Hearthstone Health And Rehabilitation
HEARTHSTONE HEALTH AND REHABILITATION in SPARKS, NV — inspection on March 3, 2025.
Found 20 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the LPN1's name and the LPN1 gave the resident the LPN1's name and then walked out of the room.
IV.
The nurse had come out to the nursing station to request new IV tubing.
The nurse had stated the patient refused to let the nurse reuse the IV tubing after the tubing was on the floor because it had been contaminated.
The nurse documenting the progress note went into the resident's room to speak with the resident and apologize for the incident between the resident and the nurse.
The resident was upset about the nurse being unprofessional.
A Social Services note, dated 01/30/2025, documented the resident claimed the resident had never been treated the way the nurse had treated the resident on 01/28/2025 and felt the nurse was extremely hostile.
On 02/26/2025 at 11:50 AM, the Director of Nursing Services (DNS) verbalized the LPN1 had dropped the IV tubing for Resident #251 on the floor when preparing to administer an IV antibiotic on 01/28/2025.
The resident had brought the issue to the nurse's attention and the nurse had told the resident the nurse would wipe the tubing with an alcohol swab and the tubing would be safe to use.
The DNS confirmed it would not have been okay to use the tubing after the IV spike had touched the floor.
On 02/26/2025 at 12:02 PM, the Executive Director verbalized the facility had substantiated the events from the allegations in the FRI.
The facility document titled Resident Rights, undated, documented a resident in the facility would have the right to be treated with respect and dignity.
FRI #NV00073280
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Minimum Data Set 3.0 (MDS) assessment for 1 of 3 closed records sampled residents (Resident #99).
relative to their current health management needs upon discharge home.
Findings include: Resident #99 Resident #99 was admitted to the facility on [DATE], and discharged on 12/18/2024, with diagnoses including encounter for surgical aftercare following surgery on the digestive system, cognitive communication deficit, prediabetes, and other abnormalities of gait and mobility.
A Nursing Progress Note dated 12/18/2024, documented the resident was discharged home with all medications and belongings.
A discharge MDS assessment dated [DATE], Section A - Discharge Status, documented the resident was discharged short-term to the hospital.
On 02/25/2025 at 12:46 PM, the MDS Coordinator explained the MDS assessments were used to gather information for plan of care accuracy.
Once information was gathered, the information was used for reimbursement and quality measures.
The accuracy of MDS assessments were important to ensure proper care of residents at the level of care needed.
The MDS Coordinator confirmed Resident #99's discharge MDS assessment documented the resident was discharged to the hospital and was incorrect.
The MDS assessment should have accurately documented the resident was discharged home.
The facility policy titled Resident Assessment and Associated Processes, last revised 12/2023, documented the facility would electronically transmit encoded, accurate, and complete MDS data to the Centers for Medicare & Medicaid Services (CMS) system.
Transmission of the MDS data would include the discharge documents.
The MDS data was electronically signed in the clinical health record.
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residents, visitors, and staff.
The DNS confirmed the Care Plan did not include the behaviors and the
The facility policy titled Comprehensive Person-Centered Care Planning, revised 12/2023,
would include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs.
Cross reference with tag F-F740 Resident #83 Resident #83 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute on chronic diastolic (congestive ) heart failure, and chronic kidney disease, stage 2, mild.
The resident's list of diagnoses did not include edema.
A Provider Visit note dated 02/21/2025, documented Resident #83 complained of significant edema.
Edema was noted by the provider and a new order for furosemide 20 milligrams (mg) daily for edema was documented.
On 02/24/2025 at 2:37 PM, Resident #83 complained of edema to bilateral lower extremities (BLE). Resident #83 verbalized the resident was not being provided medication for edema. Resident #83 had notable edema to the resident's BLE. Resident #83's clinical record did not include any additional documentation related to edema. Resident #83's physician's orders did not include an order for furosemide 20 mg daily for edema.
On 02/262025 at 9:35 AM, LPN2 verbalized nurse entered care plans as needed and the care plans were reviewed by the Assistant Director of Nursing and/or the DNS.
The LPN was not able to locate a care plan related to edema and/or the use of diuretic medications.
One 02/27/2025 at 9:31 AM, the DNS confirmed Resident #83's Comprehensive Care Plan did not include a care plan related to edema or the use of diuretic medications.
The facility policy titled Comprehensive Person-Centered Care Planning, revised 12/2023, documented a comprehensive person-centered care plan would be developed for each resident and would include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs.
Cross reference with tag F-F684
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Resident #83's EHR and implemented on 02/21/2025 as ordered by the resident's provider.
The DNS
recorded the actual order received from the provider into the resident's medical record immediately.
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Based on the evaluation, interventions were developed, implemented, monitored, and revised as necessary to prevent or manage the resident's pain.
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provision of dialysis services.
