Lassen Nursing & Rehab: Pharmacy Review Failures - CA
That admission sits at the center of a complaint inspection completed September 12, 2025, at the 2005 River Street facility. Federal inspectors cited the nursing home under F0755, a deficiency covering the role of the pharmacist consultant, known internally as the PC, in reviewing residents' medications when their condition changes.
Weight loss in nursing home residents is not a minor inconvenience. It can signal infections, medication side effects, swallowing problems, depression, or the progression of underlying disease. A pharmacist's medication-related review, called an MRR, exists precisely to catch whether something a resident is taking is contributing to the decline, and to flag it before the situation worsens.
None of that happened for Residents 1, 2, or 3.
The Director of Nursing confirmed to inspectors that no change-of-condition notification had been sent to the pharmacist consultant for any of the three residents. She confirmed there was no documentation that the consultant had performed an immediate MRR. She said she had not known the notification was required.
The pharmacist consultant, interviewed separately the same evening at 7:21 p.m., confirmed the same gap from the other side. There had been no pharmacy review regarding weight loss for any of the three residents. There was no documentation that the facility had ever told the consultant the weight loss had occurred.
Two interviews. The same missing record. Nobody had called. Nobody had documented. Nobody had reviewed.
What makes the lapse notable is not just the procedural failure but the duration implied by it. The inspection narrative does not specify when the weight loss was first identified, but the pharmacist's statement, that no review had occurred and no notification had been received, suggests the gap persisted long enough that inspectors treating it as a completed deficiency rather than a near-miss.
The Director of Nursing told inspectors she had planned to contact the pharmacist about the three residents "later today," the day inspectors were already on-site asking questions.
Inspectors rated the deficiency at a harm level of minimal harm or potential for actual harm, and noted that some residents were affected. The facility serves residents at its Susanville location in Lassen County, a rural area of northeastern California where access to outside medical resources is limited and internal oversight carries more weight than it might in an urban setting with nearby hospital systems.
The citation does not describe what happened to Residents 1, 2, or 3 after the inspection. It does not say whether the weight loss continued, stabilized, or whether a cause was ever identified. The pharmacist review that should have happened, and the medication adjustments that might have followed it, are not in the record because the record was never made.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 20, 2026 · Our methodology
LASSEN NURSING & REHABILITATION CENTER in SUSANVILLE, CA was cited for violations during a health inspection on September 12, 2025.
That admission sits at the center of a complaint inspection completed September 12, 2025, at the 2005 River Street facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.