Lassen Nursing & Rehabilitation Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

also stated, I'm not hungry, it's hard to eat just because I'm supposed to eat. I feel pressure down here, I don't know what it is, while pointing to her lower abdomen [lower belly/gut area]. During an observation on 9/3/25 at 12:31 pm, LN E entered the RNA dining room and squatted next to Resident 1's wheelchair to assess Resident 1's lower abdomen while three other residents were eating lunch at the same table.

Resident 1 stated, I just don't want to eat. RNA B responded, We're just going to drink some more of this and be here for a few more minutes. LN E told RNA B, I don't want her to drink it if she's having pressure.

LN E then informed Resident 1, After you're done eating, we can go to the bathroom to see if that pressure goes away. LN E then left the RNA dining room, and RNA B asked Resident 1, How about some hot chocolate? Resident 1 replied, I don't know what's happening, I don't want it, I have to go to the bathroom.

Facility staff arrived and took Resident 1 to her room and then to the bathroom. During an interview on 9/3/25 at 12:35 pm, RNA B confirmed the observations made in the RNA dining room and stated Resident 1's, family member said she has to be in here. Sometimes I sit in her room and help her eat.During an

interview on 9/3/25 at 1:56 pm, RNA B stated, I know she [Resident 1] is more comfortable eating in her room, she should have been taken out of the dining room long before she was, and should have been allowed to drink her Boost [nutritional, milkshake like drink] in her room.During an interview on 9/3/25 at 1:40 pm, Resident 1 confirmed the observations made in the RNA dining room and stated, I don't like eating in front of other people, I don't like going [to RNA dining]. Resident 1 stated, I would expect the conversation about using the bathroom to be private and confidential, I didn't like being asked in front of others.During an interview on 9/3/25 at 1:47 pm, LN E confirmed the observation from the RNA dining and stated, I normally take them out to assess, that wasn't how it was supposed to be. LN E confirmed talking to Resident 1 in front of other residents about using the bathroom and stated, that conversation should have been in private. LN E stated, from what I know, we offer three times to eat in RNA dining, after the third time

we will take her to her room. We thought RNA dining would be a good idea for socialization, sometimes she wants to stay in her room and she has the right to refuse. During an interview on 9/3/25 at 1:56 pm, RNA B stated, Usually, on a normal day, she says I don't want to be here [RNA dining room], and she is taken back to her room. I know she is more comfortable eating in her room.During an interview on 9/4/25 at 8:46 am, RNA A confirmed the observation made on 9/3/25 at 11:54 am. RNA A stated, I was told by the Lead RNA that [Resident 1] had to be here [RNA dining room] yesterday. During an interview on 9/4/25 at 5:55 pm, Director of Staff Development (DSD), the observations of Resident 1, RNA A, and RNA B, that were made

on 9/3/25, were described. DSD confirmed, Resident 1's rights were violated and stated, we ask three times, then let the nurse know.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lassen Nursing & Rehabilitation Center

2005 River Street Susanville, CA 96130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637

Assess the resident when there is a significant change in condition

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to perform a Minimum Data Set (MDS, a resident assessment tool), assessment for one out of three sampled residents (Resident 1) when a significant change of condition was identified. This had the potential for a delay in the review and revision of the care plan (documented resident goals that included instructions for care). Findings: A review of the facility's policies and procedures (P&P) titled, Comprehensive Assessments, revised 10/1/23, indicated, a significant change in status assessment would be performed when the IDT (interdisciplinary team, healthcare professionals who care for the resident work together to coordinate care) determined the resident met the significant change in condition requirements. The P&P defined a significant change in condition as a decline that would not resolve on its own, required staff intervention, impacted more than one area of the resident's health status, and required IDT review and/or revision of the care plan. A review of the admission Record, dated 3/29/22, indicated, Resident 1 was admitted to the facility on [DATE REDACTED] with the diagnoses of major depression (a sad mood), anemia (a condition where there was a lower-than-normal number of red blood cells in the blood, red blood cells carried oxygen throughout the body), and fatigue (extreme feeling of tiredness or a complete lack of energy that made it difficult to do everyday tasks). Resident 1 was not her own responsible party (decision maker). A review of the Neuropsychological Assessment (a detailed evaluation that measured how the brain functioned and how it affected behavior and thinking), dated 12/1/23, indicated, Resident 1 had a major neurocognitive (how the brain processed information) disorder due to possible Alzheimer's Disease (memory loss, problems with thinking, and reasoning). A review of the Quarterly MDS, GG-Functional Abilities, dated 7/17/25, indicated, Resident 1 was independent with care in

the following areas: dressing the upper and lower body, changing position for sitting to standing, transferring from the bed to a chair or toilet, and walking 50 feet that included two turns. The MDS indicated Resident 1 required assistance for setting up and cleaning up during mealtimes. During an interview on 9/3/25 at 10:05 am, Certified Nurse Assistant (CNA) D stated, Resident 1 had experienced a functional decline recently and [Resident 1] required much more assistance with transfers, she has been having weakness and balance problems, uses her cane more and needs help getting out of bed. A review of the Multidisciplinary Care Conference (care conference), dated 8/20/25, indicated that on 8/21/25, a care conference (staff, resident and or resident's RP met to discuss care) meeting was conducted. The document indicated Resident 1 had a gradual decline in physical ability, previously was able to walk around facility, and now required a wheelchair. The care conference indicated, on 8/12/25, Resident 1 had triggered for a change of condition on 8/12/25 for weight loss. During an interview on 9/4/25 at 1:01 pm, MDS Nurse stated, functional decline and weight loss would require a change of condition MDS assessment to be done.

