Lassen Nursing & Rehab: Care Plan Tracking Failure - CA
The gap surfaced during a September 2025 complaint inspection at Lassen Nursing & Rehabilitation Center, a 99-bed facility on River Street. Federal inspectors reviewed the medical record of Resident 1 and found no documentation showing how much Boost, a caloric supplement drink, the resident had consumed. The record tracked fluid intake in combined totals. The Boost was folded in. Nobody had separated it out.
That distinction matters. A supplement like Boost gets added to a care plan because something is wrong, typically weight loss, poor appetite, or a clinical need for additional calories or protein. If staff can't see how much of it a resident is actually drinking, they can't tell whether the intervention is working. They can't adjust it. They can't flag a problem.
The facility's own RNA, a restorative nursing assistant, confirmed to inspectors on September 5th that there was nowhere in the system to enter Boost intake separately. The documentation, she said, included all fluid combined.
The Director of Nursing said the same thing, more plainly. There was no documentation in Resident 1's medical record showing how much Boost the resident consumed. And without that documentation, the DON acknowledged, you couldn't monitor the intervention.
That sentence is worth sitting with. The person responsible for nursing care at the facility confirmed that a nutritional intervention written into a resident's care plan could not be monitored, because the records to support monitoring didn't exist.
Inspectors cited the facility under F0656, which covers the development and implementation of care plans. The deficiency was tagged at a level of minimal harm or potential for actual harm, and inspectors noted that few residents were affected.
What the inspection report doesn't say is how long this gap existed, how much Boost Resident 1 was supposed to be consuming, or what clinical condition prompted the supplement in the first place. The record, as documented, doesn't answer those questions. It only shows that when inspectors looked for evidence the care plan was being followed, they found none.
A care plan intervention that can't be tracked is, in practical terms, a care plan intervention that can't be evaluated. Staff showing up to a shift wouldn't know if the resident had been drinking the supplement consistently or skipping it entirely. A physician reviewing the chart wouldn't know either. The combined fluid totals would look the same either way.
The facility had a plan for Resident 1. It just had no way to know if the plan was working.
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.
The gap surfaced during a September 2025 complaint inspection at Lassen Nursing & Rehabilitation Center, a 99-bed facility on River Street.
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.