The Facility would ensure that all appropriate medical, social,
changes in a patient's condition (physical or mental), change of medication, and diet or fluid intake.
A facility policy titled Hemodialysis Policy, undated, documented the facility would participate in ongoing communication with the dialysis center by using the Dialysis Communication Form filed in the resident's medical record.
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greater than one year, sampled for personnel record review (Employee #7, and #8).
Findings include: Employee #7 Employee #7 was hired on 01/01/2024, as a CNA.
Employee #7's personnel record lacked documented evidence an annual performance review had been conducted by the employee's anniversary date of 01/01/2025.
Employee #8 Employee #8 was hired on 01/01/2024, as a CNA.
Employee #8's personnel record documented an annual performance review had been conducted on 02/25/2025, 55 days after the employee's anniversary date of 01/01/2025.
On 02/25/2025 at 12:56 PM, the Human Resources Manager confirmed Employee's #7 did not have an annual performance evaluation for 2025 and Employee #8's annual performance evaluation for 2025 was completed late.
The Human Resources Manager verbalized all CNAs were required to have an evaluation every year by the hire anniversary date and they were to be completed by the Director of Nursing.
The Facility policy titled Performance Evaluations, revised 07/2010, documented performance evaluations would occur on but not limited to the employee's annual date of hire anniversary.
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minimal harm the facility.
This deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the number of nursing and direct care staff on duty.
Findings include: On 02/26/2025 at 11:11 AM, the nursing staff posting for the facility was dated 02/25/2025.
The posting of licensed & unlicensed direct care staff for the facility on 02/26/2025 was not posted.
On 02/26/25 at 11:14 AM, the Assistant Director of Nursing (ADON) verbalized the Staffing Coordinator was responsible to post the direct care staff posting daily at shift change.
On 02/26/2025 at 11:16 AM, the ADON confirmed the nursing staff information was not posted for 02/26/2025.
forms.
Cross reference with tag F-F656
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assessments, and communication with the dialysis center were completed and correctly documented.
On 03/03/2025 at 1:13 PM, the Executive Director confirmed the facility lacked a process to ensure pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center was completed and correctly documented on the facility's Dialysis Communication Record.
The Executive Director explained it was important the process was followed to ensure continuity of care between the facility and the dialysis center.
On 02/27/2025 at 3:02 PM, the Executive Director verbalized not understanding why the deficient practice was a substandard quality of care. It was explained to the Executive Director the scope and severity of the deficient practice included all of the facility's dialysis patients and was a systemic failure of the facility's dialysis process.
The facility policy titled Dialysis-Hemodialysis, revised 07/01/2016, documented the facility staff participated in ongoing communication with the dialysis center by using the Dialysis Communication Form which was filed in the resident's medical record.
Cross reference with F-F698
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D-26-50 percent consumed
-02/24/2025 B-76-100 percent consumed L-76-100 percent consumed D-76-100 percent consumed -02/25/2025 B-26-50 percent consumed L-26-50 percent consumed D-76-100 percent consumed On 02/27/2025 at 8:22 AM, the Registered Dietician explained when a resident experienced significant weight loss, the RD will have the percentages consumed documented, contact the resident's physician, add food preferences to the resident's diet, and add supplements if needed.
The Registered Dietician verbalized Resident #1 was experiencing significant weight loss related to a medication the resident was taking. As a result, the Registered Dietician asked the percentage of meals be documented for the resident.
The Registered Dietician confirmed the meal consumption logs were not completed for each day and meal time and verbalized the documentation was important so the Registered Dietician could figure out what the reasoning was for the weight loss and address the concern so the resident would not experience any health problems related to the weight loss.
On 02/27/2025 at 10:02 AM, the Director of Nursing Services (DNS) explained when a resident was identified as experiencing significant weight loss, the Certified Nursing Assistants (CNA) were to document the percentage amount of every meal the resident consumed. It was important for the CNAs to document to be able to determine what issues the resident could be experiencing with the resident's health.
The DNS confirmed the meal consumption logs for Resident #1 were not complete and were missing important documentation related to the resident's health.
The facility policy titled Nutrition Status Management, last revised 12/2023, documented a resident experiencing weight loss would require a dietary evaluation.
The evaluation would include ideal body weight range, usual body weight, current diet order, percentage of food eaten, possible dental problems, current illness, resident likes and dislikes, psychosocial needs, and any other changes in medical conditions that may have an impact on weight loss.
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post dialysis assessments, documentation of the assessments, and communication with the dialysis
a manner allowing the facility to easily locate the records and ensure the records were not misfiled and/or lost.
This deficient practice resulted in a substandard quality of care related to the facility's dialysis process and keeping of medical records.
