Health inspection·September 3, 2024

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 record review, and facility P&P review, the facility failed to ensure the resident personal belongings were properly recorded for two of 10 sampled residents (Residents 2 and 6). This failure had the potential for the residents' personal belongings being lost or stolen. Findings: Review of the facility's P&P titled Resident Personal Belongings revised 12/2022 showed all residents personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. Additional possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory listing. Following the discharge or death of a resident, all personal clothing and items of a customized personal nature are to be given to the designated resident representative. Review of the facility's P&P titled Theft and Loss Program revised 12/2022 showed the following under policy interpretation and implementation: upon admission, residents/responsible parties will be informed of the facility's theft and loss program policies and procedures. A resident property inventory will be completed to identify personal property the resident brought with him/her to the facility. The items will be listed on a two part form; Resident's Clothing and Possessions. After completing the admission section of the Resident's Clothing and Possessions form, the resident/surrogate will sign the form. The yellow copy of the form is then given to the resident/surrogate and the white copy becomes part of the resident's medical record. 1. Medical record review for Resident 2 was initiated on 8/29/24. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Clothing and Possessions form failed to show a date and signature from the resident or responsible party. There were personal belongings listed on the form. On 8/29/24 at 1017 hours, a concurrent interview and facility document review was conducted with LVN 1. LVN 1 stated the resident's inventory list was done upon the resident's admission. LVN 1 stated Resident 2 was readmitted to the facility on [DATE]. LVN 1 verified Resident 2's Clothing and Possessions form was incomplete and there was no documented evidence a Resident 2's Clothing and Possessions form was completed on 8/19/24, upon Resident 2's readmission. 2. Medical record review for Resident 6 was initiated on 8/29/24. Resident 6 was admitted to the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 555797 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2024 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)