Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tahoe Forest Hospital D/p Snf during CMS and state inspections, most recent first.
Incomplete Physician Review of Monthly Drug Regimen Reviews: The facility did not ensure the attending physician reviewed and signed the Consultant Pharmacist’s MRR recommendations for three residents. One resident with diabetic neuropathy, TBI, and GERD had recommendations for dose reduction, medication replacement, and discontinuation that lacked documented physician response; another resident with CHF, dementia, and psychosis had an MRR noting a needed GDR attempt for quetiapine that was not signed; and a third resident with CHF and CKD had MRR recommendations for electrolyte monitoring, lab review, and possible diuretic discontinuation that were also unsigned. The DON confirmed the missing signatures and could not locate documentation showing physician review or implementation.
Improper Labeling and Storage of Medications and Biologicals: Unlabeled insulin pens were found in one med cart, expired COVID-19 test kits were stored in the med storage area, and an MDI with no resident name or use-by date was available in another med cart. An LPN confirmed the unlabeled items, the IP confirmed the test kits were expired, and the DON stated meds should be properly labeled and expired items disposed of per policy.
Food service safety standards were not followed when a cook was observed without a beard restraint and outdated food items were found in a residents' refrigerator. The EC confirmed the beard restraint was missing, and an LPN and the DD confirmed the expired dressing and cream cheese items should have been removed from the fridge.
Failure to include lap belt use in the care plan for a resident with MS, blindness, and a history of falls. The resident was observed in a wheelchair with a lap belt, stated she had fallen out of her wheelchair many times, and said she had used the belt long term with verbal consent. The physician approved the belt for wheelchair use, but the care plan did not reflect it, and an RNS stated the documentation was missed after the trial was successful.
A resident with MS and blindness was observed using a wheelchair lap belt without a written MD order, although staff said it had been used to prevent falls and a note indicated physician approval. Another resident with GERD did not receive omeprazole as prescribed because an LPN gave the medication after the resident ate bread, despite instructions for it to be given before meals.
A resident with vascular dementia and severely impaired memory was observed lying in bed with one headrail down, despite physician orders for both head siderails to be kept up. Staff stated the resident was prone to wander and fall, had a history of falling when trying to get out of bed, and that the missing headrail was forgotten.
A housekeeper cleaned inside a resident’s room without wearing a gown while the resident was on EBP for a urinary catheter. The housekeeper said there was no sign indicating precautions, while an LPN confirmed an orange magnet was posted by the door. The IP stated staff were expected to follow proper infection prevention and control practices before entering rooms on precautions.
Incomplete Physician Review of Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant’s monthly drug regimen review recommendations were reviewed and signed by the attending physician for three sampled residents. For Resident 2, who had diagnoses including diabetic polyneuropathy, traumatic brain injury, and GERD with esophagitis, the record showed orders for pregabalin, clopidogrel, and pantoprazole. The Consultant Pharmacist’s MRR notes dated 12/31/25 and 2/2/26 documented recommendations for dose reduction, medication replacement, and discontinuation, but there was no documented physician response to those recommendations. The DON stated the MRRs for December 2025 and January 2026 were incomplete because there was no documented response to the pharmacist’s medication recommendations and no further documentation could be located. For Resident 9, who had CHF and dementia with behavioral disturbance, the physician order included quetiapine for psychosis, and the Consultant Pharmacist’s MRR indicated the resident was due for a gradual dose reduction attempt; however, the MRR was not signed by the physician. For Resident 12, who had CHF and CKD and was receiving furosemide and spironolactone, the Consultant Pharmacist’s MRR recommended monitoring for possible electrolyte imbalance, repeating labs if necessary, and considering discontinuation if fluid retention improved, but the MRR was also not signed by the physician. During interview and record review, the DON confirmed the MRRs for Residents 9 and 12 were not signed and stated he could not find documentation that the physician reviewed or implemented the recommendations.
Improper Labeling and Storage of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals for a census of 31 residents. During a concurrent observation and interview, two unlabeled insulin pens were found in the top drawer of medication cart 1. The licensed nurse confirmed the pens were unlabeled and stated she was unsure which resident they belonged to because they had no pharmacy labels attached. The pharmacy consultant stated prescribed medications should have pharmacy labels to ensure residents received the correct medications and that the medications were within their expiration date. The facility also had expired COVID-19 test kits stored inside the medication storage room. During observation, thirty-eight boxes of test kits with an expiration date of 3/13/25 were found in the infection preventionist cart within the medication storage area, and the infection preventionist confirmed they were expired and should have been discarded. In addition, an MDI with no name and no use-by date was available for resident use inside medication cart 2. The licensed nurse confirmed the inhaler lacked proper labeling, and the DON stated medications should be labeled properly with at least the resident's name and expired medications should be disposed of according to facility policy.
Food Service Safety Deficiencies
Penalty
Summary
Food service safety standards were not followed when a cook was observed in the kitchen without a beard restraint. During the observation and interview, the cook stated he normally did not wear a beard restraint. The Executive Chef confirmed the cook was not wearing one and stated he should have put one on. The Dietary Director reviewed the 2022 Food Code and agreed with the guidelines, and the facility policy on Dietary Staff Dress Code stated that failure to follow the dress code violates food code and creates a potential for contaminating food. The residents' refrigerator at station two contained outdated food items during observation. Surveyors found several pouches of single-serve thousand island dressing with a use-by date of 12/25/25, several pouches of single-serve ranch dressing with a use-by date of 1/16/26, and an undated bag containing several containers of single-serve low-fat cream cheese. An LPN confirmed the items were expired and stated they should be disposed of, and also stated residents could potentially get ill from using outdated foods. The Dietary Director confirmed the items were outdated and stated outdated food items should have been removed from the fridge because they can cause food borne illness among residents if used.
