Lassen Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lassen Nursing & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 25, 2026

  The facility failed to store, prepare, and serve food in a safe and sanitary manner when:1.Meat was not thawed appropriately.2.Water from thawing meat splashed onto ready to eat vegetables causing possible cross contamination (transfer of harmful bacteria, viruses, or allergens from one surface, food, or object to another between raw meat thawing and cooked vegetables).3.Staff did not wash hands after handing dirty items on the dirty side of the dish machine and before touching clean items such as eating utensils, water pitchers, and food storage tubs.Staff did not wash hands upon entering the kitchen and before starting kitchen tasks.4.Cooking pans were in poor condition.5.The can opener blade and holder was not clean.6.Cutting boards were in poor condition.7.The standing mixer was not… […]

• No harm, potential for more than minimal, patternF600Jul 8, 2026

  Based on interview and record review, the facility failed to ensure the residents' right to be free from verbal abuse for four of four sampled residents when the Activities Assistant (AA), yelled at Residents during a smoke break activity. (Residents 1, 2, 3 and 4)This resulted in embarrassment, fear, humiliation and made the Residents felt like children. This caused Resident 1 emotional distress and had the potential to negatively impact the other Resident's emotional and psychosocial well-being.During a review of the facility's policy and procedure titled, Abuse Prevention Program indicated, the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. […]

• No harm, potential for more than minimal, patternF725Jun 25, 2026

  Based on interview and facility policy and procedure (P&P) review, the facility failed to ensure call lights were answered timely for 8 of 19 sampled residents (Residents 73, 98, 3, 85, 74, 57, 6, 93) and four of seven confidentially interviewed residents.This failure resulted in dependent residents (residents not able to help themselves to the bathroom, out of bed, or out of their wheelchairs) not receiving the assistance they needed. Findings: Review of a facility procedure titled, Answering the Call Light revised October 2023 indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs.1. […]

• No harm, potential for more than minimal, patternF802Jun 25, 2026

  Based on observation, interview, and facility document review, the facility failed to ensure Food and Nutrition Services (FNS) staff had the appropriate competencies and skills sets to carry out the functions of the FNS department when:1.Two staff did not know manual dishwashing procedures;2.One staff did not follow the recipe for pureed food;3.One staff used expired test strips for testing sanitizer strength; and4.Two staff did not follow proper hand hygiene procedures (Cross Reference F812).The failure to ensure FNS staff competency and skills sets resulted in 4 of 10 FNS staff not appropriately carrying out tasks related to their jog duties which had the potential to lead to contamination of food and food service equipment, and decreased quality of food for a census of 90.Findings:… […]

• No harm, potential for more than minimal, patternF806Jun 25, 2026

  Based on observation and interview, the facility failed to provide alternate entrees of equal nutritive value to the entree served. This failure had the potential to result in decreased nutrient intake leading to food related medical issues for 11 out of 11 residents who requested an egg salad sandwich alternate entree for a lunch meal out of a census of 90. Findings: Review of the policy and procedure titled, Menus dated 2001, showed menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. […]