Findings include: Dialysis On 03/03/2025 at 1:13 PM, the Executive Director confirmed the QAPI committee had not identified the lack of a process to ensure pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center was completed and correctly documented on the facility's Dialysis Communication Record.
The Executive Director explained it was important the process was followed to ensure continuity of care between the facility and the dialysis center.
Medical Records On 03/03/2025 at 1:19 PM, the Executive Director confirmed the QAPI committee had not identified a concern related to the keeping of medical records resulting in the facility filing incomplete records, having difficulty locating records and/or not being able to locate records.
The Executive Director verbalized it was important to keep accurate records in order to be able to provide appropriate care to residents.
The facility policy titles Quality Assurance and Performance Improvement, revised 12/2023, documented the QAPI committee continually assessed the facility's performance using a systematic, interdisciplinary, comprehensive, and stat driven approach to maintain and improve safety and quality in the facility.
Quality assurance was both anticipatory and retrospective in it's efforts to identify how the facility was performing, including where and why the facility performance was at risk or had failed to meet standards.
Cross Reference with F-F698 and F-F842
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care for its residents.
resident rights training was completed by staff upon hire for 2 of 16 sampled employees (Employee
Findings include: Employee #13 Employee #13 was hired as a Licensed Practical Nurse with a start date on 05/07/2024.
Employee #13's personnel record lacked documented evidence of resident rights training.
Employee #15 Employee #15 was hired as a Certified Nursing Assistant with a start date on 01/08/2025.
Employee #15's personnel record lacked documented evidence of resident rights training.
On 03/03/2025 at 12:22 PM, the Executive Director verbalized all staff were required to take resident rights training upon hire and confirmed Employee #13 and #15 did not receive resident rights training upon hire.
The facility policy titled In Service Training Program, last revised April 2024, documented all personnel must participate in regularly scheduled in-service training classes including patient rights and civil rights.
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Hearthstone 1950 Baring Blvd Sparks, NV 89434
Employee #13 was hired as an LPN with a start date on 05/07/2024.
Employee #13's personnel record lacked documented evidence of annual QAPI training for 2024.
Employee #16 Employee #16 was hired as a [NAME] with a start date on 01/01/2024.
Employee #16's personnel record documented QAPI training dated 01/31/2024 and lacked documented evidence of annual QAPI training for 2025.
On 03/03/2025 at 12:22 PM, the Executive Director (ED) verbalized all staff were required to take QAPI training upon hire and annually.
The ED confirmed Employee #1, #3, #4, #7, #8, #9, and #16 did not receive annual QAPI training and Employee #13 did not receive QAPI training upon hire.
The facility policy titled Quality Assurance and Performance Improvement, last revised 12/2023, documented staff will be educated on QAPI (committee, plan, and performance improvement projects) at the time of hire, as needed, and annually thereafter.
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compliance and ethics training upon hire and annually.
The ED confirmed Employee #1, #3, #4, #6, #7,
The facility policy titled Compliance Training, last revised May 2019, documented the policy outlines
employees, new hire and annual refresher training includes the requirements of the Code of Conduct, the Compliance Program, the concepts of fraud, waste and abuse, and reporting of compliance and ethical concerns.
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295044
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295044 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hearthstone 1950 Baring Blvd Sparks, NV 89434
295044
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295044 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hearthstone 1950 Baring Blvd Sparks, NV 89434
295044
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295044 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hearthstone 1950 Baring Blvd Sparks, NV 89434
43310
Resident #83
Resident #83 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute on chronic diastolic (congestive ) heart failure, and chronic kidney disease, stage 2, mild.
The resident's list of diagnoses did not include edema.
A Provider Visit note dated 02/21/2025, documented Resident #83 complained of significant edema.
Edema was noted by the provider and a new order for furosemide 20 milligrams (mg) daily for edema was documented.
On 02/24/2025 at 2:37 PM, Resident #83 complained of edema to bilateral lower extremities (BLE). Resident #83 verbalized the resident was not being provided medication for edema. Resident #83 had notable edema to the resident's BLE.
Resident #83's clinical record did not include any additional documentation related to edema.
Resident #83's physician's orders did not include an order for furosemide 20 mg daily for edema.
On 02/262025 at 9:35 AM, LPN2 verbalized nurse entered care plans as needed and the care plans were reviewed by the Assistant Director of Nursing and/or the DNS.
The LPN was not able to locate a care plan related to edema and/or the use of diuretic medications.
One 02/27/2025 at 9:31 AM, the DNS confirmed Resident #83's Comprehensive Care Plan did not include a care plan related to edema or the use of diuretic medications.
The facility policy titled Comprehensive Person-Centered Care Planning, revised 12/2023, documented a comprehensive person-centered care plan would be developed for each resident and would include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs.
Cross reference with tag
295044
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 295044 B.
Wing 03/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hearthstone 1950 Baring Blvd Sparks, NV 89434
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.