Health inspection·June 2, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Review of Resident 4's medical record failed to show documented evidence the abuse allegation was reported within the required time frame, the resident's responsible party was notified of the allegation, an abuse investigation was initiated, the resident was monitored for the clinical/psychosocial status after the alleged incident occurred from 5/25 to 6/1/25. Additionally, there was no care plan initiated for the alleged incident. Residents Affected - Few On 5/30/25 at 1540 hours, an interview was conducted with the SSD. The SSD stated she was not aware of the incident until now. The SSD verified Resident 4's responsible party was not notified of the incident. On 5/30/25 at 1614 hours, a telephone interview was conducted with CNA 10. CNA 10 stated while she was walking down the hall, her bra came undone. CNA 10 went into Resident 4's room to fix it. CNA 10 stated CNA 11 walked in the room and saw her scrub top was lifted. CNA 10 stated she jokingly told CNA 11 she was flashing the resident. CNA 10 further stated she knew she made a huge mistake and was being childish about the joke. CNA 10 verified her scrub top was up, and her bra was down by her waist. CNA 10 verified her breasts were exposed. CNA 10 verified Resident 4 was awake. On 5/30/25 at 1647 hours, an interview was conducted with the Administrator. The Administrator verified there was no report made to CDPH, ombudsman, law enforcement or the physician. The Administrator stated for an allegation to be deemed sexual, there had to be contact. On 6/2/25 at 0750 hours, an interview was conducted with the Administrator. The Administratorstated the alleged incident was reported to her right after it occurred. The Administrator stated on 5/24/25, the alleged CNA (CNA 10) had a wardrobe malfunction and went inside Resident 4's room. The alleged CNA was sent home immediately pending an investigation. The Administratorstated the alleged incident was not reported to CDPH because it was considered a code of conduct issue rather than an abuse allegation. On 6/2/25 at 1000 hours, an interview was conducted with the DSD. The DSD stated the alleged incident occurred on 5/24/25, during the evening shift. The DSD was asked why was not reported. The DSD responded, it was just a report of an employee, and it was just a rumor. The DSD verified there was no in-service given to facility staff regarding the code of conduct or sexual abuse prevention, after the allegation was reported. On 6/2/25 at 1200 hours, a phone interview was conducted with CNA 12. CNA 12 stated she saw CNAs 10 and 11 talking right by Resident 4's room. CNA 12 stated she observed CNA 11's facial expression and noted something was wrong. CNA 12 further stated CNA 11 informed her CNA 10's scrub top was up when CNA 11 opened the door. CNA 11 informed CNA 12, CNA 10 stated she wanted to give Resident 4 something special because it was his birthday, seeing the balloons, she flashed her breasts. On 6/2/25 at 1340 hours, a telephone interview was conducted with CNA 11. CNA 11 stated on 5/24/25, she had finished providing care to her assigned residents. CNA 11 stated she wondered why Resident 4's door was closed. CNA 11 stated she knocked on the door and saw CNA 10 lifting her scrub top in front of Resident 4. CNA 11 stated she got scared and closed the door. CNA 10 immediately followed CNA 11 and stated it was Resident 4's birthday so she flashed her breast. CNA 11 stated CNA 10 told her she did not know what was on her mind at that moment. CNA 11 further stated CNA 10 apologized to her and immediately reported the incident to the supervisor on duty. When asked if she had witnessed this incident before, CNA 11 stated no but CNA 10 told her she had exposed her breasts to Resident 4 before. