Report
TheVardellReport
Lakeport Post Acute
Skilled nursing facility and nursing facility
1291 Craig Avenue
Lakeport, CA 95453
Report
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The Vardell Report.Lakeport Post Acute
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Lakeport, CA
- Record Period
- 2022–2026
- Source Documents
- 9
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 7 inspections from June 2022 to May 2026, state surveyors documented 49 findings at Lakeport Post Acute; 49 have a recorded correction; CMS lists 1 enforcement action in the window.
- Inspections
- 7
- 2022–2026, complaint and standard
- Findings
- 49
- Deficiencies cited by state inspectors
- Corrected
- 49
- Of 49 findings, with a recorded correction date
- Penalties
- 1
- 1 fine; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2022 | 1 | 18 | 0 |
| 2023 | 3 | 20 | 0 |
| 2024 | 0 | 0 | 0 |
| 2025 | 2 | 10 | 0 |
| 2026 | 1 | 1 | 1 |
What the Record Shows
- 49 of 49 findings have a recorded correction date.
- CMS lists 1 enforcement action in the window: 1 fine of $8,492, its payment not published.
- 5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, June 19, 2025, recorded 9 findings (most serious: Level F).
What to Ask About
- Infection Control, Cited in Three Inspections
- Care Plans, Cited in Two Inspections
- Care Plan Timing and Review, Cited in Two Inspections
- Professional Standards, Cited in Two Inspections
- Quality of Care, Cited in Two Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Nursing Staff Levels, Cited in Two Inspections
- Food Quality and Temperature, Cited in Two Inspections
- Kitchen and Food Safety, Cited in Two Inspections
Report at a Glance
- Facility
- Lakeport Post Acute
- Address
- 1291 Craig Avenue, Lakeport, CA 95453
- CMS Certification Number
- 555222
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 81
- Ownership
- For profit - Limited Liability company
- Record Window
- June 28, 2022 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F760Ensure that residents are free from significant medication errors.Level GActual harmCorrected May 26, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
9 findings
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Jul 10, 2025
- F697Provide safe, appropriate pain management for a resident who requires such services.Level ENo actual harm, potential for moreCorrected Jul 10, 2025
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Jul 10, 2025
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jul 10, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jul 10, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 10, 2025
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jul 10, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Jul 10, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 10, 2025
Enforcement Action
Civil money penalty, $8,492 imposed May 13, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 19, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Mar 13, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
18 findings
The same visit included a complaint investigation.
- F574The resident has the right to receive notices in a format and a language he or she understands.Level FNo actual harm, potential for moreCorrected Jan 18, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Jan 18, 2024
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level FNo actual harm, potential for moreCorrected Jan 18, 2024
- F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Level FNo actual harm, potential for moreCorrected Jan 18, 2024
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Jan 18, 2024
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Feb 1, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Jan 18, 2024
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Jan 18, 2024
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Level ENo actual harm, potential for moreCorrected Jan 18, 2024
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Jan 18, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F908Keep all essential equipment working safely.Level DNo actual harm, potential for moreCorrected Jan 19, 2024
- F551Give the resident's representative the ability to exercise the resident's rights.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
- F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Level DNo actual harm, potential for moreCorrected Jan 18, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Dec 2, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 25, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2022
Standard health inspection
18 findings
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 27, 2022
- F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Jul 27, 2022
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Jul 27, 2022
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesLevel DNo actual harm, potential for moreCorrected Jul 27, 2022
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jul 27, 2022
- F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Jul 27, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jul 27, 2022
- F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Level DNo actual harm, potential for moreCorrected Jul 27, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jul 27, 2022
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Jul 27, 2022
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Infection Control, Cited in Three Inspections
Inspectors cited F880 in June 2022, December 2023 and June 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F880 across all 7 inspections, oldest to newest - 2
Care Plans, Cited in Two Inspections
Inspectors cited F656 in June 2022 and June 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F656 across all 7 inspections, oldest to newest - 3
Care Plan Timing and Review, Cited in Two Inspections
Inspectors cited F657 in June 2022 and December 2023. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F657 across all 7 inspections, oldest to newest - 4
Professional Standards, Cited in Two Inspections
Inspectors cited F658 in June 2022 and February 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F658 across all 7 inspections, oldest to newest - 5
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in December 2023 and June 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F684 across all 7 inspections, oldest to newest - 6
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in June 2022 and October 2023. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F689 across all 7 inspections, oldest to newest - 7
Nursing Staff Levels, Cited in Two Inspections
Inspectors cited F725 in June 2022 and June 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F725 across all 7 inspections, oldest to newest - 8
Food Quality and Temperature, Cited in Two Inspections
Inspectors cited F804 in June 2022 and December 2023. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F804 across all 7 inspections, oldest to newest - 9
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in June 2022 and June 2025. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
22232323252526F812 across all 7 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level F.
- 02
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level E.
- 03
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in two inspections, most seriously at level E.
- 04
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in two inspections, most seriously at level E.
- 05
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level D.
- 06
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level E.
- 07
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Nursing Staff Levels: cited in two inspections, most seriously at level F.
- 08
May we try a meal, and how do you check food temperature by the time it reaches residents?
Food Quality and Temperature: cited in two inspections, most seriously at level F.
- 09
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level E.
- 10
What led to the 2026 fine, and has it been paid?
An $8,492 civil money penalty was imposed May 13, 2026. CMS publishes the fine, not whether it has been paid.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Jun 28, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Oct 5, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Nov 6, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Dec 18, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Feb 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Jun 19, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection May 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 555222
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowJune 28, 2022 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before June 2022 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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