Health inspection·July 17, 2025

F 0602 through a sting operation. FM J confirmed, the ring that FM J identified through the photograph belonged to Resident 2 and described the ring as being yellow in color with clear stones that wrapped around it. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 2 of 7 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 07/17/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 a reasonable suspicion of a crime to the California Department of Public Health (CDPH, responsible for protecting the public's health) for two out of three sampled residents (Residents 2 and 3) when the facility suspected Certified Nurse Assistant (CNA) D had stolen two wedding rings. This failure had the potential for further abuse and could negatively affect residents' mental and psychosocial well-being. Findings: A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating, revised 9/1/22, indicated, all allegations of suspected or actual abuse, including misappropriation (taken without permission) of resident property, would be reported to the local police department, the Ombudsman's (outside person who advocated for resident rights) office, and CDPH within two hours. A review of the admission Record, dated, 5/1/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of unspecified dementia (memory loss) with behavioral disturbance and major depression (a sad mood). Resident 2 was not his own responsible party (RP, decision maker). A review of the Annual Minimum Data Set (MDS, a resident assessment tool), dated 4/24/25, indicated, Resident 2 had scored 6 out of 15 during a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), which indicated severe cognitive (thinking or remembering) impairment. The MDS indicated, Resident 2 required partial to moderate assistance from facility staff to perform personal hygiene (washing face, hands, combing hair) and to get dressed. The MDS indicated, Resident 2 required substantial (a large amount) to maximum assistance from facility staff to shower. A review of the Admissions Record, dated 4/18/25, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of depression, anxiety, and difficulty with walking. Resident 2 was not her own RP. A review of the admission MDS, dated [DATE], indicated Resident 3 had severe hearing and vision loss. The MDS indicated Resident 3 had a BIMS score of 15 out of 15, which indicated intact cognition. A review of the Discharge-return anticipated MDS, dated [DATE], indicated Resident 3 required substantial to maximum assistance from facility staff to use the bathroom, shower, and get dressed. During an interview on 7/15/25 at 11:11 am, CNA F stated, CNA D was arrested for stealing from residents. CNA E was present during the interview and confirmed, CNA D was arrested for stealing resident property and stated, the police department came to the facility to arrest CNA D. A review of the document titled, Grievance Complaint Form, dated 6/23/25, indicated, FM H, reported to the facility that Resident 3's wedding ring was missing. A review of the document titled, Grievance Complaint Form, dated 7/7/25, indicated, FM J, reported to the facility that Resident 2's wedding ring was missing. During an interview on 7/16/25, at 1:30 pm, Administrator (ADMIN) stated, a few weeks ago, I got a call from Resident 3's FM, stating Resident 3's wedding ring was missing. Admin stated, we followed the facility's protocols for lost and missing items and was not able to find the ring. ADMIN stated, on the evening of 7/7/25, ADMIN noticed an online post from CNA D with jewelry for sale and on 7/8/25, I was informed Resident 2's wife alleged Resident 2's ring was missing. ADMIN stated, CNA D was assigned to Resident 2 and 3 when the missing rings were reported and confirmed, on 7/8/25, there were suspicions that CNA D had stolen Resident 2 and 3's wedding rings. ADMIN stated, the police department was notified immediately and confirmed, that suspicions of a crime were not reported to CDPH or the Ombudsman's office. Event ID: Facility ID: 056231 If continuation sheet Page 3 of 7 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 07/17/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for three out of five residents (Residents 1, 2, and 3) when: 1. Resident 1's code status (the residents' wishes regarding life-sustaining treatment, specifically if the resident stopped breathing or the heart stopped beating) was inaccurately documented throughout Resident 1's medical records. 2. The Resident's Clothing and Possessions form, (inventory sheet, described personal belongings brought into the facility) was not signed by Residents 2, 3, or the resident's responsible party (RP, decision maker). 