Hearthstone Of Northern Nevada

F-F656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or 43310 potential for actual harm Based on observation, document review, and interview the facility failed to demonstrate effective Residents Affected - Few administration by not ensuring pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center were completed and correctly documented. This deficient practice resulted in a substandard quality of care.

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-F684

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43310 potential for actual harm Based on interview, clinical record review, and document review the facility failed to ensure a medication Residents Affected - Few ordered for edema was entered into a resident's order set and Medication Administration Record (MAR) for 1 of 22 sampled residents (Resident #83). This deficient practice resulted in the resident not receiving the medication and continuing to have edema and discomfort and the potential to result in an exacerbation of chronic illnesses.

Findings include:

Resident #83

Resident #83 was admitted to the facility on [DATE REDACTED], with diagnoses including chronic obstructive pulmonary disease (COPD) and acute on chronic diastolic (congestive) heart failure (CHF), and pain, unspecified. The resident's diagnoses list did not include a diagnosis for edema.

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.

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.

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 2/26/2025 at 3:30 PM, a Licensed Practical Nurse (LPN) explained when providers ordered a new medication, the order was given to the resident's nurse, and the nurse entered the order into the resident's electronic health record (EHR) and faxed it to the pharmacy. The LPN confirmed Resident #83's orders did not include an order for furosemide.

02/27/25 at 8:24 AM, Resident #83 complained of edema and discomfort to the resident's BLE and was observed to have swelling consistent with edema to the resident's BLE.

On 02/27/25 at 8:32 AM, the Director of Nursing Services (DNS) assessed Resident #83's BLE for edema and confirmed the resident had BLE edema. The DNS verbalized the edema was 1 to 2 plus (+) pitting edema and described the resident's feet and legs as feeling tight.

On 02/27/25 at 9:06 AM, the DNS confirmed Resident #83's EHR included a providers note dated 02/21/2025, and the provider's note documented the resident was to have an order for furosemide 20 mg.

The DNS was not sure why the order was not entered into the resident's order set and MAR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 On 02/27/25 at 9:08 AM, the provider, an Advanced Practice Registered Nurse (APRN) verbalized when the APRN ordered new medications, the order was given to the resident's nurse verbally and in writing. The Level of Harm - Minimal harm or APRN confirmed the order for furosemide 20 mg for edema, should have been entered into Resident #83's potential for actual harm EHR by the nurse on 02/21/2025 and administered to the resident.

Residents Affected - Few On 02/27/25 at 9:21 AM, the DNS confirmed the order for furosemide should have been entered into Resident #83's EHR and implemented on 02/21/2025 as ordered by the resident's provider. The DNS explained not implementing the order could have led to increased edema, an exacerbation of congestive heart failure and/or chronic obstructive pulmonary disease, increased pain and discomfort.

The facility policy titled Nursing Policies and Procedures, dated 07/01/2016, documented nurses recorded

the actual order received from the provider into the resident's medical record immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43310 potential for actual harm Based on observation, interview, clinical record review, and document review the facility failed to ensure a Residents Affected - Few resident's pain was managed, a physician was notified when pain medication was not effective and/or the resident's pain exceeded the parameters of the medication ordered for 1 of 22 sampled residents (Resident #83). This deficient practice could have the potential for unrelieved pain, discomfort, and inadequate pain management.

Resident #83

Resident #83 was admitted to the facility on [DATE REDACTED], with diagnoses including pain, unspecified, pain in left hip, cellulitis of left upper limb, restless leg syndrome, pain in left hip, and pain in right hip.

A physician's order dated 04/19/2024, documented acetaminophen tablet 325 milligrams (mg). Give one tablet by mouth every four hours as needed for mild pain/headache not to exceed three grams per day.

Resident #83's Medication Administration Record (MAR) for February 2025, documented the resident was administered one tablet of acetaminophen 325 mg for pain levels greater than 0-3 out 10 on a numeric pain scale of 10 as follows:

-On 02/14/2025 at 3:57 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 4 out 10.

-On 02/15/2025 at 5:57 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 5 out 10.

-On 02/18/2025 at 12:15 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 5 out 10.

-On 02/20/2025 at 6:35 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 7 out of 10.

-On 02/23/2025 at 2:57 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 10 out of 10.

-On 02/24/2025 at 12:45 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 5 out of 10.

-On 02/24/2025 at 6:34 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 5 out of 10.

-On 02/25/2025 at 5:34 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 4 out of 10.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 -On 02/26/2025 at 6:06 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 6 out of 10. Level of Harm - Minimal harm or potential for actual harm -On 02/26/2025 at 1:03 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 6 out of 10. Residents Affected - Few

The MAR lacked documented evidence the resident's pain was reassessed to ensure efficacy of the medication.

On 02/24/2025 at 2:30 PM, Resident #83 verbalized the resident had a history of knee replacement and had frequent knee pain. Resident #83 explained the resident's only ordered pain medication was acetaminophen and the medication did not effectively manage the resident's pain.

On 02/26/2025 at 3:20 PM, a Licensed Practical Nurse (LPN) verbalized orders for pain medication instructed to give pain medication for either mild, moderate, and/or severe pain. The LPN explained a numeric scale of 0 - 10 was used to assess the severity of a resident's pain. Mild pain was 1-3/10, moderate pain was 4-6/10, and severe pain was 7-10/10. The LPN verbalized if a resident reported a pain level the resident's pain medication was not prescribed for, the expectation was the nurse would contact the resident's provider for instructions and/or new orders to treat the reported level of pain.

On 02/26/2025 at 3:23 PM, the LPN reviewed Resident #83's MAR for February and confirmed pain levels documented above three, were moderate to severe pain and the resident's pain medication (acetaminophen) was prescribed for mild pain (1-3/10).

On 02/26/2025 at 3:49 PM, the Director of Nursing Services (DNS) verbalized a pain rated as 0-3 on a numeric scale of 10 was mild pain and confirmed pain rated as 4 -10/10 was moderate to severe pain and was not to be considered mild pain. The expectation was when a resident reported a pain level outside of the parameters of the resident's prescribed pain medication, the nurse would contact the provider for instructions and/or new orders.

On 02/27/2025 at 8:24 AM, Resident #83 complained of 10/10 knee pain and 8/10 neck and shoulder pain at rest, increasing to 10/10 with movement. The resident verbalized the pain was keeping the resident awake at night, limiting the resident's range of motion, and limiting the resident's ability to do things the resident enjoyed. The resident verbalized the facility was aware of the resident's pain but had not done anything to help alleviate the pain.

