Lakewood Healthcare Center: Oxygen Safety Failure - CA
The violation, cited under federal tag F0695, covered respiratory care. Inspectors found the facility had not administered oxygen as prescribed, raising the prospect that residents received either too much or too little of it. The Director of Nursing acknowledged the stakes directly, telling inspectors it was important to deliver the correct amount of oxygen to maintain residents at their indicated levels.
That statement made the lapse harder to explain away.
Oxygen is not a medication where approximate dosing is the standard. Too little leaves residents hypoxic, their organs and brain tissue starved. Too much, particularly in residents with certain chronic lung conditions, can suppress the drive to breathe, or cause damage to lung tissue over time. The correct amount is prescribed for a reason, and the reason is that the wrong amount causes harm.
The facility's own policy, last updated in November 2017, was unambiguous. Oxygen would be administered under safe and sanitary conditions to meet resident needs. Licensed nursing staff would administer it as prescribed. Nasal tubing would be changed no more than every seven days and labeled with the date of the change.
The labeling requirement exists precisely so that anyone looking at a resident's tubing can tell immediately whether it is within its safe use window. Without a date on the tubing, there is no way to know how long it has been in place. Tubing that sits too long becomes a vector for bacterial growth and can degrade in ways that affect how oxygen flows.
Inspectors found the facility was not following that protocol.
The inspection was triggered by a complaint, meaning someone, a resident, a family member, or a staff member, contacted regulators before investigators ever walked through the door. The complaint process is the primary mechanism through which problems that don't surface during routine annual surveys get reported. Facilities can go months between standard inspections. A complaint inspection compresses that timeline when there is reason to believe residents are being harmed now.
The harm level in this citation was classified as minimal harm or potential for actual harm, and the number of residents affected was listed as few. Those are the lowest rungs on the federal harm scale, and they matter for how a facility is scored and whether fines are assessed. But they describe the regulatory classification, not the experience of the residents involved.
A resident who depends on supplemental oxygen typically depends on it because their lungs cannot do the work on their own. They may have chronic obstructive pulmonary disease, heart failure, pneumonia, or any number of conditions that have left their respiratory system unable to maintain adequate blood oxygen without help. For those residents, the equipment delivering that oxygen is not incidental to their care. It is central to it.
Lakewood Healthcare Center is a skilled nursing facility operating in Downey, in Los Angeles County. The inspection was conducted on August 27, 2025.
The Director of Nursing's own words during the inspection, that delivering the correct amount of oxygen matters for maintaining residents at their indicated levels, described a standard the facility had not met. The policy was written. The expectation was clear. The tubing was not being labeled and changed as required, and oxygen was not being administered as prescribed.
For the residents on supplemental oxygen at the time, the gap between what the policy said and what was actually happening was measured in the air they were breathing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakewood Healthcare Center from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 14, 2026 · Our methodology
LAKEWOOD HEALTHCARE CENTER in DOWNEY, CA was cited for violations during a health inspection on August 27, 2025.
The violation, cited under federal tag F0695, covered respiratory care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.