Tahoe Forest Hospital D/P SNF

In the surveyor’s words

From the most serious findings on record at Tahoe Forest Hospital D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF756Feb 12, 2026

  Based on interview and record review, the facility failed to ensure the Pharmacy Consultant's (PC) recommendations were followed for three of 13 sampled residents (Resident 2, Resident 9 and Resident 12), when Resident 2, Resident 9 and Resident 12's monthly medication regimen reviews (MRRs) for December 2025 and January 2026 were not reviewed by the attending physician.This failure decreased the facility's potential to prevent the residents' unnecessary medication use and experiencing of adverse drug reactions.Findings: 1. […]

• No harm, potential for more than minimal, patternF761Feb 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications and biologicals for a census of 31 residents, when:1. Opened and unlabeled insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pens were found in medication cart 1;2. Expired Coronavirus disease 2019 (COVID 19; an infectious disease that causes respiratory illness) test kits were found inside the medication storage room; and3. […]

• No harm, potential for more than minimal, patternF812Feb 12, 2026

  Based on observation, interview, and record review, the facility failed to follow professional standards for food service safety for a census of 31 residents, when:Cook (CK) 1 was observed without a beard restraint (facial hair covering) in the kitchen, andOutdated food items were found in the residents' fridge.These failures decreased the facility's potential to prevent food contamination and illnesses among vulnerable residents.Findings: 1.During a concurrent observation and interview on 2/9/26 at 8:30 a.m. with CK 1, CK 1 was observed in the kitchen without wearing a beard restraint. CK 1 stated he normally did not wear a beard restraint.During an interview on 2/9/26 at 8:50 a.m. […]

• No harm, potential for more than minimal, isolatedF656Feb 12, 2026

  Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of 13 sampled residents (Resident 7), when Resident 7's care plan did indicate the use of safety lap belt due to fall risk.This failure decreased the facility's potential to address Resident 7's specific health care needs.Findings:A review of Resident 7's Record of Admission, indicated she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a chronic condition where the immune system damages the protective covering of nerve cells, causing muscle weakness and coordination problems) and blindness. […]

• No harm, potential for more than minimal, isolatedF658Feb 12, 2026

  Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for two of 13 sampled residents (Resident 7 and Resident 8), when:1. A wheelchair lap belt was used for Resident 7 without a physician's written order; and 2. Omeprazole (a medication that reduces stomach acid production) was not administered to Resident 8 as prescribed.These failures decreased the facility's potential to follow the residents' physician orders.Findings: 1. […]