The facility policy titled Pain Management, dated 05/05/2023, documented pain was whatever the experiencing person said it was and existed whenever the experiencing person said it did. Ongoing evaluations of a resident's pain was competed each shift and documented on the resident's MAR. Based on

the evaluation, interventions were developed, implemented, monitored, and revised as necessary to prevent or manage the resident's pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43311 potential for actual harm Based on clinical record review, interview and document review, the facility failed to: 1) perform nursing pre Residents Affected - Many and post dialysis assessments and 2) access and maintain completed dialysis communication transfer forms

in collaboration with the dialysis provider for 6 of 6 sampled residents on dialysis (Resident # 9, #20, #151, #51, #61, and #60). The deficient practice potentially placed the residents at risk for improper coordination of care between the facility and the dialysis provider.

Findings include:

Resident #9

Resident #9 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including end stage renal disease, type two diabetes mellitus without complications, and heart failure.

Physician orders for Resident #9 documented the following:

-05/31/2024: Hemodialysis: Monday-Wednesday-Friday. Special instructions; Vital signs (VS) after each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday.

-06/03/2024: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS before each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday.

-05/12/2024: check arteriovenous (AV) fistula every shift for positive thrill and bruit, access site right upper arm.

Resident #9's Comprehensive Care Plan documented the following dialysis nursing interventions/tasks:

-check arteriovenous fistula every day for bruit and thrill,

-monitor/document peripheral edema, and

-monitor/document/report to physician as needed any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage.

The facility Transportation Log documented Resident #9 was transported to dialysis on the following dates:

-12/02/2024

-12/27/2024

-12/31/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 -01/17/2025

Level of Harm - Minimal harm or -01/27/2025 potential for actual harm Resident #9's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's Residents Affected - Many clinical assessments before, during, and after dialysis for the documented dialysis transportation dates.

Resident #9's clinical record contained the following incomplete Hemodialysis Communication Forms:

-11/04/2024: Lacked the pre dialysis access site assessment, pain assessment, medications held/given, signature, title, and time of transfer, the Dialysis Center's temperature measurement, the post dialysis vitals, access site assessment, pain assessment, signature, title, and time of return.

-11/22/2024: Lacked the reason medications were not administered, signature, and time of transfer.

-12/04/2024: Lacked the pre dialysis medications held/given and pain assessment, the Dialysis Center's pain assessment, and the post dialysis pain assessment.

-12/13/2024: Lacked the pre dialysis medications held/given, access site assessment, and pain assessment, and the post dialysis pain assessment.

-12/18/2024: Lacked the pre dialysis medications held/given, access site assessment, and pain assessment.

-01/06/2025: Lacked the pre assessment time of transfer, and the reason why medications were not administered, and the Dialysis Center's pain assessment.

-01/10/2025: Lacked the pre dialysis assessment time of transfer, and the Dialysis Center's pain assessment, access site assessment, VS, pre and post dialysis weights, and dialysis start and end times.

-01/24/2025: Lacked the post dialysis vitals, pain assessment, access site assessment, signature, title, and date.

On 02/26/25 at 1:47 PM, a Licensed Practical Nurse (LPN) explained the Hemodialysis Communication Form indicated the nursing facility was responsible for completion of the top portion of the form prior to the resident's treatment and should send the form with the resident to the Dialysis Center. Upon the resident's return from the Dialysis Center, the bottom portion was to be completed by the nursing facility. The Dialysis Center should have completed the middle section and returned the form to the nursing facility after the treatment was completed to advise of the resident's post dialysis status.

On 02/26/2025 at 1:51 PM, the LPN explained a consequence to an incomplete or missing Hemodialysis Communication Form was the resident could be in trouble metabolically and the form was one way to track what was happening at the time and informing the nurse of what occurred during dialysis.

Resident #20

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Resident #20 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, and acute Level of Harm - Minimal harm or posthemorrhagic anemia. potential for actual harm Physician orders for Resident #20 documented the following: Residents Affected - Many -10/07/2024: Dialysis every Tuesday, Thursday, and Saturday in the AM, every 48 hours for dialysis.

-10/08/2024: Check AV fistula every shift for positive bruit and thrill, access site left upper arm every shift.

-10/08/2024: Check the access site dressing to left upper arm every shift.

-01/02/2025: Hemodialysis: Tuesday, Thursday, and Saturday. Special instructions; VS before and after each session. Send/receive communication form with patient. Medical Records to scan upon return, every day shift, every Tuesday, Thursday, and Saturday.

Resident #20's Comprehensive Care Plan documented the following dialysis nursing interventions/tasks:

-check and change dressing daily at access site, document,

-check AV fistula every day for bruit and thrill,

-monitor/document for peripheral edema, and

-monitor/document/report to physician as needed any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage.

The facility Transportation Log documented Resident #20 was transported to dialysis on the following dates:

-11/09/2024

-11/30/2024

-12/07/2024

-12/21/2024

-12/23/2024

-12/26/2024

-12/28/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Resident #20's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's clinical assessments before, during, and after dialysis for the documented dialysis transportation dates. Level of Harm - Minimal harm or potential for actual harm Resident #20's clinical record contained the following incomplete Hemodialysis Communication Forms:

Residents Affected - Many -11/12/2024: Lacked the Dialysis Center's access site assessment, pain assessment, and observations.

-11/14/2024: Lacked the Dialysis Center's access site assessment, pain assessment, and observations.

-11/23/2024: Lacked the facility nurse post dialysis access site assessment, pain assessment, date and signature.

-11/28/2024: Lacked the Dialysis Center's access site assessment, pain assessment, dialysis start and end times, and post dialysis weight and the facility nurse post dialysis pain assessment.

-12/14/2024: Lacked the Dialysis Center's access site assessment and the facility nurse post dialysis assessment, VS, signature, title and date.

-12/31/2024: Lacked the Dialysis Center's access site assessment, post dialysis weight, dialysis start and end times, and the facility nurse's pre dialysis transfer time, the post dialysis access site assessment and vitals.

-01/04/2025: Lacked the facility nurse post dialysis assessment, signature, title, and date.

-01/07/2025: Lacked the facility nurse pre dialysis access site assessment, medication held/given, pain assessment, and the Dialysis Center's post dialysis weight.

-01/16/2025: Lacked the facility nurse pre and post dialysis signatures, titles, time of departure, and post dialysis assessment.

-01/23/2025: Lacked the facility nurse pre dialysis medications held/given and time of transfer, the Dialysis Center's access site assessment and pain assessment, and the facility nurse post dialysis access site assessment, VS, signature, title, date, and time of return.

