Federal inspectors found that multiple staff members at Lassen Nursing & Rehabilitation Center knew about the resident's food complaints but failed to communicate them to dietary services. The resident continued receiving chocolate nutritional drinks and oversized portions despite her expressed preferences.
The Clinical Dietary Manager confirmed that the resident's food preference form, dated June 28, 2022, indicated she should receive small portions. During the intake process at admission, the manager explained, "she was overwhelmed. If she was presented too much food she would refuse [to eat] and at one point she was small portions."
Diet orders from July 1, 2022, specified small portions for the resident. But by July 28, 2022, a new diet order removed the small portion requirement due to weight loss concerns. When inspectors requested all past diet orders, the facility provided everything except the July 28, 2025 order.
During breakfast observation on September 5, inspectors found an untouched chocolate Boost on the resident's tray. The Clinical Dietary Manager acknowledged, "I was unaware she was tired of chocolate; it's listed as a liked preference, we have vanilla and can get strawberry." The resident had only partially eaten her food, leaving large amounts on her plate and an entire bowl of hot cereal untouched.
Food covered 75 percent of the resident's breakfast plate during the inspection.
Restorative Nurse Assistant A told inspectors that the resident had previously complained about chocolate drinks. "One time in the past, [Resident 1] said she was tired of chocolate, I don't recall if I offered another flavor," the assistant stated. The resident's nutritional supplements and ice cream desserts provided for weight loss were "usually chocolate."
The assistant confirmed the resident frequently complained about portion sizes. "[Resident 1] says, it's too much food, like all the time. I tell her she doesn't have to eat it all or to just pick at it (eating a little bite here and there)."
Despite knowing about these complaints, the assistant admitted: "The dietary department or nurse had not been notified of Resident 1's statements regarding food preferences and stated, I was not aware I needed to."
Licensed Nurse E revealed that the resident had been complaining about chocolate drinks since early August. "[Resident 1] had told me she was tired of chocolate drinks, so I switched the Ready Care to vanilla to give her a change and alternate between chocolate and vanilla. I think she was referring to Boost. I don't know if we have different flavors for Boost."
But even this nurse failed to notify dietary services about the resident's preferences.
Licensed Nurse C described the resident's ongoing complaints: "[Resident 1] has always stated that she didn't eat like this, it's way too much food, and she loves her hot chocolate in the morning."
During the inspection, staff provided the resident with hot chocolate at breakfast. She took one sip and didn't drink any more.
The breakdown in communication left the resident receiving meals that contradicted her stated preferences for months. While she expressed being overwhelmed by large portions and tired of chocolate nutritional drinks, the facility continued serving both without adjustment.
The Clinical Dietary Manager's surprise at learning about the chocolate preference during the inspection highlighted the systemic failure. Despite having vanilla and strawberry alternatives available, the resident continued receiving unwanted chocolate supplements because staff never communicated her complaints to the kitchen.
The resident's case illustrates how communication failures can undermine individualized care in nursing homes. Food preferences and portion sizes directly impact nutritional intake and quality of life for residents, particularly those with weight loss concerns requiring careful monitoring.
Multiple staff members heard the same complaints over months but assumed someone else would handle them or didn't realize they needed to report the information. The resident continued expressing frustration with her meals while staff continued serving what she didn't want.
The facility's inability to track and update a basic diet order from July 2025 further demonstrated organizational problems. Missing documentation prevented inspectors from fully understanding how the resident's dietary needs had been managed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lassen Nursing & Rehabilitation Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
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