
Report
TheVardellReport
Lakewood Healthcare Center
Skilled nursing facility and nursing facility
12023 Lakewood Blvd.
Downey, CA 90242

TheVardellReport
Skilled nursing facility and nursing facility
12023 Lakewood Blvd.
Downey, CA 90242
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 31 inspections from October 2023 to June 2026, state surveyors documented 121 findings at Lakewood Healthcare Center; 121 have a recorded correction; CMS lists 5 enforcement actions in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 20 | 0 |
| 2024 | 9 | 43 | 1 |
| 2025 | 16 | 51 | 3 |
| 2026 | 4 | 7 | 0 |
Chronology
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.
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
26 findings
Enforcement Action
Civil money penalty, $87,071 imposed December 18, 2025. 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 December 18, 2025, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed December 18, 2025. Status: Closed, February 26, 2026. CMS does not tie a penalty to a survey; listed with the standard health inspection of December 18, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
26 findings
Enforcement Action
Civil money penalty, $14,901 imposed June 13, 2025. 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 October 4, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed June 13, 2025. Status: Closed, July 23, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 4, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
5 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
19 findings
The same visit included a complaint investigation.
Enforcement Action
Civil money penalty, $26,625 imposed August 2, 2024. 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 October 2, 2023, the nearest before the penalty date.
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
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F689 in October 2023, October 2023, March 2024, August 2024, February 2025, May 2025, June 2025, July 2025, December 2025, December 2025 and June 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F656 in October 2024, April 2025, July 2025, August 2025, December 2025, January 2026 and June 2026. 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.
Inspectors cited F609 in October 2023, February 2024, March 2024, August 2024 and March 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. 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.
Inspectors cited F657 in October 2023, April 2024, October 2024, April 2025 and June 2025. 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.
Inspectors cited F658 in August 2024, September 2024, June 2025, June 2025 and July 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.
Inspectors cited F684 in October 2023, August 2024, February 2025, March 2025 and December 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. 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.
Inspectors cited F580 in October 2024, November 2024, July 2025 and January 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. 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.
Inspectors cited F600 in April 2024, August 2024, July 2025 and December 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in October 2023, April 2024, October 2024 and December 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. 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.
Inspectors cited F550 in March 2024, October 2024 and June 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. 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.
Inspectors cited F558 in October 2023, October 2024 and December 2025. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. 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.
Inspectors cited F584 in October 2024, November 2024 and December 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. 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.
Inspectors cited F604 in October 2023, October 2024 and January 2026. The agency describes it this way: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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.
Inspectors cited F726 in October 2023, October 2024 and December 2025. The agency describes it this way: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. 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.
Inspectors cited F755 in October 2024, February 2025 and December 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. 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.
Inspectors cited F760 in August 2024, October 2024 and December 2025. This citation covers whether residents are free from significant medication errors. 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.
Inspectors cited F804 in October 2023, October 2024 and December 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. 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.
Inspectors cited F812 in October 2023, October 2024 and December 2025. This citation covers how food is stored, prepared and served. 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.
Inspectors cited F912 in October 2023, October 2024 and December 2025. The agency describes it this way: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. 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.
Inspectors cited F557 in October 2023 and April 2026. The agency describes it this way: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. 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.
Inspectors cited F610 in October 2023 and August 2024. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. 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.
Inspectors cited F688 in October 2024 and December 2025. This citation covers care that keeps or improves a resident’s movement and mobility. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F695 in October 2024 and August 2025. This citation covers oxygen, breathing treatments and other respiratory care. 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.
Inspectors cited F759 in October 2024 and December 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. 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.
Inspectors cited F761 in October 2023 and October 2024. This citation covers how drugs are labeled and kept locked, including controlled drugs. 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.
Inspectors cited F802 in October 2024 and December 2025. The agency describes it this way: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. 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.
Inspectors cited F814 in October 2023 and October 2024. This citation covers whether garbage and refuse are disposed of properly. 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.
Inspectors cited F842 in February 2025 and August 2025. This citation covers whether resident records are complete, accurate and kept confidential. 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.
Inspectors cited F911 in October 2024 and December 2025. The agency describes it this way: Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. None rose above level B (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
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 11 inspections, most seriously at level J.
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in seven inspections, most seriously at level E.
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in five inspections, most seriously at level E.
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in five inspections, most seriously at level E.
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in five inspections, most seriously at level E.
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 five inspections, most seriously at level E.
How quickly will we hear about a fall, an injury or a change in condition, and from whom?
Telling Families About Changes: cited in four inspections, most seriously at level E.
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in four inspections, most seriously at level G.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in four inspections, most seriously at level E.
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in three inspections, most seriously at level D.
How do you adjust rooms, schedules and routines to a resident’s needs and preferences?
Needs and Preferences: cited in three inspections, most seriously at level E.
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in three inspections, most seriously at level E.
What changed after F604 was cited, and how do you check it now?
Citation F604: cited in three inspections, most seriously at level D.
What changed after F726 was cited, and how do you check it now?
Citation F726: cited in three inspections, most seriously at level E.
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in three inspections, most seriously at level E.
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in three inspections, most seriously at level E.
May we try a meal, and how do you check food temperature by the time it reaches residents?
Food Quality and Temperature: cited in three inspections, most seriously at level E.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in three inspections, most seriously at level F.
What changed after F912 was cited, and how do you check it now?
Citation F912: cited in three inspections, most seriously at level E.
What changed after F557 was cited, and how do you check it now?
Citation F557: cited in two inspections, most seriously at level E.
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in two inspections, most seriously at level E.
What do you do to keep residents moving, and who provides range-of-motion care?
Mobility and Range of Motion: cited in two inspections, most seriously at level G.
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in two inspections, most seriously at level E.
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level E.
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level E.
What changed after F802 was cited, and how do you check it now?
Citation F802: cited in two inspections, most seriously at level E.
How is waste handled around the kitchen and resident areas?
Garbage and Refuse: cited in two inspections, most seriously at level F.
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level D.
What changed after F911 was cited, and how do you check it now?
Citation F911: cited in two inspections, most seriously at level B.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
What led to the 2025 fine, and has it been paid?
An $87,071 civil money penalty was imposed December 18, 2025. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
California state survey agency
Inspection Oct 2, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Oct 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Feb 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Mar 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Aug 2, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Aug 26, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Sep 24, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Oct 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Nov 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Feb 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Feb 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Mar 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection May 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jun 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jun 24, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jul 8, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jul 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jul 30, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jul 31, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Aug 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Aug 28, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Dec 31, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jan 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jan 28, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Apr 28, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
California state survey agency
Inspection Jun 8, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 555099
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowOctober 2, 2023 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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