-01/28/2025: Lacked the Dialysis Center's access site assessment, dialysis start and end times, and pain assessment.

-01/30/2025: Lacked the pre dialysis time of transfer, the Dialysis Center's access site assessment, pain assessment, and time of assessment, and the facility nurse post dialysis access site assessment, vitals, pain assessment, signature, title and time of return.

-02/06/2025: Lacked the facility nurse pre dialysis access site assessment, pain assessment, medications held/given, signature, title, and time of transfer, the Dialysis Center's post dialysis weight, and facility nurse post dialysis access site assessment, pain assessment, signature, title, and time of return.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 -02/08/2025: Lacked the pre dialysis pain assessment and medications held/given, the Dialysis Center's access site assessment, pain assessment, and start and end times for dialysis. Level of Harm - Minimal harm or potential for actual harm -02/13/2025: Lacked the time of transfer to dialysis and the facility nurse post dialysis access site assessment, pain assessment, vitals, signature, title, and date. Residents Affected - Many Resident #151

Resident #151 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including acute and chronic respiratory failure with hypercapnia, anemia in chronic kidney disease, dependence on renal dialysis, and chronic atrial fibrillation, unspecified.

Physician orders for Resident #151 documented the following:

-01/09/2025: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS before each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday.

-01/09/2025: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS after each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday.

-02/19/2025: Receives hemodialysis three times per week on Monday, Wednesday, and Friday.

-02/19/2025: Check AV fistula every shift for positive thrill and bruit, access site left AV.

-02/19/2025: check the access site dressing to left intrajugular perma-cath, report signs and symptoms of infection to physician, every shift.

Resident #151's Comprehensive Care Plan documented the following dialysis nursing interventions/tasks:

-pain assessment every shift related to dialysis

-monitor and report to physician as needed for any sign or symptom of decreased appetite, nausea/vomiting, complaints of stomach pain.

Resident #151's clinical record contained the following incomplete Hemodialysis Communication Forms:

-01/15/2025: Lacked the pre dialysis access site assessment, the Dialysis Center's access site assessment pain assessment, and time of assessment, and the facility nurse access site assessment post dialysis access site assessment, pain assessment, and time of return.

-02/12/2025: Lacked the facility nurse pre dialysis access site assessment and time of transfer, the Dialysis Center's complete VS, dialysis start and end times, access site assessment and pain assessment, and the facility nurse post dialysis access site assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 -02/14/2025: Lacked the pre dialysis medications given/held and time of transfer, and the facility nurse post dialysis access site assessment, pain assessment, signature, title, and return time. Level of Harm - Minimal harm or potential for actual harm -02/21/2025: Lacked the Dialysis Center's post dialysis weight and the facility nurse post dialysis access site assessment, pain assessment, vitals, signature, title and return time. Residents Affected - Many -02/24/2025: Lacked the Dialysis Center's access site assessment, pain assessment, resident's temperature, and time of assessment, and the facility nurse access site assessment and pain assessment.

-02/26/2025: Lacked the pre dialysis medications given/held, pain assessment, and time of transfer, the Dialysis Center's access site assessment, and the facility nurse post dialysis access site assessment, pain assessment, signature, title and return time.

Resident #61

Resident #61 was admitted to the facility on [DATE REDACTED], with diagnoses including dependence on renal dialysis, type two diabetes mellitus without complications, and atherosclerotic heart disease of native coronary artery, and anemia in other chronic diseases classified elsewhere.

Physician orders for Resident #61 documented the following:

-12/12/2024: Receives Hemodialysis Tuesday, Thursday, and Saturday.

-12/14/2024: Hemodialysis: Tuesday, Thursday, Saturday. Special instructions; VS before session. Send/receive communication form with patient. Medical Records to scan upon return, every shift, every Tuesday, Thursday, and Saturday.

-12/14/2024: Hemodialysis: Tuesday, Thursday, Saturday. Special instructions; VS after session. Send/receive communication form with patient. Medical Records to scan upon return, every shift, every Tuesday, Thursday, and Saturday.

Resident #61's Comprehensive Care Plan documented the following dialysis nursing interventions/tasks:

-Monitor/document for peripheral edema,

-Monitor/document/report to physician as needed any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage,

-Monitor/document/report to physician as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds,

-Report significant changes in pulse, respirations, and blood pressure immediately.

Resident #61's clinical record contained the following incomplete Dialysis Communication Forms:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 -12/18/2024: Lacked the pre dialysis access site assessment and time of transfer, the Dialysis Center's access site assessment, and the facility nurse post dialysis access site assessment. Level of Harm - Minimal harm or potential for actual harm -01/04/2025: Lacked the pre dialysis access site assessment, pain assessment, medications given/held, signature, title, and time of transfer, the Dialysis Center's access site assessment and post dialysis weight. Residents Affected - Many -01/08/2025: Lacked the pre dialysis access site assessment, the Dialysis Center's VS and access site assessments, visit documentation, and the facility nurse post dialysis access site assessment.

-01/11/2025: Lacked the pre dialysis access site assessment, pain assessment, signature, title and time of transfer, and the Dialysis Center's access site assessment.

Resident #51

Resident #51 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including end stage renal disease, type two diabetes mellitus without complications, chronic obstructive pulmonary disease, and anemia in chronic kidney disease.

Physician orders for Resident #51 documented the following:

-02/17/2025: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS before each session. Send/receive communication form with patient. Medical Records to scan upon return, every day shift, every Monday, Wednesday, and Friday.

-02/17/2025: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS after each session. Send/receive communication form with patient. Medical Records to scan upon return, every day shift, every Monday, Wednesday, and Friday.

-02/17/2025: Check the access site dressing right upper arm every shift.

-02/24/2025: Check AV fistula every shift for positive thrill and bruit, access site right upper arm, every shift.

Resident #51's Comprehensive Care Plan documented the following nursing interventions/tasks:

-Administer medications as ordered, monitor/document for side effects and effectiveness,

-Monitor VS as ordered and record, notify physician of significant abnormalities.

The facility Transportation Log documented Resident #51 was transported to dialysis on the following dates:

-02/03/2025

-02/05/2025

-02/07/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Resident #51's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's clinical assessments before, during, and after dialysis for the documented dialysis transportation dates. Level of Harm - Minimal harm or potential for actual harm Resident #51's clinical record contained the following incomplete Hemodialysis Communication Forms:

Residents Affected - Many -02/10/2025: Lacked the pre dialysis medications given/held, the Dialysis Center's access site assessment, pain assessment, pre and post dialysis weight, dialysis start and end times, signature and title.