3. Resident 3's wedding ring and wristwatch were not added to the inventory sheet. These failures had the potential to cause a delay in life sustaining care and personal belongings to not be identified if lost or stolen. Findings: 1. A review of the facility's policies and procedures (P&P) titled, Advance Directives (written instruction on care to be provided when someone was not able to make own decisions and included the code status), revised [DATE], indicated Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. A review of the facility's P&P titled, Attending Physician Responsibilities, revised [DATE], indicated, the attending physician was responsible to ensure orders were appropriate. The P&P indicated, The Physician will provide orders to ensure that individuals have appropriate comfort and supportive measures needed. The P&P indicated, The Physician will keep the well-being of residents as the principal consideration in his/her decisions. A review of the admission Record, dated [DATE], indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of lobar pneumonia (infection in more than one lobe of the lungs) and encounter for palliative care (a specialized approach to medical care that focused on providing comfort and support to residents with serious or life-limiting illnesses). The admission Record indicated, Resident 1 was a DNR (Do Not Resuscitate, if the heart stopped beating, CPR [rescue chest compressions or rescue breathing] would not be provided). Resident 1 was her own RP. During a concurrent interview and record review on [DATE] at 11:38 am, with Licensed Nurse (LN) C, Resident 1's Physician Order, dated [DATE] and POLST (Physician Order for Life-Sustaining Treatment), dated [DATE], was reviewed. LN C stated, Resident 1's Physician's Order indicated, Resident 1 was a DNR (no CPR to be provided) and the POLST indicated CPR with selective treatment. LN C confirmed, the Physician's Order and POLST did not match and stated, Whoever reviewed the POLST with the resident was responsible for entering the Physician's Order. During a concurrent interview and record review on [DATE] at 12:13 pm, with LN B, Resident 1's Health Status Note (progress note), dated [DATE], was reviewed. LN B confirmed, the progress note, indicated, a Certified Nurse Assistant (CNA) requested LN B to assess Resident 1, who was found in bed, not breathing, had no pulse, and was cold to the touch. LN B stated, Resident 1's electronic medical records indicated, Resident 1 was a DNR, and the POLST indicated, Resident 1 wanted CPR. LN B confirmed, the Physician's order and the POLST did not match and stated, it caused confusion. During a concurrent interview and record review on [DATE] at 2:13 pm, with Family Nurse Practitioner (FNP), Resident 1's POLST, dated [DATE] and signed by FNP on [DATE] was reviewed. FNP stated, When Resident 1 came to the facility, at first, she wanted to be comfort care [also known as palliative care]. At a care conference meeting, she wanted CPR. FNP confirmed, Resident 1 signed the POLST, requesting CPR, on [DATE] and confirmed, FNP signed the POLST on [DATE]. FNP stated unawareness if the code status change occurred after the physician orders were reviewed and approved by the Attending Physician (AP). Nurses fill out the POLST and I just review it with the resident and sign it. I did not sign the Physician's Orders. During a concurrent interview and record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 4 of 7 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 07/17/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review on [DATE] at 2:17 pm, with Social Services Director (SSD), Resident 1's Care Conference, dated [DATE] was reviewed. SSD stated, during Care Conferences, we review a bit of everything, including a resident's code status. SSD confirmed, during Care Conference, the Physician's Order and POLST should be reviewed for accuracy. SSD confirmed, the Care Conference note indicated, Resident 1's POLST had been reviewed and confirmed, the Physician Orders and POLST inaccuracies were missed during the Care Conference meeting. During a concurrent interview and record review on [DATE] at 9:33 am, with LN A, Resident 1's Physician's Orders and admission Summary progress note was reviewed. LN A confirmed, LN A performed Resident 1's admission to the facility and stated, paperwork from the hospital indicated Resident 1 wanted to be on Hospice (end of life care with a focus on comfort). During the admission process, Resident 1 wanted to change from a DNR to CPR. LN A reviewed Physician's Order, dated, [DATE] and confirmed, the Physician's Order indicated, Resident 1 was a DNR. LN A stated, I forgot Resident 1 wanted CPR, and entered the order as DNR. LN A reviewed the admission Summary progress note, and confirmed, LN A's documentation indicated, Resident 1 was pursuing Hospice end of life care. Resident is a DNR, selective treatment. LN A reviewed Resident 1's untitled care plan, dated [DATE] and confirmed, the care plan indicated, Resident 1 wished to be a DNR. LN A reviewed Resident 1's POLST, signed and dated by Resident 1 on [DATE], and confirmed, the POLST was filled out and reviewed by LN A during the admission process and it indicated Resident 1 wanted CPR. During an interview on [DATE] at 10:00 am, AP stated, orders are entered by the nurse, I sign them. If things look [NAME], I address it. There is an element of trust, I trust the nurse to enter the code status order correctly. I do not look at the order and compare it to the POLST. Who ever signed the POLST is responsible to ensure the resident wants that status. During an interview on [DATE] at 11:50 am, the Administrator (ADMIN) confirmed, Resident 1's POLST and Physician's Order, did not match and stated, the error occurred during Resident 1's admission. ADMIN confirmed the inaccuracies should have been discovered when the AP signed the orders, during the care conference meeting, and when the care plan was developed. 