Inspection citations
14’22
6’23
38’24
29’25
2’26
89 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jun 23, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 23, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Aug 4, 2025 | B · minimal | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Aug 4, 2025 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Routine |
| Aug 4, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Aug 4, 2025 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Aug 4, 2025 | D · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Aug 4, 2025 | D · potential | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Routine |
| Aug 4, 2025 | D · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Aug 4, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Aug 4, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Aug 4, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Aug 4, 2025 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Aug 4, 2025 | D · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Routine |
| Aug 4, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Aug 4, 2025 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Aug 4, 2025 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Aug 4, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Aug 4, 2025 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Aug 4, 2025 | D · potential | Ensure 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. | Routine |
| Aug 4, 2025 | D · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Aug 4, 2025 | D · potential | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Routine |
| Aug 4, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Aug 4, 2025 | D · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Routine |
| Aug 4, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Aug 4, 2025 | D · potential | Implement a program that monitors antibiotic use. | Complaint |
| Aug 4, 2025 | D · potential | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Routine |
| Jun 18, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jun 2, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Jun 2, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Feb 5, 2025 | B · minimal | Ensure 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. | Complaint |
| Nov 21, 2024 | B · minimal | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Nov 21, 2024 | B · minimal | Provide and implement an infection prevention and control program. | Complaint |
| Oct 2, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Oct 2, 2024 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Oct 2, 2024 | D · potential | Implement 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. | Complaint |
| Sep 3, 2024 | B · minimal | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Sep 3, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Sep 3, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jun 26, 2024 | B · minimal | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jun 26, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jun 26, 2024 | B · minimal | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Apr 12, 2024 | B · minimal | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Apr 12, 2024 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Apr 12, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Apr 12, 2024 | B · minimal | Honor 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. | Routine |
| Apr 12, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Apr 12, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Apr 12, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Apr 12, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Apr 12, 2024 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Apr 12, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Apr 12, 2024 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Apr 12, 2024 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Apr 12, 2024 | D · potential | 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. | Routine |
| Apr 12, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Apr 12, 2024 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Apr 12, 2024 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Apr 12, 2024 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Apr 12, 2024 | E · potential | Ensure 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. | Routine |
| Apr 12, 2024 | D · potential | Ensure 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. | Routine |
| Apr 12, 2024 | D · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Apr 12, 2024 | D · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Apr 12, 2024 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Apr 12, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 12, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Apr 12, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 12, 2024 | D · potential | Keep all essential equipment working safely. | Routine |
| Apr 12, 2024 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Dec 13, 2023 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Complaint |
| Dec 13, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 24, 2023 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Complaint |
| Oct 24, 2023 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Complaint |
| Oct 24, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Oct 2, 2023 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Mar 18, 2022 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Mar 18, 2022 | D · potential | 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. | Routine |
| Mar 18, 2022 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Mar 18, 2022 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Mar 18, 2022 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Mar 18, 2022 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Mar 18, 2022 | D · potential | Implement 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. | Routine |
| Mar 18, 2022 | D · potential | Ensure 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. | Routine |
| Mar 18, 2022 | E · potential | Ensure 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. | Routine |
| Mar 18, 2022 | D · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Mar 18, 2022 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Mar 18, 2022 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Mar 18, 2022 | D · potential | Implement a program that monitors antibiotic use. | Routine |
| Mar 18, 2022 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Gordon Lane Care Center
1821 E Chapman Ave, Fullerton, CA 92831 · (714) 879-7301
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555797
- Certified beds
- 99
- Legal owner
- Gordon Lane Healthcare LLC
- Part of
- David Johnson
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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