-02/19/2025: Lacked the Dialysis Center's access site assessment, pain assessment, pre and post dialysis weight, dialysis start and end times, signature, title, and time of assessment. A notation on the Dialysis Center portion of the form wrote Dialysis Center did not fill out.

-02/21/2025: Lacked the Dialysis Center's post dialysis weight and dialysis start and end times.

-02/24/2025: Lacked the pre dialysis VS, medications held/given, and time of transfer, and the Dialysis Center's access site assessment, pain assessment, VS, pre and post dialysis weight, dialysis start and end times, signature, and title.

On 02/27/25 at 10:24 AM, the Director of Nursing Services (DNS) explained if a Hemodialysis Communication Record was not present in the clinical chart, it would mean the form was not implemented for

the Dialysis visit. The DNS confirmed the missing forms were not present and confirmed the incomplete dialysis visit records for the reviewed residents. The expectation was the form would be filled out for every resident dialysis visit as a tool of communication between the facility and the Dialysis Center. The DNS confirmed if the visit was refused or canceled it should have been documented in a nursing progress note.

The DNS explained if the Hemodialysis Communication Record had missing information from the Dialysis Center staff, the charge nurse on duty would call the Dialysis Center and get the information or have the information faxed to the facility. The DNS confirmed it was the responsibility of the charge nurse on duty to verify the Hemodialysis Communication Record was complete and accurately documented the resident's post dialysis status.

On 03/03/25 at 12:30 PM, the DNS verbalized the DNS was the Dialysis Coordinator and had the overall responsibility for coordination of dialysis for facility residents.

40377

Resident #60

Resident #60 was admitted to the facility on [DATE REDACTED], with diagnoses including end stage renal disease, type 2 diabetes mellitus without complication, renovascular hypertension, and dependence on renal dialysis.

A physician's order dated 01/28/2025, documented Hemodialysis: Monday, Wednesday and Friday at 6:15 AM, Special Instructions: VS before each session. Send/receive communication form with patient. Medical Records to scan document upon return every day shift every Monday, Wednesday, and Friday.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 A physician's order dated 01/28/2025, documented Hemodialysis: Monday, Wednesday and Friday at 6:15 AM, Special Instructions: VS after each session. Send/receive communication form with patient. Medical Level of Harm - Minimal harm or Records to scan document upon return every day shift every Monday, Wednesday, and Friday. potential for actual harm

A physician's order dated 01/28/2025, documented check the access site dressing right chest every shift. Residents Affected - Many Resident #60's Comprehensive Care Plan dated 02/04/2025, documented Resident #60 required hemodialysis resulting from renal failure with interventions including:

- monitor and document for peripheral edema.

- monitor/document and report to physician as needed any signs and symptoms of infection to access site: redness, swelling, warmth or drainage.

- obtain VS and weight. Report significant changes in pulse, respirations and BP immediately.

The facility Transportation Log documented Resident #60 was transported to dialysis on the following dates:

- 01/29/2025 at 5:45 AM

- 01/31/2025 at 5:45 AM

- 02/03/2025 at 5:45 AM

- 02/05/2025 at 5:45 AM

- 02/07/2025 at 5:45 AM

- 02/10/2025 at 5:45 AM

- 02/12/2025 at 5;45 AM

- 02/14/2025 at 5:45 AM

- 02/17/2025 at 5:45 AM

- 02/19/2025 at 5:45 AM

- 02/21/2025 at 5:45 AM

Resident #60's clinical record documented the following Hemodialysis Communication Records lacked completion:

-On 01/29/2025, lacked assessment of the access site prior to dialysis, time of transfer to dialysis, and assessment of the access after dialysis and time of return.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 -On 02/03/2025, lacked medications given/held before dialysis, assessment of the access site before dialysis, time of transfer to dialysis, all of the dialysis center's clinical information, assessment of the access Level of Harm - Minimal harm or site after dialysis, nurses signature, title, and time of return. potential for actual harm -On 02/05/2025, lacked reason medication held before dialysis, resident's VS after dialysis, assessment of Residents Affected - Many access site, nurse's signature, title and time of return.

-On 02/07/2025, lacked resident's VS prior to leaving, title of person signing form and time of transfer to dialysis, assessment of access on return from dialysis, nurse's signature, title and time of return.

-On 02/10/2025, lacked medications given/held, assessment of access site, title of person signing form and time of transfer to dialysis, and all of the dialysis center's clinical information.

-On 02/12/2025, lacked medications given/held before dialysis, the resident's VS upon return, and assessment of the access site.

-On 02/17/2025, lacked reason medication held before dialysis, and title of person signing form after dialysis.

-On 02/19/2025, lacked assessment of access site before dialysis, assessment of the access site after dialysis, the nurse's signature, title and time of return.

-On 02/21/2025, lacked the resident's post dialysis weight, and the nurse's signature, title and time of return.

-On 02/24/2025, lacked medications given/held, assessment of the access site before dialysis, the nurse's signature and time of transfer to dialysis, the resident's weight post dialysis, and the completion of the return section after dialysis, including resident vitals, access assessment, nurse's signature, title and time of return.

On 02/26/2025 at 9:32 AM, the DNS verified the Hemodialysis Communication Records were missing the aforementioned VS and/or resident assessments and/or hemodialysis center's clinical assessment information associated with the aforementioned dates.

On 02/26/25 at 9:36 AM, the DNS verbalized all residents receiving dialysis were sent with a Dialysis Communication Record. The facility nurse should complete the section prior to sending the resident to dialysis including any medications given or held, resident's VS (blood pressure, pulse, respirations, temperature), assessment of the access site, date and time of transfer and the nurse's signature and title.

The dialysis center would complete the second section including resident's VS, the resident's weight pre and post dialysis, any new orders, dialysis start and ending time, assessment of the access site, any lab work, any recommendations, the dialysis center's address and phone number and the nurse's signature, title and time. Upon return to the facility, the facility nurse would complete the last section including resident's VS, access assessment, the nurse's signature, title and time of return.

Resident #60's clinical record lacked documented evidence of a Hemodialysis Communication Record for the following dates Resident #60 was transported to dialysis:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 - 01/29/2025

Level of Harm - Minimal harm or - 02/14/2025 potential for actual harm

On 02/27/25 at 10:28 AM, the Assistant Director of Nursing verbalized the ADON expected staff to complete Residents Affected - Many the Hemodialysis Communication Record before and after the resident's dialysis and to ensure the dialysis center completed their portion and if not, to call and have the information sent via facsimile or take a verbal report and document the information in a progress note. The ADON confirmed the facility did not have the Hemodialysis Communication Records for the aforementioned dates and no other documentation was available in the facility to record the required information.

