, the admission Record indicated Resident 202 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease ([ESRD] irreversible kidney failure), hypertension ([HTN] high blood pressure) and anemia (a condition where the body does not have enough healthy red blood cells).

During a review of Resident 202's History and Physical (H&P) dated 3/9/2025, the H&P indicated Resident 202 had the mental capacity to understand and make medical decisions.

During a review of Resident 202's Minimum Data Set ([MDS] a resident assessment tool) dated 3/14/2025, the MDS indicated Resident 202's cognitive (ability to think and reason) skills for daily decision making was intact.

The MDS indicated Resident 202 required moderate assistance (staff does less than half the effort) for oral hygiene, upper body dressing, and personal hygiene.

The MDS indicated Resident 202 was on dialysis.

During a review of Resident 202's Order Summary dated 3/19/2025, the Order Summary Report indicated Resident 202 had a physician order for dialysis treatment every Tuesday, Thursday, and Saturday.

During a concurrent interview and record review on 3/19/2025 at 2:15 p.m., with the Minimum Data Set Nurse (MDSN), Resident 202's clinical records were reviewed.

The MDSN stated Resident 202 did not have a baseline care plan specific for the resident's dialysis treatment.

The MDSN stated a baseline care plan should have been developed and completed by licensed nursing staff upon the resident's admission to the facility.

The MDSN stated the baseline care plan was the initial goal for the resident based on the admission orders and interventions needed to implement the resident's care.

The MDSN stated facility staff would not be able to properly assess and manage the dialysis need of Resident 202 since there was no baseline care plan developed for the resident.

During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plans dated 3/2022, the P&P indicated A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

The P&P indicated baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 105's diagnoses included end stage renal disease ([ESRD] irreversible kidney failure, diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 105's Minimum Data Set ([MDS] a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 105's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired.

The MDS indicated Resident 105 was dependent on staff for showering and dressing.

The MDS indicated Resident 105 required respiratory treatment with O2 therapy (providing a patient with supplemental O2, which is extra oxygen beyond what they can breathe from the air).

During an interview on 3/19/2025 at 12:25 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated there was no care plan to address Resident 105's use of O2. LVN 2 stated it was important to develop a care plan for Resident 105's use of O2 to reflect what services the staff needed to provide for the resident. LVN 2 stated the development of a care plan would help the staff keep track of the interventions and the outcomes of those interventions. LVN 2 also stated the care plan would show Resident 105's progression with the use of oxygen and to see if the interventions were working.

During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan describes the services that were to include measurable objectives and timeframes.

The P&P indicated the care plan were to include resident's goals and desired outcomes.

The P&P indicated the care plan was to reflect current recognized standards of practice for problem areas and conditions.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of the facility's P&P titled, Medication Administration-General Guidelines dated 4/2008, the P&P indicated, medications should be administered in accordance with written orders of the attending physician.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

pressure ulcers.

The P&P indicated the physician will order pertinent wound treatments, including

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of the facility's policy and procedure (P&P), titled, Tracheostomy Site Care, Dressing Change, and Inner Cannula, dated 10/25/2011, the P&P indicated, tracheostomy care must be performed on tracheostomy patients every shift and ensure patency of the altered airway and minimize potential for infection.

• During a review of Resident 16's admission Record, the admission Record indicated, Resident 16 was

initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included COPD, anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 16's MDS, dated [DATE], the MDS indicated, Resident 16's cognitive skills for daily decision making was severely impaired.

The MDS indicated Resident 16 was dependent (helper does all of the effort) from staff with oral hygiene, upper body dressing, and personal hygiene.

During a review of Resident 16's Order Summary Report, dated 3/20/2025, the Order Summary Report indicated, Resident 16's order for Albuterol Sulfate (drug use to treat and prevent shortness of breath) 2.5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) 1 vial (a small plastic bottle often used to store medication in the form of liquid) via nebulizer (machine) every 6 hours as needed for shortness of breath/respiratory distress.

During a concurrent observation and interview on 3/18/2025 at 9:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), in Resident 16's room, LVN 3 stated the face mask nebulizer tubing of Resident 16 was not dated. LVN 3 stated it was unknown when Resident 16's face mask nebulizer tubing was changed because it was not dated and labeled. LVN 3 stated respiratory tubing should be changed once a week for resident safety and infection control.

