Lassen Nursing & Rehabilitation Center
LASSEN NURSING & REHABILITATION CENTER in SUSANVILLE, CA — inspection on September 12, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Lassen Nursing & Rehabilitation Center
2005 River Street Susanville, CA 96130
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Lassen Nursing & Rehabilitation Center
2005 River Street Susanville, CA 96130
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Lassen Nursing & Rehabilitation Center
2005 River Street Susanville, CA 96130
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Lassen Nursing & Rehabilitation Center
2005 River Street Susanville, CA 96130
SUMMARY STATEMENT OF DEFICIENCIES
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] 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Lassen Nursing & Rehabilitation Center
2005 River Street Susanville, CA 96130
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Lassen Nursing & Rehabilitation Center
2005 River Street Susanville, CA 96130
SUMMARY STATEMENT OF DEFICIENCIES
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.
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