The American Heart Association (AHA) journal titled Risk Assessment for Sudden Cardiac Death in Dialysis Patients, Volume 3; Number 5, viewed 02/26/2025, documented patients with end-stage renal disease (ESRD) on long-term dialysis therapy had a very high mortality due to predominantly cardiovascular causes.

The single most common form of death in dialysis patients was sudden cardiac death. Dialysis could cause significant sudden shifts in electrolytes and fluid volume and could act as a trigger to initiating life-threatening arrhythmias. Precipitating factors included hyper-hypokalemia, anemia, hypertension, diabetic autonomic neuropathy, rapid fluctuations in volume status and blood pressure around dialysis treatments, atrial dilation from fluid overload, fluctuations in electrolytes including potassium, around or during dialysis treatments, and acute changes in autonomic regulations during dialysis.

A Dialysis Transfer Agreement, effective 03/14/2024, documented the Dialysis Center would provide to Facility information on aspects of the management of a Designated Resident's care related to the provision of dialysis services. The Facility would ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents to include the following: treatment provided to the Designated Resident, appropriate medical records, medications and any 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 46301 potential for actual harm Based on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant Residents Affected - Few (CNA) had an annual performance evaluation completed timely for 2 of 2 CNAs employed 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 40377 minimal harm Based on observation and interview, the facility failed to ensure current nursing hours was posted for the Residents Affected - Many 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41848

Residents Affected - Few Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's behaviors of threatening staff members with physical and sexual violence were monitored per facility policy for 1 of 22 sampled residents (Resident #78). This deficient practice had the potential to result

in a resident's behaviors worsening or escalating with no monitoring in place.

Findings include:

Resident #78

Resident # 78 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including alcohol dependence with alcohol-induced persisting dementia, schizoaffective disorder, unspecified, and hallucinations, unspecified.

A Nursing Progress Note, dated 01/06/2025, documented the resident used profane language toward the Licensed Practical Nurse (LPN) and called the LPN derogatory names. The resident told the LPN to get on

the LPN's knees and perform a sexual act for the resident and apologize to the resident until the resident was tired of the LPN. The resident yelled and blocked the LPN from leaving the area. The resident threatened to break the LPN's face and was using numerous expletives. The resident then threatened to catch the LPN off-guard and rape the LPN.

The task for Behavior Monitoring, documented the resident had no behaviors observed on 01/06/2025.

A Nursing Progress Note, dated 01/09/2025, documented the resident approached the LPN and started laughing while calling the LPN a derogatory name.

The task for Behavior Monitoring, documented the resident had no behaviors observed on 01/09/2025.

A Nursing Progress Note, dated 01/15/2025, documented the LPN walked by Resident #78 and the resident called the LPN a derogatory name. The LPN walked away from the resident to avoid any further comments from the resident as the resident's use of derogatory language towards the LPN and other staff was an ongoing concern. The resident then threatened to rape the LPN and told the LPN the resident would wait for

the LPN outside and would torture the LPN. The resident then referred to the LPN as a derogatory name in Spanish.

The task for Behavior Monitoring, documented the resident had no behaviors observed on 01/15/2025.

The Care Plan for Resident #78 did not include the behaviors of threatening staff.

On 02/26/2025 at 12:42 PM, the LPN verbalized the resident had snapped and the resident began making violent threats toward the LPN when the LPN had taken the resident's alcohol away.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 On 02/26/2025 at 4:08 PM, the Director of Nursing Services (DNS) verbalized the resident's behavior of making threats of sexual violence against staff should have been care planned with interventions for the Level of Harm - Minimal harm or safety of residents, visitors, and staff. The DNS confirmed the Care Plan did not include the behaviors and potential for actual harm the behaviors should have been included on the Care Plan. The DNS verbalized behavior monitoring should have included documentation of the behaviors for each day a behavior occurred. Residents Affected - Few

The facility policy titled Documentation - Licensed Nursing, revised 01/01/2016, documented behaviors would be documented and tracked as they occurred using the appropriate behavior tracking forms.

Cross reference with tag

F-F698

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43311

Residents Affected - Few Based on interview, clinical record review, and document review, the facility failed to ensure a resident's medical record was complete for 6 of 6 sampled residents (Resident #9, #20, #151, #61, #51, and #60), and to accurately document monitoring of a resident with significant weight loss for 1 of 22 sampled residents (Resident #1). The deficient practice had the potential for the resident to experience health risks associated with additional unknown weight loss.

Findings include:

Resident #9

Resident #9 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including end stage renal disease, type two diabetes mellitus without complications, and heart failure.

A physician's order dated 05/31/2024, documented Hemodialysis: Monday-Wednesday-Friday. Special instructions; Vital signs (VS) after each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday.

A physician's order dated 06/04/2024, documented Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS before each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday

The facility Transportation Log documented Resident #9 was transported to dialysis on the following dates:

-12/02/2024

-12/27/2024

-12/31/2024

-01/17/2025

-01/27/2025

Resident #9's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's clinical assessments before, during, and after dialysis for the documented dialysis transportation dates.

Resident #9's clinical record contained the following incomplete Hemodialysis Communication Forms:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -11/04/2024: Lacked the facility nurse pre dialysis access site assessment, pain assessment, medications held/given, signature, title, and time of transfer, the Dialysis Center's temperature measurement, the post Level of Harm - Minimal harm or dialysis vitals, access site assessment, pain assessment, signature, title, and time of return. potential for actual harm -11/22/2024: Lacked the reason medications were not administered, signature, and time of transfer. Residents Affected - Few -12/04/2024: Lacked the facility nurse pre dialysis medications held/given and pain assessment, the Dialysis Center's pain assessment, and the post dialysis pain assessment.

-12/13/2024: Lacked the facility nurse pre dialysis medications held/given, access site assessment, and pain assessment, and the post dialysis pain assessment.

-12/18/2024: Lacked the facility nurse pre dialysis medications held/given, access site assessment, and pain assessment.

-01/06/2025: Lacked the facility nurse pre assessment time of transfer, and the reason why medications were not administered, and the Dialysis Center's pain assessment.

-01/10/2025: Lacked the facility nurse pre dialysis assessment time of transfer, and the Dialysis Center's pain assessment, access site assessment, vital signs, pre and post dialysis weights, and dialysis start and end times.

