Hearthstone Health and Rehab: Care Plan Failures - NV
Inspectors from the Centers for Medicare and Medicaid Services visited the facility at 1950 Baring Blvd on March 3, 2025, and documented what they found in a deficiency report. The problems they identified came down to a failure at the most basic level of nursing home care: knowing what a resident needs and making sure it happens.
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See the Derila PillowResident 83 was admitted to Hearthstone with chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease. On February 21, a provider saw her and noted she was complaining of significant edema, the medical term for fluid buildup that causes visible, sometimes painful swelling. The provider wrote a new order: furosemide 20 milligrams daily, a common diuretic used to reduce that swelling.
Three days passed.
On February 24 at 2:37 in the afternoon, the resident told staff her legs were swollen and that she was not receiving medication for edema. Inspectors noted she had notable edema to both lower extremities. When staff checked her physician's orders, the furosemide order wasn't there. The prescription written on February 21 had never been entered.
Her care plan didn't mention edema. It didn't mention the diuretic. There was no documentation in her clinical record showing anyone had followed up on the swelling after the provider visit.
A licensed practical nurse told inspectors on February 26 that nurses entered care plans as needed, and that those plans were reviewed by the Assistant Director of Nursing or the Director of Nursing Services. The LPN could not find a care plan related to edema or diuretic medications. The DNS confirmed the same thing the following morning: no care plan for edema, no care plan for the medication prescribed to treat it.
The inspection report also flagged a second resident, identified as Resident 83 in a separate section of the deficiency, whose behavioral symptoms had not been included in their care plan. The DNS confirmed those behaviors should have been documented and weren't.
Both failures point to the same gap. Care plans at Hearthstone are supposed to be comprehensive and person-centered, built around each resident's specific medical, nursing, and psychosocial needs, with measurable goals and timeframes. The facility's own policy, revised in December 2023, requires exactly that. What inspectors found was a resident sitting with swollen legs, telling a nurse she wasn't getting her medication, and a paper trail that confirmed she was correct and that no one had noticed.
Edema in a patient with congestive heart failure and chronic kidney disease is not a minor footnote. Fluid retention in that population can escalate. A diuretic ordered and then not administered for days is not a clerical inconvenience.
CMS rated the level of harm in this deficiency as minimal, with few residents affected. That classification reflects the regulatory framework inspectors work within, not necessarily the experience of a resident who spent days with swollen legs asking about a medication that existed on a provider's note and nowhere else.
The facility did not respond to a request for comment. Hearthstone's plan of correction, if submitted, was not included in the inspection materials reviewed for this report.
Resident 83 was still living at the facility when inspectors confirmed, on February 27, that her care plan contained no reference to edema or the drug prescribed to treat it. Whether the order was eventually entered, and whether she received the medication in the days between the provider visit and the inspection, the report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hearthstone Health and Rehabilitation from 2025-03-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
HEARTHSTONE HEALTH AND REHABILITATION in SPARKS, NV was cited for violations during a health inspection on March 3, 2025.
The problems they identified came down to a failure at the most basic level of nursing home care: knowing what a resident needs and making sure it happens.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.