Unless it was communicated to me, I wouldn't know to do it. MDS Nurse confirmed, there had been no MDS change of condition assessment completed and it should have been completed within 14 days of Resident 1's significant change of condition. MDS Nurse stated, the purpose of the change of condition MDS was to trigger care plans and ensure we are providing appropriate care. During an interview on 9/5/25 at 1:07 pm, the Administrator confirmed there was no change of condition MDS assessment completed.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lassen Nursing & Rehabilitation Center

2005 River Street Susanville, CA 96130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm

measured amount of fluid consumed in the form of cc's. RNA E confirmed, there was nowhere to enter the Boost intake and stated, the documentation included all fluid combined. During an interview on 9/5/25 at 1:05 pm, Director of Nursing (DON) confirmed, there was no documentation present in Resident 1's medical record that supported how much Boost Resident 1 consumed and stated, without the documentation you couldn't monitor the intervention.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lassen Nursing & Rehabilitation Center

2005 River Street Susanville, CA 96130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

three residents later today and call back. During an interview on 9/5/25 at 12:02 pm, Director of Nursing (DON) stated, change of condition to PC was not done, I didn't know I needed to. DON confirmed, there was no documentation that supported the PC had performed an immediate MRR for Resident 1, 2, and 3's weight loss. During an interview on 9/5/25 at 7:21 pm, PC confirmed, there had been no pharmacy review regarding weight loss for Residents 1, 2, or 3 and there was no documentation that supported the facility notified the PC.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lassen Nursing & Rehabilitation Center

2005 River Street Susanville, CA 96130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated, the hot cereal was fortified. During a concurrent record review and interview on 9/4/25 at 9:07 am, with Registered Dietician (RD), Resident 1's Nutrition Assessment-V1.5 dated 7/14/25 was reviewed. RD confirmed the Nutrition Assessment, indicated that Resident 1 was on a fortified diet. RD reviewed the care plan (a detailed plan that outlined resident goals and interventions in place for staff to utilize to assist resident with achieving their goals) titled, Nutritional Problem, dated 4/12/22, and confirmed the care plan indicated, an intervention was in place for Resident 1's fortified diet. RD stated, you would fortify every meal and every meal is different.During a concurrent interview and record review on 9/5/25 at 9:40 am with CDM, Resident 2's Physician's Order, dated 5/28/25, was reviewed. CDM stated, the Physician's Order, indicated, Resident 2's diet was fortified. CDM confirmed that lunches were not fortified. 2. A review of the admission Record, dated 10/28/24, indicated, Resident 3 was admitted to the facility on [DATE REDACTED] with the diagnoses of Alzheimer's, dementia, and type 2 diabetes (body was unable to regulate blood sugar levels) with diabetic neuropathy (high blood sugar levels over time caused nerve damage). Resident 3 was not his own RP.During a concurrent observation and record review, on 9/3/25 at 12:16 pm, Resident 3 was observed in the RNA dining room. Resident 3 was provided with one grilled cheese sandwich. During an

interview on 9/4/25 at 4:42 pm, Resident 3's RP stated, my concerns are the nutritionist ordered double portions, I'm here almost every single night for dinner, he isn't getting double portions, not even the double proteins. RP confirmed, facility staff were required to obtain additional food during dinner in order for Resident 3 to have double protein. During a concurrent interview and record review on 9/5/25 at 9:40 am with CDM, Resident 3's Physician's Order, dated 8/5/25 was reviewed. CDM stated the Physician's Order, indicated, Resident 3 was on a fortified diet that included double portions for protein/meat. There were issues with the PM (evening) cook and double portions were not being provided. It's been an ongoing battle with the cook. CDM confirmed, no resident lunches had been fortified.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lassen Nursing & Rehabilitation Center

