Hearthstone Health and Rehabilitation: MDS Error - NV
The discharge assessment filed with the Centers for Medicare and Medicaid Services recorded that the resident had been transferred short-term to a hospital. The resident had not gone to a hospital. The resident had gone home.
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See the Derila PillowThat discrepancy sat in the record until federal inspectors reviewed it during a March 2025 survey. When they did, the facility's own MDS Coordinator confirmed the filing was wrong.
Resident 99, as the inspection report identifies the person, had been admitted to Hearthstone for surgical aftercare following an operation on the digestive system. The resident also carried diagnoses of cognitive communication deficit, prediabetes, and abnormalities of gait and mobility. When discharge came in December, a nursing progress note captured the moment accurately: the resident left for home with everything in hand.
The Minimum Data Set assessment, the standardized federal form that nursing homes use to document resident status and transmit data to CMS, said something else entirely. Section A, which records discharge destination, listed a short-term hospital transfer.
The MDS Coordinator, speaking with inspectors on February 25, 2025, explained what these assessments are actually for. They gather information used to build care plans, determine reimbursement, and feed into quality measures. Accuracy, the coordinator said, matters because the data shapes what level of care a resident is understood to need.
Then the coordinator confirmed what the inspectors had already found. The discharge assessment for Resident 99 documented a hospital transfer. It should have documented a discharge home. It was incorrect.
Inspectors noted the error had the potential to deprive the resident of necessary services tied to their actual health needs upon returning home. A resident discharged to a hospital setting and a resident discharged to their own home have different follow-up needs, different care transitions, different community supports that might be arranged. The record, as filed, described a person going to a place with around-the-clock clinical oversight. The reality was a person walking out the door with their medications in a bag.
The facility's own written policy, last revised in December 2023, states that MDS data transmitted to CMS must be encoded accurately and completely, and that discharge documents are included in that transmission. The data is electronically signed in the clinical health record. The signature went on a document that was wrong.
This was not a finding that rose to what federal inspectors classify as immediate jeopardy, the most serious level of harm. It was rated at the lower end of the scale, minimal harm or potential for actual harm, affecting few residents. The inspection sampled three closed records and found the error in one of them.
But the architecture of how nursing home care gets tracked, funded, and evaluated depends on these assessments being filed correctly. When a resident with a cognitive communication deficit and mobility problems leaves a facility, the information transmitted in their discharge record is not administrative paperwork in the way that a misfiled form might be in another industry. It is the account of what happened to that person and where they went. Insurers, follow-up providers, and quality measurement systems draw from it.
In this case, the account was wrong, and the coordinator who oversees these assessments confirmed it only when inspectors asked.
Hearthstone Health and Rehabilitation sits at 1950 Baring Boulevard in Sparks. The inspection was completed on March 3, 2025. Resident 99 had been home for more than two months by then, their discharge destination still listed incorrectly in the federal record.
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 discharge assessment filed with the Centers for Medicare and Medicaid Services recorded that the resident had been transferred short-term to a hospital.
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.