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555797 If continuation sheet Page 2 of 5 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 06/02/2025 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 6/2/25 at 1449 hours, a telephone interview was conducted with CNA 10. CNA 10 stated as she was walking down the hallway, she felt the clip of her bra was off and quickly went inside Resident 4's room to fix it. CNA 10 stated CNA 11 walked in the room and saw her scrub top was lifted up. CNA 10 stated she jokingly told CNA 11 she was flashing the resident. CNA 10 further stated she was not even in the room for 2-3 minutes, and she was not sure what she thought CNA 11 thought she was doing. CNA 10 further stated she should have gone to the bathroom and denied exposing her breasts to the resident. CNA 10 stated she was sent home immediately after the incident. Event ID: Facility ID: 555797 If continuation sheet Page 3 of 5 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 06/02/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the medications were administered as ordered for one of five sampled residents (Resident 2). * Resident 2 did not receive the prescribed medications upon admission as ordered by the physician. This failure had the potential to negatively impact Resident 2's medical condition. Findings: Medical record review for Resident 2 was initiated on 5/28/35. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 5/27/25 showed the following physician orders: - dated 5/14/25, omeprazole (medication to treat heart burn) DR (delayed release) 20 mg capsule to give one capsule by mouth one time a day - dated 5/14/25, venlafaxine HCL (antidepressant medication) ER (extended release) 150 mg capsule, two capsules by mouth one time a day - dated 5/12/25, lamotrigine (antiseizure medication) oral tablet 150 mg, one tablet by mouth two times a day - dated 5/12/25, lisinopril (antihypertensive medication) oral tablet 10 mg, one tablet by mouth one time a day - dated 5/12/25, metformin (medication to treat diabetes) HCL oral tablet 500 mg, one tablet by mouth two times a day - dated 5/12/25, metoprolol tartrate oral tablet 25 mg, one tablet by mouth two times a day - dated 5/13/25, vitamin C (supplement) oral tablet 500 mg, one tablet by mouth one time a day - dated 5/12/25, acetaminophen (pain reliever) oral tablet 325 mg, two tablets by mouth every four hours as needed for mild pain - dated 5/12/25, magnesium hydroxide (laxative medication) oral suspension, 30 ml by mouth as needed for constipation for 60 Days - dated 5/12/25, gabapentin (nerve pain medication) oral capsule 300 mg, one capsule by mouth one time a day - dated 5/12/25, vitamin B-12 (supplement) oral tablet 1000 mcg, one tablet by mouth one time a day - dated 5/12/25, clonidine HCl (antihypertensive medication) oral tablet 0.1 mg, one tablet by mouth every eight hours as needed for HTN for 60 Days SBP greater than 160 mmHg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555797 If continuation sheet Page 4 of 5 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 06/02/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - dated 5/12/25, dextromethorphan-guaifenesin (medication for cough) oral syrup 10-100 mg/5ml, 10 ml by mouth every six hours as needed for cough and congestion On 5/28/25 at 0908 hours, an interview was conducted with LVN 1. LVN 1 stated on 5/13/25, as he was giving medications, LVN 1 noted Resident 2's medications were not delivered except for one (gabapentin medication). LVN 1 stated he contacted the pharmacy and refaxed the orders to the pharmacy. LVN 1 stated the nursing supervisor, and the physician were notified the resident's medications were not delivered upon readmission. LVN 1 stated the resident's medications were still not delivered on the following day. LVN 1 called the pharmacy, refaxed the orders and notified the DON. LVN 1 verified the medications were not available from 5/13 until he came to work on 5/15/25. On 5/29/25 at 1414 hours, an interview and concurrent facility document review was conducted with the Pharmacy Manager. The Pharmacy Manager stated Resident 4's orders were electronically misfiled to an unknown folder instead of filing it to the admission file. The Pharmacy Manager further stated Resident 4's readmission orders, were not reviewed and medications were not processed. Review of the pharmacy's tracking log showed the following: - 5/12/25 at 1910 hours, received fax - 5/13/25 at 2125 hours, received fax for Ascorbic Acid (Vitamin C) - 5/13/25 at 1700 hours, guaifenesin, clonidine, Vitamin B-12, gabapentin, magnesium, Tylenol (acetaminophen) orders received - 5/13/25 at 0650 hours, clonidine and gabapentin were sent to the facility. - 5/14/25 at 1323 hours, phone call received from the DON, medications not received; - Medications were delivered on the evening of 5/14/25 at 1746 hours. The Pharmacy Manager verified the above findings. On 6/2/25 at 1635 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555797 If continuation sheet Page 5 of 5