-01/24/2025: Lacked the facility nurse post dialysis vitals, pain assessment, access site assessment, signature, title, and date.

On 02/26/25 at 1:47 PM, a Licensed Practical Nurse (LPN)/Charge Nurse explained the Hemodialysis Communication Form indicated the nursing facility was responsible for completion of the top portion of the form prior to the resident's treatment and should send the form with the resident to the Dialysis Center. Upon

the resident's return from the Dialysis Center, the bottom portion was to be completed by the nursing facility.

The Dialysis Center should have completed the middle section and returned the form to the nursing facility

after the treatment was completed to advise of the resident's post dialysis status.

On 02/26/2025 at 1:51 PM, the LPN/Charge Nurse explained a consequence to an incomplete or missing Hemodialysis Communication Form was the resident could be in trouble metabolically and the form was one way to track what was happening at the time and informing the nurse of what occurred during dialysis.

Resident #20

Resident #20 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, and acute posthemorrhagic anemia.

A physician's order dated 10/07/2024, documented Dialysis every Tuesday, Thursday, and Saturday in the AM, every 48 hours for dialysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 A physician's order dated 10/08/2024, documented Check AV fistula every shift for positive bruit and thrill, access site left upper arm every shift. Level of Harm - Minimal harm or potential for actual harm The facility Transportation Log documented Resident #20 was transported to dialysis on the following dates:

Residents Affected - Few -11/09/2024

-11/30/2024

-12/07/2024

-12/21/2024

-12/23/2024

-12/26/2024

-12/28/2024

Resident #20's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's clinical assessments before, during, and after dialysis for the documented dialysis transportation dates.

Resident #20's clinical record contained the following incomplete Hemodialysis Communication Forms:

-11/12/2024: Lacked the Dialysis Center's access site assessment and pain assessment.

-11/14/2024: Lacked the Dialysis Center's access site assessment and pain assessment.

-11/23/2024: Lacked the facility nurse post dialysis access site assessment, pain assessment, date and signature.

-11/28/2024: Lacked the Dialysis Center's access site assessment, pain assessment, dialysis start and end times, and post dialysis weight and the facility nurse post dialysis pain assessment.

-12/14/2024: Lacked the Dialysis Center's access site assessment and the facility nurse post dialysis assessment, vital signs, signature, title and date.

-12/31/2024: Lacked the Dialysis Center's access site assessment, post dialysis weight, dialysis start and end times, and the facility nurse's pre dialysis transfer time, the post dialysis access site assessment and vitals.

-01/04/2025: Lacked the facility nurse post dialysis assessment, signature, title, and date.

-01/07/2025: Lacked the facility nurse pre dialysis access site assessment, medication held/given, pain assessment, and the Dialysis Center's post dialysis weight.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -01/16/2025: Lacked the facility nurse pre and post dialysis signatures, titles, time of departure, and post dialysis assessment. Level of Harm - Minimal harm or potential for actual harm -01/23/2025: Lacked the facility nurse pre dialysis medications held/given and time of transfer, the Dialysis Center's access site assessment and pain assessment, and the facility nurse post dialysis access site Residents Affected - Few assessment, vital signs, signature, title, date, and time of return.

-01/28/2025: Lacked the Dialysis Center's access site assessment, dialysis start and end times, and pain assessment.

-01/30/2025: Lacked the facility nurse pre dialysis time of transfer, the Dialysis Center's access site assessment, pain assessment, and time of assessment, and the facility nurse post dialysis access site assessment, vitals, pain assessment, signature, title and time of return.

-02/06/2025: Lacked the facility nurse pre dialysis access site assessment, pain assessment, medications held/given, signature, title, and time of transfer, the Dialysis Center's post dialysis weight, and facility nurse post dialysis access site assessment, pain assessment, signature, title, and time of return.

-02/08/2025: Lacked the facility nurse pre dialysis pain assessment and medications held/given, the Dialysis Center's access site assessment, pain assessment, and start and end times for dialysis.

-02/13/2025: Lacked the time of transfer to dialysis and the facility nurse post dialysis access site assessment, pain assessment, vitals, signature, title, and date.

Resident #151

Resident #151 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including acute and chronic respiratory failure with hypercapnia, anemia in chronic kidney disease, dependence on renal dialysis, and chronic atrial fibrillation, unspecified.

A physician's order dated 01/09/2025, documented Hemodialysis: Monday-Wednesday-Friday. Special instructions: VS before each session. Send/receive communication form with patient. Medical Records scanned upon return, every day shift, every Monday, Wednesday, and Friday.

A physician's order dated 01/09/2025, documented Hemodialysis: Monday-Wednesday-Friday. Special instructions: VS after each session. Send/receive communication form with patient. Medical Records scanned upon return, every day shift, every Monday, Wednesday, and Friday.

Resident #151's clinical record contained the following incomplete Hemodialysis Communication Forms:

-01/15/2025: Lacked the facility nurse pre dialysis access site assessment, the Dialysis Center's access site assessment pain assessment, and time of assessment, and the facility nurse access site assessment post dialysis access site assessment, pain assessment, and time of return.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -02/12/2025: Lacked the facility nurse pre dialysis access site assessment and time of transfer, the Dialysis Center's complete vital signs, dialysis start and end times, access site assessment and pain assessment, Level of Harm - Minimal harm or and the facility nurse post dialysis access site assessment. potential for actual harm -02/14/2025: Lacked the facility nurse pre dialysis assessment of medications given/held and time of Residents Affected - Few transfer, and the facility nurse post dialysis access site assessment, pain assessment, signature, title, and return time.

-02/21/2025: Lacked the Dialysis Center's post dialysis weight and the facility nurse post dialysis access site assessment, pain assessment, vitals, signature, title and return time.

-02/24/2025: Lacked the Dialysis Center's access site assessment, pain assessment, resident's temperature, and time of assessment, and the facility nurse access site assessment and pain assessment.

-02/26/2025: Lacked the facility nurse pre dialysis assessment of medications given/held, pain assessment, and time of transfer, the Dialysis Center's access site assessment, and the facility nurse post dialysis access site assessment, pain assessment, signature, title and return time.

Resident #61

Resident #61 was admitted to the facility on [DATE REDACTED], with diagnoses including dependence on renal dialysis, type two diabetes mellitus without complications, and atherosclerotic heart disease of native coronary artery, and anemia in other chronic diseases classified elsewhere.

A physician's order dated 12/14/2024, documented Hemodialysis: Tuesday, Thursday, Saturday. Special instructions: VS before session. Send/receive communication form with patient. Medical Records to scan upon return, every shift, every Tuesday, Thursday, and Saturday.