2. A review of the facility's P&P titled, Personal Property, revised [DATE], indicated, The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. During a concurrent interview and record review on [DATE] at 10:10 am, with Director of Staff Development (DSD), Resident 2's inventory sheet, dated [DATE], and Resident 3's inventory sheet, dated [DATE] was reviewed. DSD stated, the CNA completes the inventory sheet upon admission. Once it's completed the staff who completed the inventory sheet sign it, have the resident or RP sign it, and then it's given to the nurse who also signs. DSD confirmed, Resident 2 and 3's inventory sheet was not signed by the resident or the nurse. 3. During an interview on [DATE] at 5:17 pm, Family Member (FM) H stated, my mom was wearing her wedding ring when she was admitted to the facility. She never took it off. FM I stated, We [FM H and FM I] traveled to the facility after Resident 3 was admitted and I took photos of my mother-in-law with her new pajamas on. Her wedding ring was on her hand. FM H, stated, during a telephone conversation, my mom said she had to go for an x-ray and a girl at the facility told her she could not wear the ring for the x-ray and needed to take it off. My mom said she took the ring off at the facility, and never got it back. During an interview on [DATE] at 8:13 am, CNA F stated, the inventory sheet is done by the CNA or the nurse at admit. I know that after admission I never saw a ring. Then one day I did. I never checked her [Resident 3] inventory sheet to see if it was on the list, Not sure if I needed to. During an observation on [DATE] at 8:20 am, Resident 3 was sitting in bed eating breakfast. A wristwatch, white in color, was observed on the bedside table next to Resident 3's breakfast tray. During an observation on [DATE] at 8:25 am, CNA G stated, I remember seeing a ring on her [Resident 3's] hand the end of May or beginning (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 5 of 7 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 07/17/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete of April and I don't remember seeing it right after admission. CNA G confirmed, CNA G did not review or update Resident 3's inventory list to ensure the ring had been added. During an interview on [DATE] at 9:00 am, Resident 3 stated, before leaving the facility, a girl told me I had to take my wedding ring off and give it to her because I couldn't wear it for the xray. I never got it back. During a concurrent interview and record review on [DATE] at 10:10 am, with DSD, Resident 3's inventory sheets, dated [DATE] and [DATE] were reviewed. DSD confirmed, during the admission process, facility staff ensured all resident personal belongings were added to the inventory sheet and stated, if a CNA identified a new item in the resident's room, they should talk with the charge nurse to ensure it's on the list. DSD confirmed, there was a wristwatch, that was white in color, located in Resident 3's room. DSD confirmed, the inventory sheets did not include Resident 3's wristwatch or wedding ring. Event ID: Facility ID: 056231 If continuation sheet Page 6 of 7 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 07/17/2025 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain an effective training program when facility staff did not attend mandatory in-services (training classes), and the facility failed to provide additional opportunities to make-up the missed in-services. This had the potential for residents not to attain or maintain their physical, mental, and psychosocial well-being.Findings: A review of the facility's policies and procedures (P&P) titled, Attendance at Training Classes, revised [DATE], indicated, All personnel are required to attend their scheduled training classes. The P&P indicated, facility staff would attend make-up classes for any training class (in-service) that was missed. During a concurrent interview and record review on [DATE], at 10:10 am, with Director of Staff Development (DSD), attendance sheets for facility provided in-services were reviewed. DSD confirmed, the attendance record titled, Theft and Loss-Residents Personal Property, dated [DATE], indicated, three facility staff members attended the in-service. DSD stated, the theft and loss in-service was not done this year, should have been done on [DATE]th and [DATE]th, and had not been rescheduled. DSD confirmed, the attendance record titled, Dementia (inability to remember) Module #2, dated [DATE], indicated, three facility staff members attended the in-service. DSD confirmed, the attendance record titled, Abuse and Neglect, dated [DATE], indicated, at 6:30 am and at 2:30 pm, two facility staff members attended each in-service. DSD confirmed, the attendance record titled, Advanced Directives (a legal document that outlined medical care wishes) and POLST (Physician Orders for Life-Sustaining Treatment, a legal document that indicated whether a person wanted CPR), dated [DATE], indicated, two staff members attended the in-service. DSD stated, when in-services were scheduled, they were provided two times a week so they could attend the second one if they missed it. DSD stated, when facility staff did not attend the in-services, it was made up by providing one-on-one education or during team huddles (when staff gathered for a short meeting). DSD confirmed, there were no attempts to provide the facility staff with in-service make-up classes. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056231 If continuation sheet Page 7 of 7