Health inspection·February 5, 2025

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, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in a safe and secure manner as evidence by: * Resident 7 had a bottle of One a Day Multivitamin/Multimineral (supplement) on the top of the bedside table. * A Hibiclens (antiseptic skin cleanser) was observed on top of the grab bars unattended inside Shower room [ROOM NUMBER]. These failuresposed the risk for non-licensed staff and visitors to have access to the medications. Findings: Review of the facility's P&P titled Resident Self Administration of Medication revised 12/2022 showed it is the policy of this facility to support each resident's right to self-administer the medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. Review of the facility's P&P titled Resident Showers revised 12/2022 showed help the resident back to their room and return personal hygiene products to their designated spot. 1. Medical record review for Resident 7 was initiated on 1/29/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. On 1/29/25 at 1044 hours, an observation was conducted in Resident 7's room. A bottle of One a Day Multivitamin/Multimineral was observed on the top of the bedside table. (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 2 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 02/05/2025 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)