Health inspection·June 18, 2025

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 failed to maintain the infection prevention and control practices to help prevent the transmission of communicable diseases and infections for one of three sampled residents (Resident 1) placed on contact precautions. Residents Affected - Few * The facility failed to ensure the staff donned an isolation gown before contacting with Resident 1 and/or his environment. Additionally, the staff did not properly discard the isolation gown after wearing it in Resident 1's room. * The facility failed to handle the clean linens so as to prevent the spread of infection. These failures posed the risk for transmission of infection and the development of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Head Lice and Scabies Exposure and Treatment dated 12/19/22,showed the staff will follow appropriate transmission-based precautions, including PPE use, when providing care to the affected resident/s. Review of Resident 1's medical record was initiated on 6/17/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report dated 6/17/25, showed a physician's order dated 6/11/25, for contact precautions for scabies until further orders. On 6/17/25 at 0740 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 was inside Resident 1's room feeding Resident 1. CNA 4 was not wearing an isolation gown while in the room. There was a contact precautions sign posted outside of Resident 1's room, to don PPE before entering the room. CNA 4 was asked why he did not don an isolation gown. CNA 4 stated there was no isolation gown by the designated supply area. CNA 4 verified he should have worn a gown before going inside Resident 1's room. CNA 4 then donned an isolation gown continued with Resident 1's feeding. When finished, CNA 4 removed his isolation gown and discarded the used gown in a regular trash bin which was overflowing with used gowns in Resident 1's room bathroom. CNA 4 stated there was no black trash bin available, so he discarded the used gown in the regular trash bin. CNA 4 further stated, if there was a black trash bin, he would have discarded the used gown in there and not in the regular trash bin. (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 06/18/2025 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)