Crenshaw Nursing Home

In the surveyor’s words

From the most serious findings on record at Crenshaw Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF622Apr 11, 2025

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had severe cognitive impairment, was safely discharged when the facility failed to: 1. Ensure an Interdisciplinary Meeting ([IDT] gathering where healthcare professionals from different disciplines collaborate to discuss a patient's care, develop shared understandings, and coordinate treatment plans) for discharge planning was conducted for Resident 1. 2. Ensure Resident 1 ' s discharge location (house) could meet the resident ' s needs. 3. Follow up with Resident 1 after his discharge from the facility to the house, to ensure Resident 1 was safe and comfortably settled. 4. […]

• Immediate jeopardy, isolatedF600Apr 26, 2024

  Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse (willful infliction of injury with resulting physical harm, pain, or mental anguish) by Resident 2, by failing to: 1. Ensure Resident 1 (victim) was not subjected to a repetitive physical abuse from Resident 2 (aggressor). 2. Ensure Resident 1 and Resident 2 were separated and were not left to continue residing in the same room, after Resident 1 reported to a Licensed Vocational Nurse (LVN 1) that Resident 2 hit him on 4/1/ 2024. 3. […]

• Immediate jeopardy, isolatedF684Feb 13, 2023

  Based on observation, interview, and record review, the facility's licensed nurses failed to provide the necessary care and services for one of seven sampled residents (Resident A). Resident A, who had a long history of psychotic behavior (disorganized or incoherent speech confused thinking strange, possibly dangerous behavior) and a diagnosis that included schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), to meet the mental/physical care needs of Resident A. The facility failed to: 1. […]

• Immediate jeopardy, isolatedF689Jan 11, 2023

  Based on observation, interview, and record review, the facility failed to provide supervision to prevent the resident, who was at risk for elopement and had a physician order for one-to-one [(1:1) one staff to resident supervision] monitoring, from eloping (leaving unnoticed/unsupervised without permission/authorization) from the facility, for one of five sampled residents with elopement risks (Resident 1). The facility failed to: 1. Ensure the Licensed Vocational Nurse (LVN 3) assigned staff to conduct 1:1 monitoring of Resident 1 on the night shift of 12/29/2022 as ordered by the physician. 2. Ensure the nursing staff monitor Resident 1 at frequent intervals as documented in the resident's care plan titled 'Elopement/Wandering Risk.' 3. […]

• Immediate jeopardy, isolatedF689May 3, 2022

  Based on observation, interview, and record review, the facility failed to ensure the resident, who was a high risk for elopement (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) was monitored and supervised to prevent the resident's elopement from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Supervise Resident 1 while on the back patio to ensure the resident did not elope by going through an opened door of the assisted living facility which was sharing the same patio area. 2. […]