A physician's order dated 12/14/2024, documented Hemodialysis: Tuesday, Thursday, Saturday. Special instructions: VS after session. Send/receive communication form with patient. Medical Records to scan upon return, every shift, every Tuesday, Thursday, and Saturday.

Resident #61's clinical record contained the following incomplete Dialysis Communication Forms:

-12/18/2024: Lacked the facility nurse pre dialysis access site assessment and time of transfer, the Dialysis Center's access site assessment, and the facility nurse post dialysis access site assessment.

-01/04/2025: Lacked the facility nurse pre dialysis access site assessment, pain assessment, medications given/held, signature, title, and time of transfer, the Dialysis Center's access site assessment and post dialysis weight.

-01/08/2025: Lacked the facility nurse pre dialysis access site assessment, the Dialysis Center's vital sign and access site assessments, visit documentation, and the facility nurse post dialysis access site assessment.

-01/11/2025: Lacked the facility nurse pre dialysis access site assessment, pain assessment, signature, title and time of transfer, and the Dialysis Center's access site assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Resident #51

Level of Harm - Minimal harm or Resident #51 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including end potential for actual harm stage renal disease, type two diabetes mellitus without complications, chronic obstructive pulmonary disease, and anemia in chronic kidney disease. Residents Affected - Few

A physician's order dated 02/17/2025, documented Hemodialysis: Monday-Wednesday-Friday. Special instructions: VS before each session. Send/receive communication form with patient. Medical Records to scan upon return, every day shift, every Monday, Wednesday, and Friday.

A physician's order dated 02/17/2025, documented Hemodialysis: Monday-Wednesday-Friday. Special instructions: VS after each session. Send/receive communication form with patient. Medical Records to scan upon return, every day shift, every Monday, Wednesday, and Friday.

A physician's order dated 02/24/2025, documented Check AV fistula every shift for positive thrill and bruit, access site right upper arm, every shift.

The facility Transportation Log documented Resident #51 was transported to dialysis on the following dates:

-02/03/2025

-02/05/2025

-02/07/2025

Resident #51's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's clinical assessments before, during, and after dialysis for the documented dialysis transportation dates.

Resident #51's clinical record contained the following incomplete Hemodialysis Communication Forms:

-02/10/2025: Lacked the pre dialysis medications given/held, the Dialysis Center's access site assessment, pain assessment, pre and post dialysis weight, dialysis start and end times, signature and title.

-02/19/2025: Lacked the Dialysis Center's access site assessment, pain assessment, pre and post dialysis weight, dialysis start and end times, signature, title, and time of assessment. A notation on the Dialysis Center portion of the form wrote Dialysis Center did not fill out.

-02/21/2025: Lacked the Dialysis Center's post dialysis weight and dialysis start and end times.

-02/24/2025: Lacked the facility nurse pre dialysis vital signs, medications held/given, and time of transfer, and the Dialysis Center's access site assessment, pain assessment, vital signs, pre and post dialysis weight, dialysis start and end times, signature, and title.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 On 02/27/25 at 10:24 AM, the Director of Nursing Services (DNS) explained if a Hemodialysis Communication Record was not present in the clinical chart, it would mean the form was not implemented for Level of Harm - Minimal harm or the Dialysis visit. The DNS confirmed the missing forms were not present and confirmed the incomplete potential for actual harm dialysis visit records for the reviewed residents. The expectation was the form would be filled out for every resident dialysis visit as a tool of communication between the facility and the Dialysis Center. The DNS Residents Affected - Few confirmed if the visit was refused or canceled it should have been documented in a nursing progress note.

The DNS explained if the Hemodialysis Communication Record had missing information from the Dialysis Center staff, the charge nurse on duty would call the Dialysis Center and get the information or have the information faxed to the facility. The DNS confirmed it was the responsibility of the charge nurse on duty to verify the Hemodialysis Communication Record was complete and accurately documented the resident's post dialysis status.

On 03/03/25 at 12:30 PM, the DNS verbalized the DNS was the Dialysis Coordinator and had the overall responsibility for coordination of dialysis for facility residents.

40377

Resident #60

Resident #60 was admitted to the facility on [DATE REDACTED], with diagnoses including end stage renal disease, type 2 diabetes mellitus without complication, renovascular hypertension, and dependence on renal dialysis.

A physician's order dated 01/28/2025, documented Hemodialysis: Monday, Wednesday and Friday at 6;15 AM, Special Instructions: vital signs before each session. Send/receive communication form with patient. Medical Records to scan document upon return every day shift every Monday, Wednesday, and Friday.

A physician's order dated 01/28/2025, documented Hemodialysis: Monday, Wednesday and Friday at 6:15 AM, Special Instructions: vital signs after each session. Send/receive communication form with patient. Medical Records to scan document upon return every day shift every Monday, Wednesday, and Friday.

A physician's order dated 01/28/2025, documented check the access site dressing right chest every shift.

The facility Transportation Log documented Resident #60 was transported to dialysis on the following dates:

- 01/29/2025 at 5:45 AM

- 01/31/2025 at 5:45 AM

- 02/03/2025 at 5:45 AM

- 02/05/2025 at 5:45 AM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 - 02/07/2025 at 5:45 AM

Level of Harm - Minimal harm or - 02/10/2025 at 5:45 AM potential for actual harm - 02/12/2025 at 5;45 AM Residents Affected - Few - 02/14/2025 at 5:45 AM

- 02/17/2025 at 5:45 AM

- 02/19/2025 at 5:45 AM

- 02/21/2025 at 5:45 AM

Resident #60's clinical record documented the following Hemodialysis Communication Records lacked completion:

-On 01/29/2025, lacked assessment of the access site prior to dialysis, time of transfer to dialysis, and assessment of the access after dialysis and time of return.

-On 02/03/2025, lacked medications given/held before dialysis, assessment of the access site before dialysis, time of transfer to dialysis, all of the dialysis center's clinical information, assessment of the access site after dialysis, nurses signature, title, and time of return.

-On 02/05/2025, lacked reason medication held before dialysis, resident's vital signs after dialysis, assessment of access site, nurse's signature, title and time of return.

-On 02/07/2025, lacked resident's vital signs prior to leaving, title of person signing form and time of transfer to dialysis, assessment of access on return from dialysis, nurse's signature, title and time of return.

-On 02/10/2025, lacked medications given/held, assessment of access site, title of person signing form and time of transfer to dialysis, and all of the dialysis center's clinical information.

