Clyde E Lassen State Veterans Nursing Home

In the surveyor’s words

From the most serious findings on record at Clyde E Lassen State Veterans Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF919Nov 4, 2021

  Based on observations and staff interviews, the facility failed to ensure a fully functioning resident call light system in one (House 3) of six resident care units in the facility. This failure potentially affected 15 of 78 residents residing in the facility. The findings include: On November 1, 2021 at 11:07 a.m., the bedside call light in room 306 (House 3) was triggered. No sound emitted in the room, hallway or on the unit. A second bedside call light was then triggered in room 308 as well as the bathroom call light. No sound emitted on the unit. In an interview with Certified Nursing Assistant (CNA) D at 11:12 a.m. on November 1, 2021, he was asked if the call light had a volume alert such as dinging or chiming. He stated, Yes, it usually does. […]

• No harm, potential for more than minimal, isolatedF695Aug 22, 2025

  Based on observations, interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure that residents who required respiratory care, received such care, consistent with professional standards of practice for one (Resident #91) of seven residents receiving respiratory care from a total survey sample of 26 residents. The findings include: On 8/18/25 at 1:05 PM, Resident #91 was observed dressed and sitting in his electric wheelchair outside of his doorway. He was wearing a nasal cannula connected to a green, portable oxygen tank on the back of his wheelchair. The oxygen flow rate setting was for one Liter per minute (L/min). (Photographic evidence obtained) On 8/19/25 at 11:27 AM, Resident #91 was observed in bed. […]

• No harm, potential for more than minimal, isolatedF561Nov 4, 2021

  Based on observations, staff and resident interviews, and record reviews, the facility failed to promote and facilitate resident self-determination through support of resident choice, by not allowing the resident to make choices about aspects of his/her life in the facility that were significant to the resident for one (Resident #21) out of a total sample of 24 residents. The findings include: A tour of House 5, including the lunch meal observation, was on conducted at 12:00 p.m. on 11/1/2021. Resident #21 was observed rejecting his lunch tray. Certified Nursing Assistant (CNA) H delivered the facility-provided meal the to resident. When the resident saw what was offered, he declined the meal. CNA H set the food to the side and stated, I guess you are not eating today. and left the room. […]

• No harm, potential for more than minimal, isolatedF676Nov 4, 2021

  Based on record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve a resident's ability to carry out activities of daily living for one (Resident #32) of 24 residents sampled. The findings include: A medical record review was conducted for Resident #32, revealing an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment was completed on 9/2/2021 due to a significant change (decline) in status. The resident's Brief Interview for Mental Status (BIMS) score was 00 out of a possible 15 points, indicating severe cognitive impairment. His activities of daily living needs ranged from limited assistance of one person to extensive assistance of one person. […]

• No harm, potential for more than minimal, isolatedF693Nov 4, 2021

  Based on record review, observations and staff interviews, the facility failed to provide appropriate treatment and services to prevent potential complications of enteral feeding, by failing to adhere to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: A record review for Resident #70 revealed an [AGE] year-old male admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He required total assistance with all activities of daily living and tube feeding for nutrition and hydration. He was unable to take any nutrition by mouth. A review of Resident #70's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an 11:50 a.m. observation on 11/1/21, the [MEDICATION(S)] 1.5 feeding and bag of water for flush were not running. […]