Health inspection·November 21, 2024

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** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current wound care treatment and interventions as ordered for one of three sampled residents (Resident 2). * Resident 2's care plan was not revised to address the use of wound vac for the pressure ulcer of the sacrococcyx area. This failure posed the risk of not providing the resident with individualized and person-centered care. Findings: Closed medical record review for Resident 2 was initiated on 11/21/24. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 2's physician's order dated 6/8/22 to 9/15/22, showed to perform the following wound care to the pressure ulcer of the sacrococcyx site: clean with normal saline, pat dry, apply a granulating foam on wound bed, seal with a transparent dressing, and connect to wound vac at 150 mmHg setting every day shift on Mondays, Wednesdays, and Fridays for 30 days. Review of Resident 2's plan of care dated 7/8/22, showed the wound management goal and interventions for the pressure ulcer of the sacrococcyx site to include the following wound care: apply the skin protectant as ordered, elevate the lower extremities when in bed, handle gently during care, keep clean and dry, perform the laboratory tests as ordered, medicate as ordered, monitor for any signs and symptoms of infection, and reposition every two hours. However, the care plan failed to include the use of wound vac every Monday, Wednesday, and Friday on the day shifts for 30 days as ordered. On 11/15/24 at 1620 hours, a concurrent interview and closed medical record review for Resident 2 was conducted with RN 1. RN 1 stated the care plan should be individualized and updated to reflect the current treatment and interventions for the pressure ulcer of the sacrococcyx site. On 11/21/24 at 1615 hours, the DON acknowledged the findings. 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 3 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 11/21/2024 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)