Health inspection·December 13, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an alleged verbal abuse incident to the California Department of Public Health (CDPH) State Survey Agency within two hours for one of three sampled residents (Resident 1). Resident 1 alleged Licensed Vocational Nurse (LVN) 1 yelled at her and called her a liar in front of everyone in the dining room. Resident 1 ' s allegation of verbal abuse was made on 11/28/2023 and the first report CDPH the State Survey Agency received from the facility was on 12/1/2023. This failure had the potential to delay the investigation and affect the psychosocial well-being of Resident 1 and subject other residents to verbal abuse. Findings: During a review of the facility policy titled, Abuse Investigation and Reporting, dated July 2017, indicated all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility. An alleged violation of abuse will be reported immediately but no later than 2 hours if the alleged violation involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violation does not involve abuse and has not resulted in serious injury. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. During a review of Resident 1 ' s record titled, Face Sheet, indicated Resident 1 was originally admitted on [DATE]. Resident 1 ' s record indicated she had diagnoses of unspecified mood disorder, major depression, and mild cognitive impairment. During a review of a self-reported incident the facility submitted to CDPH State Agency record titled, 5 Day for self-report on 11/28/2023, indicated on 11/28/2023 Resident 1 alleged that she had fallen on the floor and when she told LVN 1, LVN 1 called her a liar. The facility made a self-report of an unreported fall and alleged verbal abuse. During a review of Resident 1 ' s record titled, Progress Notes; IDT Review, dated 12/02/2023 at 10:54 am, indicated Resident 1 alleged LVN 1 yelled at her and called her a liar while she was in the dining room. Certified Nursing Assistant (CNA) 1, who was present in the dining room at the time of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056231 Printed: 05/15/2026 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 056231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 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)