Gordon Lane Care Center

F-F656.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 555797 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555797 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Gordon Lane Care Center 1821 E Chapman Ave Fullerton, CA 92831

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37726

Residents Affected - Some Based on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate medical record for one of seven sampled residents (Resident 1).

* The facility failed to ensure the licensed nurse documented her initials on Resident 1's TAR (indicating the treatment was provided) as per the facility's P&P. This failure had the potential for the resident's needs not being met as the medical information was incomplete.

Findings:

Review of the facility's P&P titled Documentation in Medical Record dated 12/19/22, showed the licensed staff shall document all services provided in the resident's medical record in accordance with state law and facility policy.

Medical record review for Resident 1 was initiated on 6/6/24. Resident 1 was admitted to the facility on [DATE REDACTED].

Review of Resident 1's Order Summary Report showed an order dated 5/20/24, to apply a warm compress to Resident 1's right groin area for 20 minutes four times a day for five days.

Review of Resident 1's TAR for May 2024 showed the licensed nurse failed to document her initials on the TAR for the application of Resident 1's warm compress to the right groin area for 20 minutes on 5/21/24 at 0900 and 1300 hours.

On 6/25/24 at 1035 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified she was assigned to care for Resident 1 on 5/21/24, duringthe morning shift (0700 to 1500 hours). LVN 4 verified Resident 1's TAR failed to show documentation (licensed nurse's initials) Resident 1's warm compress to the right groin was applied on 5/21/24 at 0900 and 1300 hours. LVN 4 stated the treatment nurse who administered Resident 1's warm compress was responsible for documenting (on the TAR) the warm compress was applied. LVN 4 stated the purpose of documenting the licensed nurse's initials

on the resident's TARwas to indicate the resident's treatment was provided as ordered by the physician and applied at the time the treatment was ordered by the physician.

On 6/25/24 at 1145 hours, an interview was conducted with the DON. The DON was asked about the facility's policy specific to documentation of the resident'streatments. The DON stated after a licensed nurse administered a treatment, the licensed nurse was required to document on the resident's TAR to show the treatment was administered in accordance with the physician's order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 555797