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Public Record

Gordon Lane Care Center

Nursing HomeFullerton, CACMS 555797
120 citations on record

From CMS

Facility profile

CMS overall rating
2 / 5

*CMS Five-Star

Certified beds
99

*CMS

Avg. residents per day
93.1

*CMS

Inspection record

On record from CMS

Citations on record
120

*CMS

Inspections on file
19

*CMS

Last inspection
2025-08-04

*CMS

Citations

120 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0645Generalpotential for harm

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0628Generalpotential for harm

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  • 0605Generalpotential for harm

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  • 0578Generalpotential for harm

    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.

  • 0558Generalpotential for harm

    Reasonably accommodate the needs and preferences of each resident.

  • 0557Generalpotential for harm

    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  • 0550Generalno actual harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0838Generalpotential for harm

    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.

  • 0813Generalpotential for harm

    Have a policy regarding use and storage of foods brought to residents by family and other visitors.

  • 0761Generalpotential for harm

    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.

  • 0757Generalpotential for harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0698Generalpotential for harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0697Generalpotential for harm

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0694Generalpotential for harm

    Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  • 0693Generalpotential for harm

    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.

  • 0686Generalpotential for harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0161Generalpotential for harm

    Use approved construction type or materials.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0909Generalpotential for harm

    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.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0849Generalpotential for harm

    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.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0761Generalno actual harm

    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.

  • 0880Generalno actual harm

    Provide and implement an infection prevention and control program.

  • 0657Generalno actual harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0609Generalpotential for harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0758Generalpotential for harm

    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.

  • 0557Generalno actual harm

    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0842Generalno actual harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0656Generalno actual harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0804Generalpotential for harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0271Generalpotential for harm

    Have exits that are accessible at all times.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0355Generalpotential for harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0550Generalno actual harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0558Generalpotential for harm

    Reasonably accommodate the needs and preferences of each resident.

  • 0585Generalno actual harm

    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.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0686Generalpotential for harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0693Generalpotential for harm

    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.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0697Generalpotential for harm

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0698Generalpotential for harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0726Generalpotential for harm

    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.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0761Generalpotential for harm

    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.

  • 0803Generalpotential for harm

    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.

  • 0805Generalpotential for harm

    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  • 0806Generalpotential for harm

    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0908Generalpotential for harm

    Keep all essential equipment working safely.

  • 0919Generalpotential for harm

    Make sure that a working call system is available in each resident's bathroom and bathing area.

  • 0552Generalpotential for harm

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • 0032Generalpotential for harm

    Provide primary/alternate means for communication.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0578Generalpotential for harm

    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.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0623Generalpotential for harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0625Generalpotential for harm

    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.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0580Generalpotential for harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0583Generalno actual harm

    Keep residents' personal and medical records private and confidential.

  • 0836Generalpotential for harm

    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0761Generalpotential for harm

    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.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0656Generalno actual harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0770Generalpotential for harm

    Provide timely, quality laboratory services/tests to meet the needs of residents.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0757Generalpotential for harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0223Generalpotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0374Generalpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0923Generalpotential for harm

    Have proper medical gas storage and administration areas.

  • 0921Generalpotential for harm

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0805Generalpotential for harm

    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  • 0803Generalpotential for harm

    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.

  • 0761Generalpotential for harm

    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.

  • 0758Generalpotential for harm

    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.

  • 0757Generalpotential for harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

  • 0688Generalpotential for harm

    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.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

  • Inspection29 deficiencies

    F 0550 Level of Harm - Potential for minimal harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation…

    Read full statement of deficiencies
  • Inspection29 deficiencies
    View inspection report
  • Inspection1 deficiency

    F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility…

    Read full statement of deficiencies
  • Inspection2 deficiencies

    F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the allegation…

    Read full statement of deficiencies
  • Inspection1 deficiency

    F 0761 Level of Harm - Potential for minimal harm Residents Affected - Some 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…

    Read full statement of deficiencies
  • Inspection2 deficiencies

    F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**…

    Read full statement of deficiencies
  • Inspection3 deficiencies

    F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview…

    Read full statement of deficiencies
  • Inspection3 deficiencies

    F 0557 Level of Harm - Potential for minimal harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical…

    Read full statement of deficiencies
  • Inspection3 deficiencies

    F 0656 Level of Harm - Potential for minimal harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview…

    Read full statement of deficiencies
  • Inspection34 deficiencies
    Read full statement of deficiencies

Showing the 10 most recent inspections. 10 earlier inspections are also on record.

FAQ

Questions and answers

What is Gordon Lane Care Center?
Gordon Lane Care Center is a Medicare- and Medicaid-certified nursing home in Fullerton, CA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 555797.
What is the CMS rating for Gordon Lane Care Center?
Gordon Lane Care Center has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Gordon Lane Care Center have?
Gordon Lane Care Center is certified for 99 beds. It serves an average of 93.1 residents per day.
How many citations does Gordon Lane Care Center have?
Gordon Lane Care Center has 120 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Gordon Lane Care Center last inspected?
Gordon Lane Care Center was last inspected on August 4, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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