2005 River Street Susanville, CA 96130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview on 9/5/25 at 9:13 am, ADMIN stated, we talked with the RD yesterday to get nutritional assessments completed, Resident 1's assessment is in there [electronical medical records], I have not seen it yet, and I am reviewing it now. The RD did not call, text, or email that the assessments for all three residents (Residents 1, 2, and 3) were completed or that there were recommendations. During an interview

on 9/5/25 at 10:26 am, RD was asked how nutritional assessment information for the residents was obtained. RD stated, my assessments are performed by information [gathered] in the system, I didn't speak to anyone. RD stated, Resident 1's nutritional assessment was performed on 9/4/25 at 5:55 pm and confirmed, RD had not contacted the facility regarding recommendations that were made. RD stated, I wanted the CDM to review the food preferences and for the facility to obtain lab work (drawing blood). RD indicated the information obtained from the lab work would assist with looking for changes to protein levels and electrolyte imbalances. (Good protein levels were required for the body's constant need to repair and grow cells and electrolytes were essential minerals required for muscle contraction, nerve function, and heart function.) During an interview on 9/5/25 at 10:37 am, RD stated, I started [Resident 2's] assessment

on 8/31/25 and completed it yesterday [the assessment was signed by RD on 9/5/25, five says after starting

the assessment]. My recommendations were to clarify the med plus (liquid, nutritional supplement provided with medication) order, and I ordered labs. RD confirmed, RD had not called the facility to discuss RD recommendations and stated, when I call to discuss [Resident 2], we can discuss other interventions that

we might do. During an interview on 9/5/25 at 10:47 am, RD stated, I did an assessment yesterday and I recommended Boost (liquid nutritional supplement) three times a day. RD confirmed, the facility had not been notified. 4. A review of the RD contract, dated 7/25/25, indicated the RD would provide RD services based on the facility's P&P and would periodically review with the facility P&Ps for the food and nutrition department. The RD contract indicated, the facility would orient the RD to the facility's P&Ps and would notify the RD in writing when there were residents that had significant weight losses. During a concurrent

interview and record review on 9/5/25 at 10:39 am, with ADMIN, the RD contract was reviewed. ADMIN confirmed, the RD contract indicated, the RD would be provided orientation to the facility's P&P and was not. ADMIN confirmed that the RD contract indicated that when a resident had significant weight loss, the facility would notify the RD in writing. ADMIN stated, I didn't notify the RD about the weight loss in August. I had told her where to look for the information and told her there was a report with the residents that triggered. During an interview on 9/5/25 at 10:47 am, RD stated, I don't know their policies and the facility never notified me that there were residents with weight loss. A review of the Monthly Weight Report, dated 8/1/25, indicated, RD had performed an evaluation of resident weights taken during the month of July.

Resident 2 weighed 86 pounds and lost 14.85% body weight. Resident 3 weighed 140.5 pounds and lost 17.8% body weight. Both residents had triggered severe weight loss. A review of the Monthly Weight Report, dated 9/1/25, indicated, RD had performed an evaluation of resident weights taken during the month of August. Resident 1 weighed 74.4 pounds and lost 11.4% body weight. Resident 2 weighed 83 pounds and lost 14.4% body weight. Resident 3 weighed 139.4 pounds and lost 12.79% body weight. All three residents triggered for severe body weight.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lassen Nursing & Rehabilitation Center

2005 River Street Susanville, CA 96130

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was reviewed. CDM stated the food preferences indicated, portions are bigger than resident liking. CDM confirmed the food preferences, dated 6/28/22, and indicated Resident 1 received small portions. CDM stated, during the intake process, at admission, she was overwhelmed. If she was presented to much food

she would refuse [to eat] and at one point she was small portions. CDM reviewed past diet orders and stated, the order on 7/1/22 indicated, small portions. CDM stated, the past diet orders indicated, on 7/28/22, there was a new diet order, it indicated weight loss, and small portions were removed (a request for all past diet orders was requested. All past diet orders were provided except the order dated 7/28/25).

CDM observed Resident 1's breakfast tray and confirmed, there was an undrunk chocolate boost on the tray and stated, I was unaware she was tired of chocolate; it's listed as a liked preference, we have vanilla and can get strawberry. The food on the plate had been partially eaten and there was a large amount of food left on the plate and the bowl of hot cereal was uneaten. During an interview on 9/5/25 at 8:46 am, Restorative Nurse Assistant (RNA) A stated, one time in the past, [Resident 1] said she was tired of chocolate, I don't recall if I offered another flavor. Her Boost and the magic cup (an ice cream dessert that was provided to residents with weight loss) are usually chocolate. We offer the magic cup as an alternative (when meal was not eaten). [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). RNA A confirmed, 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. During an interview on 9/4/25 at 9:00 am, LN E was asked if Resident 1 had ever verbalized concerns regarding the amount of chocolate drinks she was provided and stated, [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. She stated that to me the beginning of August. LN E confirmed, dietary had not been notified of Resident 1's food preferences. During an interview on 9/4/25 at 10:03 am LN C stated, [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 an observation on 9/5/25 at 8:47 am, RNA A was observed providing Resident 1 with hot chocolate. Resident 1 took a sip of hot chocolate and did not drink it. During an

observation on 9/5/25 at 8:51 am, Resident 1's breakfast tray was observed to have a chocolate Boost, and

the food covered 75 percent of the plate.

Event ID:

Facility ID:

If continuation sheet