Lakewood Healthcare Center
12023 Lakewood Blvd. · Downey, CA · 90242 · 5628690978
290 certified beds For profit - Corporation Chain: Pacific Healthcare Holdings
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$128,597 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 3 · $128,597 |
Inspection citations (125 in the current record)
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Potential for harm · D April 28, 2026 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected May 8, 2026 · Resident Rights
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Potential for harm · E January 28, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected February 19, 2026 · Resident Rights
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Potential for harm · D January 28, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 19, 2026 · Resident Assessment and Care Planning
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Potential for harm · E January 28, 2026 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected February 19, 2026 · Quality of Life and Care
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Potential for harm · D January 9, 2026 · found via complaint
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected January 18, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 31, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 17, 2026 · Quality of Life and Care
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Actual harm · G December 18, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected January 21, 2026 · Quality of Life and Care
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Actual harm · G December 18, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 26, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected January 21, 2026 · Resident Rights
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Potential for harm · D December 18, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected January 21, 2026 · Resident Rights
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Potential for harm · F December 18, 2025
Keep residents' personal and medical records private and confidential.
Corrected January 21, 2026 · Resident Rights
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Potential for harm · D December 18, 2025
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected January 21, 2026 · Resident Rights
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Potential for harm · D December 18, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 21, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 18, 2025
Ensure each resident receives an accurate assessment.
Corrected January 21, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 18, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 26, 2026 · Resident Assessment and Care Planning
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Potential for harm · E December 18, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 21, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected January 21, 2026 · Quality of Life and Care
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Potential for harm · E December 18, 2025
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.
Corrected February 26, 2026 · Nursing and Physician Services
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Potential for harm · E December 18, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 26, 2026 · Pharmacy Service
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Potential for harm · D December 18, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected January 21, 2026 · Pharmacy Service
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Potential for harm · D December 18, 2025
Ensure that residents are free from significant medication errors.
Corrected February 26, 2026 · Pharmacy Service
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Potential for harm · E December 18, 2025
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected January 21, 2026 · Nutrition and Dietary
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Potential for harm · E December 18, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected January 21, 2026 · Nutrition and Dietary
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Potential for harm · E December 18, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected February 26, 2026 · Nutrition and Dietary
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Potential for harm · E December 18, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 26, 2026 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 18, 2025 | Fine | $87,071 |
| December 18, 2025 | Payment Denial | 35 days |
| June 13, 2025 | Fine | $14,901 |
| June 13, 2025 | Payment Denial | 13 days |
| August 2, 2024 | Fine | $26,625 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555099 · certified since August 1, 1978. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.