Gordon Lane Care Center
1821 E Chapman Ave · Fullerton, CA · 92831 · 7148797301
99 certified beds For profit - Limited Liability company Chain: David Johnson
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
The composite number cleared 73 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.16 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.34 | 0.55–0.75 |
| Weekend hours / resident-day | 3.84 | ≈ weekday level |
| Nursing turnover / year | 29% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (101 in the current record)
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Potential for harm · D August 4, 2025
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected August 30, 2025 · Resident Rights
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Potential for harm · D August 4, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected August 30, 2025 · Resident Rights
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Potential for harm · D August 4, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected August 30, 2025 · Resident Rights
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Potential for harm · D August 4, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected August 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 4, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected August 30, 2025 · Resident Rights
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Potential for harm · D August 4, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected August 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 4, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected August 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 4, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 30, 2025 · Quality of Life and Care
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Potential for harm · D August 4, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected August 30, 2025 · Quality of Life and Care
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Potential for harm · D August 4, 2025
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected August 30, 2025 · Quality of Life and Care
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Potential for harm · D August 4, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected August 30, 2025 · Quality of Life and Care
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Potential for harm · D August 4, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected August 30, 2025 · Quality of Life and Care
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Potential for harm · D August 4, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected August 30, 2025 · Quality of Life and Care
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Potential for harm · D August 4, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected August 30, 2025 · Quality of Life and Care
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Potential for harm · D August 4, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected August 30, 2025 · Pharmacy Service
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Potential for harm · D August 4, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected August 30, 2025 · Pharmacy Service
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Potential for harm · D August 4, 2025
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.
Corrected August 30, 2025 · Pharmacy Service
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Potential for harm · D August 4, 2025
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected August 30, 2025 · Nutrition and Dietary
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Potential for harm · D August 4, 2025
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected August 30, 2025 · Administration
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Potential for harm · D August 4, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected August 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 4, 2025
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected August 30, 2025 · Administration
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Potential for harm · D August 4, 2025
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected August 30, 2025 · Environmental
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Potential for harm · D August 4, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected August 30, 2025 · Infection Control
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Potential for harm · D August 4, 2025 · found via complaint
Implement a program that monitors antibiotic use.
Corrected August 30, 2025 · Infection Control
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No harm found · B August 4, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected August 30, 2025 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555797 · certified since October 18, 2002. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.