Failure to Include Lap Belt Use in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple sclerosis and blindness who was identified as being at risk for falls. The resident’s record showed she was admitted with diagnoses including multiple sclerosis and blindness, and her MDS dated 12/10/25 showed a BIMS score of 15 out of 15 with intact memory. During observation on 2/9/26, the resident was seen in her wheelchair with a lap belt fastened across her thighs, and she stated she had fallen out of her wheelchair many times and that the lap belt protected her from falling. During an interview on 2/11/26, she stated she had worn the belt since 2025 and verbally consented to its long-term use. The resident’s progress note dated 11/28/25 indicated the physician approved her use of a belt for the wheelchair, and the plan of care dated 9/18/22 identified her as at risk for falls due to progressive multiple sclerosis with functional decline and a history of falls at home. However, the care plan did not indicate the use of the lap belt. During interview, the RNS stated the facility missed inputting necessary documentation for the resident’s lap belt after determining the trial was successful, and stated no one would know how long she had been wearing it or how she was to use it. The facility policy stated the care plan shall be updated as indicated for change in condition, onset of new problems, and resolution of current problems.
Missing order for wheelchair lap belt and incorrect timing of omeprazole administration
Penalty
Summary
A wheelchair lap belt was used for Resident 7 without a physician's written order. Resident 7 was admitted with diagnoses including multiple sclerosis and blindness, and her MDS dated 12/10/25 showed a BIMS score of 15 out of 15 with intact memory. A facility fall risk evaluation dated 2/3/26 identified her as at risk for falling. During observation on 2/9/26, Resident 7 was seen in her wheelchair with a lap belt fastened across her thighs, and she stated she had fallen out of her wheelchair many times and the belt protected her from falling. She later stated she had worn the belt since 2025. A nurse stated the belt helped prevent falls and was not aware of an order for it. A progress note dated 11/28/25 indicated the physician approved the resident's use of a belt for her wheelchair, but the physician orders reviewed on 2/11/26 did not include a written order for the lap belt. The RN supervisor confirmed the order was missing and stated no one would know how long the resident had been wearing it or how she was to use it. Omeprazole was not administered to Resident 8 as prescribed. Resident 8 was admitted with symptomatic GERD, and a physician order dated 8/12/25 directed omeprazole 20 mg daily in the morning for GERD. During observation on 2/10/26, an LPN gave Resident 8 a slice of bread and then passed her morning medications; Resident 8 ate the bread before taking her medications, including omeprazole. The LPN later confirmed she administered omeprazole with the other morning medications after the resident had eaten bread and stated it should have been given separately before the meal as indicated on the bubble pack. The pharmacy consultant stated omeprazole should have been given before meals as indicated on the bubble pack and that staff should have followed the instructions prescribed by the doctor to ensure maximum effectiveness and assist with the resident's symptoms.
Bed Headrail Not Kept in Place as Ordered
Penalty
Summary
The facility failed to ensure that one sampled resident was safe from falling when the resident's bed headrail was not in place as ordered. Resident 11 was admitted with vascular dementia and had a BIMS score of 1 out of 15, indicating severely impaired memory. A facility fall risk evaluation identified the resident as at risk for falling, and physician orders dated 10/26/23 directed that both bed head siderails be kept in the up position. During observation on 2/9/26, Resident 11 was awake and lying diagonally in bed with his legs on the right edge of the bed, and the right headrail was in the down position. A CNA stated the resident had severe memory problems, used a position change alarm, and was supposed to have both headrails up because he was prone to wander and tended to fall, but someone forgot to put the right headrail up. An LN stated the resident had a history of falling when attempting to get out of bed, was very confused, did not use his call light, and both headrails should have been up to match the physician orders. The RNS confirmed the resident had orders for bilateral headrails.
Failure to Use Required PPE for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow proper infection control measures for one of 13 sampled residents when a housekeeper cleaned inside the resident’s room without wearing the required gown. The resident had been admitted in August 2023 with a diagnosis of urinary retention, and a physician order dated 11/2/25 indicated insertion of a urinary catheter due to urine retention. During a concurrent observation and interview on 2/9/26, the housekeeper was seen cleaning inside the resident’s room without a gown and stated she was not wearing one because there was no sign indicating the resident was on Enhanced Barrier Precaution. On 2/10/26, a licensed nurse confirmed the resident had an orange magnet by the door indicating Enhanced Barrier Precaution due to the urinary catheter. The Infection Preventionist stated staff were expected to follow proper infection prevention and control practices before entering a room on any precautions to prevent the spread of infection in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Truckee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alpine Skilled Nursing And Rehabilitation Center | 23.9 mi | ★★★★★ | 16 | 0 |
| Life Care Center Of Reno | 23.9 mi | ★★★★★ | 0 | 0 |
| Alta Skilled Nursing And Rehabilitation Center | 24.1 mi | ★★★★★ | 19 | 0 |
| Ormsby Post Acute Rehabilitation | 24.4 mi | — | 34 | 0 |
| Sierra Basin Post Acute | 25.4 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.