Gordon Lane Care Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 106 Google reviews

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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (2/5 stars)
- Above-median deficiencies (28 vs median 13.0)
Below average in CA · Critically understaffed (RN) · Above recommended total nurse staffing · Low staff turnover (stable workforce) · Below chain average · No penalties on record
What this means for your family
This facility is an excellent choice for rehabilitation and post-surgery recovery due to its highly skilled therapy teams and clean environment. However, families should closely monitor medication administration and ensure all personal belongings are clearly labeled and inventoried, as multiple reviewers have reported issues with lost property and medication errors.
Google Reviews
Google Reviews
106 reviews on Google“Gordon Lane Care Center is widely praised by families for its compassionate, professional nursing staff and its effective rehabilitation programs for post-surgery recovery. While many reviewers highlight the clean environment and engaging activities, there are serious, recurring allegations regarding neglect, medication errors, and the loss of personal property.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and attentive nursing staff
- Effective physical and occupational therapy
- Clean and well-maintained facility
- Engaging resident activities and social programs
Concerns
- Loss or mismanagement of personal belongings (mentioned by 2 reviewers)
- Slow response times to call lights (mentioned by 3 reviewers)
- Issues with hygiene and resident care (e.g., changing/bathing) (mentioned by 3 reviewers)
- Inconsistent food quality (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 101 analyzed
How They Respond to Reviews
The owner provides mostly personalized responses that acknowledge specific family members or staff members mentioned in the reviews. While they use several recurring templates, they frequently tailor the greeting and content to reflect the reviewer's specific sentiment.
Questions for Your Tour
- 1We've noticed how much the management team engages with the community online; how does that same level of communication translate to how you update families on a resident's daily care?
- 2With the focus on physical and occupational therapy here, how do you work with the therapy team to help residents maintain their mobility and independence?
- 3What specific steps are in place to ensure that medication administration is handled with high precision and that call lights are answered promptly during the night shifts?
- 4How do you manage the tracking of personal belongings to ensure that items like clothing or small keepsakes stay safe and organized within the resident's room?
- 5Can you tell us more about the daily social programs and how you ensure residents are actively engaged in the community activities?
- 6In the event of a sudden change in a resident's medical condition or an emergency after hours, what is the specific protocol for notifying the family and coordinating care?
Personalized based on this facility's data
Key Review Excerpts
“The care he received was excellent. The staff are warm, friendly and caring. The ratios were high, which surprised me as we expected to have slow response time, but the staff is quick.”
“My uncle had 2 heart attacks. When he arrived he could not move on his own. When he left months later he was able to walk out with a cane.”
“The physical therapy team Jen, Krista, Kristle... a... [was impressive]”
Staffing
Staffing Hours
per resident/day · Medicare 2026RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
14
measures
3
measures
Residents whose bladder or bowel control got worse
Residents whose walking got worse
Residents vaccinated for pneumonia
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents needing more daily help over time
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Gordon Lane Care Center shows concerning patterns with 39 complaint-triggered deficiencies indicating families have filed multiple reports about care quality. The facility has recurring problems with medication management, infection control, and resident rights that persist across surveys. While all deficiencies are reportedly corrected, the high volume of complaints and repeated violations across the same care areas suggest ongoing operational challenges families should carefully evaluate before visiting.
Aug 4, 2025Routine27
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Administration Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Administration Deficiencies
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.
Environmental Deficiencies
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.
Construction Deficiencies
Use approved construction type or materials.
Smoke Deficiencies
Provide properly protected cooking facilities.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Aug 4, 2025Complaint2
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Jun 18, 2025Complaint1
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Jun 2, 2025Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Feb 5, 2025Complaint1
Pharmacy Service Deficiencies
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.
Nov 21, 2024Complaint2
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Ownership & Operations
Who Operates This Facility
Gordon Lane Care Center
for profit
Chain Affiliation
David Johnson
46 facilities nationwide
Chain avg rating: 3.2/5 · Rank 35 of 45
Ownership & Management
Owners
Gordon Lane Healthcare LLC
Owner · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
106 reviews from families & visitors
Official Website
Visit gordonlanecarecenter.com
Medicare data downloads
Original nursing home datasets
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