California ›Susanville

Lassen Nursing & Rehabilitation Center

2005 River Street, Susanville, CA 96130 · Lassen County · 96 certified beds · avg 84 residents/day · certified since Nov 10, 1970

Abuse citation flag (CMS)

Part of chain: CAMBRIDGE HEALTHCARE SERVICES (32 facilities, chain avg rating 2.5★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

2/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
4.03
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (61)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 25, 2026F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 25, 2026E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Jun 25, 2026E · Potential for harm, repeatedThe facility did not have enough support staff to safely and effectively run its food and nutrition service.
Jun 25, 2026E · Potential for harm, repeatedThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Jun 25, 2026D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jun 25, 2026D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jun 25, 2026D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jun 25, 2026D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jun 25, 2026D · Potential for harm, one-offThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Jun 25, 2026D · Potential for harm, one-offThe facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows.
Jun 25, 2026D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Jun 10, 2026E · Potential for harm, repeatedThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
May 21, 2026D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Apr 8, 2026D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Feb 4, 2026D · Potential for harm, one-offThe facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. · from a complaint
Sep 12, 2025E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Sep 12, 2025E · Potential for harm, repeatedThe facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. · from a complaint
Sep 12, 2025E · Potential for harm, repeatedThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint
Sep 12, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Sep 12, 2025D · Potential for harm, one-offThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · from a complaint
Sep 12, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Sep 12, 2025D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint
Jul 17, 2025E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jul 17, 2025D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Jul 17, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jul 17, 2025D · Potential for harm, one-offThe facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint
Apr 17, 2025E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Apr 17, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Apr 17, 2025E · Potential for harm, repeatedThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Apr 17, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Oct 24, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Oct 24, 2024E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Oct 24, 2024E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 24, 2024E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Oct 24, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Oct 24, 2024D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Oct 24, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Oct 24, 2024D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Oct 24, 2024D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Oct 24, 2024D · Potential for harm, one-offThe facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times.
Jul 31, 2024D · Potential for harm, one-offThe facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. · from a complaint
May 21, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · from a complaint
May 21, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
May 21, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
May 21, 2024D · Potential for harm, one-offThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
May 21, 2024D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint
May 21, 2024D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint
May 21, 2024D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint
May 21, 2024D · Potential for harm, one-offThe facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint
Apr 4, 2024E · Potential for harm, repeatedThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint
Apr 4, 2024E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
Apr 4, 2024E · Potential for harm, repeatedThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint
Dec 13, 2023D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Aug 4, 2023E · Potential for harm, repeatedThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Aug 4, 2023E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Aug 4, 2023D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Aug 4, 2023D · Potential for harm, one-offThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Aug 4, 2023D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Aug 4, 2023D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Aug 4, 2023D · Potential for harm, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Aug 4, 2023D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 11).

YearCitationsSerious (G–L)Worst severity that year
202390E
2024220E
2025150E
2026150F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.034.313.95bottom 44% in California; top 38% in the U.S.
Registered Nurse hours0.790.610.69top 18% in California; top 28% in the U.S.
Weekend total nurse staffing3.193.903.50bottom 11% in California; bottom 41% in the U.S.
Weekend RN hours (not acuity-adjusted)0.470.510.48top 34% in California; top 36% in the U.S.
Total nursing staff turnover (%)60.036.745.8bottom 3% in California; bottom 17% in the U.S.
RN turnover (%)71.438.142.9bottom 7% in California; bottom 11% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.65, RN 0.72, weekend 2.89. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Bering Properties LLCOrganization5% or Greater Indirect Ownership Interest6%02/01/2007
BH AllianceOrganizationIndirect Ownership InterestNOT APPLICABLE11/01/2006
Crescent Facilities Operations LLCOrganization5% or Greater Direct Ownership Interest100%12/19/2006
Jenmax Enterprises LLCOrganization5% or Greater Indirect Ownership Interest23%02/01/2007
JK-CSH JV LLCOrganization5% or Greater Indirect Ownership Interest12%11/01/2006
Manhattan Five Partners LLCOrganization5% or Greater Indirect Ownership Interest7%11/01/2006
The Jacob Wintner TrustOrganizationIndirect Ownership InterestNOT APPLICABLE11/01/2006
The Wintner Living Trust Dated 7/08/1992OrganizationIndirect Ownership InterestNOT APPLICABLE02/01/2007
Win Win Enterprises, LLCOrganization5% or Greater Indirect Ownership Interest35%02/01/2007
Wintner, JacobIndividualIndirect Ownership InterestNOT APPLICABLE02/01/2007
2005 River, LLCOrganizationADP of the SNFNOT APPLICABLE12/01/2010
Bretsch, GregoryIndividualManaging Control - Governing BodyNOT APPLICABLE02/25/2019
Bretsch, GregoryIndividualOperational/Managerial ControlNOT APPLICABLE02/25/2019
Bretsch, GregoryIndividualADP of the SNFNOT APPLICABLE02/25/2019
Butenko, JulieIndividualOperational/Managerial ControlNOT APPLICABLE07/24/2023
Butenko, JulieIndividualADP of the SNFNOT APPLICABLE07/24/2023
Cambridge Healthcare Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE04/01/2014
Cambridge Healthcare Services LLCOrganizationADP of the SNFNOT APPLICABLE07/17/2025
Capela, HeidiIndividualOperational/Managerial ControlNOT APPLICABLE04/03/2023
Capela, HeidiIndividualADP of the SNFNOT APPLICABLE04/03/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Seneca District Hospital D/P SNF31.4 miChester, CA★★★☆☆2/5abuse
Plumas District Hospital DP/SNF36.6 miQuincy, CA—/5

Compare this facility with the 2 closest →

All facilities in Susanville →

Facility data as of CMS processing date 2026-08-01. CCN 056231.