During a review of the facility's undated P&P titled, Oxygen Administration, the P&P indicated, oxygen tubing should be changed weekly and as needed, including changing the mask, cannula, and nebulizer equipment.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of the facility's policy and procedure (P&P), titled Care of a Resident with End-Stage Renal Disease, dated 9/2010, the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.

The P&P indicated staff training and education includes timing and administration of medications particularly those before and after dialysis.

During a review of the facility's P&P, titled Medication Administration-General Guidelines, dated 4/2008, the P&P indicated, Medications are administered in accordance with written orders of the attending physician.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a concurrent interview and record review on 3/20/2025 at 2:41 p.m., with the Director of Nursing (DON), Residents 16 and 41, clinical records were reviewed.

The DON stated Residents 16 and 41's clinical records did not indicate documentations the licensed nursing staff followed-up with the residents' physicians to address the pharmacist consultant's recommendation regarding the use of lorazepam.

The DON stated the timeline to follow-up pharmacy consultant recommendation was 1 month or before the next scheduled visit of the pharmacy consultant.

The DON stated 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.

During a review of the facility's policy and procedure (P&P), titled, Consultant Pharmacist Reports, dated 8/2014, the P&P indicated, the recommendations should be acted upon and documented by the facility staff and or the prescriber.

The P&P indicated if the physician accepts and acts upon suggestion, or rejects, the physician must provide an explanation for disagreeing.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of the facility's policy and procedure (P&P), titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, for psychotropic medications that are not antipsychotic, if the prescriber or attending physician believed it was appropriate to extend the PRN order beyond 14 days, the physician should document the rationale for extending the use and include the duration for the PRN order.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

Based on observation and interview, the facility failed to ensure the medication room storage

titled, Medication Storage in the Facility.

This deficient practice had the potential for medications be stored in improper temperature, or humidity and can alter the effectiveness of the medication.

Findings

During an observation, on 3/19/2025, at 12:20 p.m., at the medication room storage refrigerator, the refrigerator had unopened insulin (a hormone that lowers the level of blood sugar in the blood) vials, insulin pens, and unopened multidose tuberculin (a substance used in a skin test to help diagnose tuberculosis [TB] infection) injection vials.

The medication storage refrigerator temperature was observed at 48 degrees Fahrenheit.

During a concurrent observation and interview, on 3/19/2025, at 12:22 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated per policy, the temperature for the refrigerator should be maintained between 36-46 degrees. LVN 1 stated the refrigerator temperature was 48 degrees. LVN 1 stated the risk of having an out of range temperature of the medication refrigerator could result in medications expiring.

During a review of the facility's P&P titled, Medication Storage in the Facility, dated 4/2008, the P&P indicated, medications requiring refrigeration or 'temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit), should be kept in a refrigerator with a thermometer to allow temperature monitoring.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

indicated, food items should be dated and labeled when placed in containers.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of Resident 105's admission Record, the admission Record indicated Resident 105 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 105's diagnoses included end stage renal disease ([ESRD] - irreversible kidney failure, diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 105's Minimum Data Set ([MDS] a resident assessment tool), dated 3/18/2025, the MDS indicated Resident 105's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired.

The MDS indicated Resident 105 was dependent on staff for showering, dressing, and from lying to sitting in chair.

The MDS indicated Resident 105 required respiratory treatment with oxygen therapy (providing a patient with supplemental oxygen, which is extra oxygen beyond what they can breathe from the air).

During an observation on 3/18/2025 at 10:34 a.m. in Resident 1's room, there was a humidifier attached to the oxygen concentrator (a medical device that extracts and concentrates oxygen from air, delivering a higher concentration of oxygen to the patient) that was not dated or labeled.

During an interview on 3/19/2025 at 12:07 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the humidifier with no date labeled, could not be identified if the humidifier was changed. LVN 2 stated the humidifier should have been changed weekly. LVN 2 stated if the humidifier was not changed weekly, it placed the resident at risk for developing a respiratory infection.

During a review of facility's undated policy and procedure (P&P) titled, Oxygen Administration, the P&P indicated the oxygen humidifier should be changed weekly and as needed.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of the facility's document titled, Request for Waiver Variation Letter, dated 3/18/2025, the waiver indicated the House Station rooms 1, 3, 4, 6, 7, 8, 10 and Annex Station rooms 3, 4, 5, 6, 7, 8, and 10, did not meet the requirement of 80 square feet (sq ft) per resident.

During a review of the facility's Client Analysis form, on 3/21/2025, at 9:45 a.m., the facility's Client Analysis form indicated: House Station Rooms a. room [ROOM NUMBER] had three resident beds, which measured 216 square feet. b. room [ROOM NUMBER] had two resident beds, which measured 144 square feet. c. room [ROOM NUMBER] had four resident beds, which measured 252 square feet. d. room [ROOM NUMBER] had three resident beds, which measured 198 square feet. e. room [ROOM NUMBER] had three resident beds, which measured 208 square feet. f. room [ROOM NUMBER] had four resident beds, which measured 260 square feet. g. room [ROOM NUMBER] had one resident bed, which measured at 99 square feet.

055525 03/21/2025

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

F 0912 h.

minimal harm Annex Station Room

a. room [ROOM NUMBER] had four resident beds, which measured at 312 square feet.

During an interview on 3/20/2025, at 9:47 a.m., with the Director of Nursing (DON), the DON stated the Administrator submitted a room waiver form on 3/18/2025.

The DON stated some of the facility's rooms were smaller than the required square footage of 80 square feet per resident.

The DON stated the risk for not meeting the required square footage for each resident could result in residents' not being able to move around freely.

The DON stated there were no harm caused to the residents in the affected rooms.

During observations made to the multiple affected rooms in the House Station Rooms (Rooms 1, 2, 3, 4, 6, 8, 9, 10) and Annex Station Room (room [ROOM NUMBER]) on 3/18/2025 to 3/21/2025, the room sizes of the above rooms did not adversely affect the residents' health and or safety.

The Department is recommending a waiver.

During a review of Resident 16's Admission Record, the Admission Record indicated, Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty of breathing) and dementia (a progressive state of decline in mental abilities).

During a review of Resident 16's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/10/2025, the MDS indicated, Resident 16's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions).

The MDS indicated Resident 16 was dependent (helper does all of the effort) from staff with oral hygiene, upper body dressing, and personal hygiene.

During a review of Resident 16's Order Summary Report (a document containing active orders), dated 3/20/2025, the Order Summary Report indicated, the physician placed a telephone order on 2/1/2025 for Resident 16 to start on lorazepam (medication used to relieve anxiety) to give 0.5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth every 12 hours as needed for anxiety manifested by restlessness (unable to stay still in bed).

2.

During a review of Resident 41's Admission Record, the Admission Record indicated 41 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 41's diagnoses included anxiety disorder, anemia (a condition where the body does not have enough healthy red blood cells), and protein calorie malnutrition (a condition caused by a severe lack of protein and calories).

During a review of Resident 41's MDS, dated [DATE], the MDS indicated, Resident 41's cognitive skills for daily decision making was severely impaired.

The MDS indicated, Resident 41 required maximal assistance (helper does more than half the effort) from staff with eating, upper body dressing, and personal hygiene.

055525

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055525 B.

Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

During a review of Resident 16's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/10/2025, the MDS indicated, Resident 16's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions).

The MDS indicated Resident 16 was dependent (helper does all of the effort) from staff with oral hygiene, upper body dressing, and personal hygiene.

During a review of Resident 16's Order Summary Report, dated 3/20/2025, the Order Summary Report indicated physician's telephone order, dated 2/1/2025, for Resident 16 to start lorazepam (medication used to relieve anxiety) 0.5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth every 12 hours as needed for anxiety manifested by restlessness (unable to stay still in bed).

During a review of the Pharmacist Consultant Medication Regimen Review (MRR), dated 2/15/2025, the MRR indicated the recommended maximum daily dose for lorazepam when used for the elderly is 2mg/day, indicating Resident 16's order of lorazepam 0.5mg/ml every 12 hours as needed, had the potential to exceed 2mg/day.

The MRR indicated pharmacy consultant's recommendation for Resident 16's physician to re-evaluate the order of lorazepam or to document the risk and benefit if the current order was indicated.

2.During a review of Resident 41's Admission Record, the Admission Record indicated 41 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 41's diagnoses included anxiety disorder, anemia (a condition where the body does not have enough healthy red blood cells), and protein calorie malnutrition (a condition caused by a severe lack of protein and calories).

055525

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055525 B.

Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016