-On 02/12/2025, lacked medications given/held before dialysis, the resident's vital signs upon return, and assessment of the access site.

-On 02/17/2025, lacked reason medication held before dialysis, and title of person signing form after dialysis.

-On 02/19/2025, lacked assessment of access site before dialysis, assessment of the access site after dialysis, the nurse's signature, title and time of return.

-On 02/21/2025, lacked the resident's post dialysis weight, and the nurse's signature, title and time of return.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -On 02/24/2025, lacked medications given/held, assessment of the access site before dialysis, the nurse's signature and time of transfer to dialysis, the resident's weight post dialysis, and the completion of the return Level of Harm - Minimal harm or section after dialysis, including resident vitals, access assessment, nurse's signature, title and time of return. potential for actual harm

On 02/26/2025 at 9:32 AM, the DNS verified the Hemodialysis Communication Records were missing the Residents Affected - Few aforementioned vitals signs and/or resident assessments and/or hemodialysis center's clinical assessment information associated with the aforementioned dates.

On 02/26/25 at 9:36 AM, the DNS verbalized all residents receiving dialysis were sent with a Dialysis Communication Record. The facility nurse should complete the section prior to sending the resident to dialysis including any medications given or held, resident's vital signs (blood pressure, pulse, respirations, temperature), assessment of the access site, date and time of transfer and the nurse's signature and title.

The dialysis center would complete the second section including resident's vital signs, the resident's weight pre and post dialysis, any new orders, dialysis start and ending time, assessment of the access site, any lab work, any recommendations, the dialysis center's address and phone number and the nurse's signature, title and time. Upon return to the facility, the facility nurse would complete the last section including resident's vital signs, access assessment, the nurse's signature, title and time of return.

Resident #60's clinical record lacked documented evidence of a Hemodialysis Communication Record for the following dates Resident #60 was transported to dialysis:

- 01/29/2025

- 02/14/2025

On 02/27/25 at 10:28 AM, the Assistant Director of Nursing verbalized the ADON expected staff to complete

the Hemodialysis Communication Record before and after the resident's dialysis and to ensure the dialysis center completed their portion and if not, to call and have the information sent via facsimile or take a verbal report and document the information in a progress note. The ADON confirmed the facility did not have the Hemodialysis Communication Records for the aforementioned dates and no other documentation was available in the facility to record the required information.

The American Heart Association (AHA) journal titled Risk Assessment for Sudden Cardiac Death in Dialysis Patients, Volume 3; Number 5, viewed 2/26/2025, documented patients with end-stage renal disease (ESRD) on long-term dialysis therapy had a very high mortality due to predominantly cardiovascular causes.

The single most common form of death in dialysis patients was sudden cardiac death. Dialysis could cause significant sudden shifts in electrolytes and fluid volume and could act as a trigger to initiating life-threatening arrhythmias. Precipitating factors included hyper-hypokalemia, anemia, hypertension, diabetic autonomic neuropathy, rapid fluctuations in volume status and blood pressure around dialysis treatments, atrial dilation from fluid overload, fluctuations in electrolytes including potassium, around or during dialysis treatments, and acute changes in autonomic regulations during dialysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 A Dialysis Transfer Agreement, effective 03/14/2024, documented the Dialysis Center would provide to Facility information on aspects of the management of a Designated Resident's care related to the provision Level of Harm - Minimal harm or of dialysis services. The Facility would ensure that all appropriate medical, social, administrative, and other potential for actual harm information accompany all Designated Residents to include the following: treatment provided to the Designated Resident, appropriate medical records, medications and any changes in a patient's condition Residents Affected - Few (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.

30748

Resident #1

Resident #1 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses including type two diabetes mellitus with diabetic neuropathy, unspecified, unspecified protein-calorie malnutrition, and type two diabetes mellitus with unspecified complications.

A Nutrition Interdisciplinary Team note dated 09/10/2024, documented the resident had a 24 pound weight gain in one month and the Registered Dietician was requesting the physician to order labs to check for chronic conditions.

A physician's order dated 12/24/2024, documented Ozempic (2 mg/dose) Subcutaneous Solution Pen-Injector 8 mg/3 ml (Semaglutide). Inject 2mg subcutaneously one time a day every Tuesday related to Type two diabetes mellitus with diabetic neuropathy, unspecified.

A Nutrition Interdisciplinary Team Update note dated 01/14/2025, documented the resident was on a prescribed weight loss program, the resident was on Ozempic, and the resident was now refusing meals at least once weekly.

Resident #1's weight log documented the resident was weighed on 12/07/2024, using a hoyer scale at 247 pounds. On 01/08/2025, using a hoyer scale, the resident weighed 222.4 pounds. This was a 10.12 percent weight loss for one month.

The resident was weighed again on 01/28/2025, using a hoyer scale at 211.2 pounds. This was a 5.05 percent weight loss in 20 days.

The meal consumption logs for the last 30 days documented the following percentages of food consumed by

the resident:

-1/28/2025

Breakfast (B)-76-100 percent consumed

Lunch (L)-76-100 percent consumed

Dinner (D)-resident refused meal

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -01/29/2025

Level of Harm - Minimal harm or B-0-25 percent consumed potential for actual harm L-resident refused meal Residents Affected - Few D-0-25 percent consumed

-01/30/2025

B-no documentation found

L-no documentation found

D-51-75 percent consumed

-01/31/2025

B-resident refused meal

L-resident not available

D-in the hospital

-02/01/2025

B-in the hospital

L-in the hospital

D-in the hospital

-02/02/2025

B-in the hospital

L-in the hospital

D-in the hospital

-02/03/2025

B-in the hospital

L-in the hospital

D-in the hospital

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -02/04/2025

Level of Harm - Minimal harm or B-in the hospital potential for actual harm L-in the hospital Residents Affected - Few D-51-75 percent consumed

-02/05/2025

B-0-25 percent consumed

L-no documentation found

D-76-100 percent consumed

-02/06/2025

B-51-75 percent consumed

L-0-25 percent consumed

D-26-50 percent consumed

-02/07/2025

B-51-75 percent consumed

L-51-75 percent consumed

D-no documentation found

-02/08/2025

B-51-75 percent consumed

L-76-100 percent consumed

D-no documentation found

-02/09/2025

B-76-100 percent consumed

L-76-100 percent consumed

D-26-50 percent consumed

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -02/10/2025

Level of Harm - Minimal harm or B-76-100 percent consumed potential for actual harm L-76-100 percent consumed Residents Affected - Few D-76-100 percent consumed

-02/11/2025

B-26-50 percent consumed

L-no documentation found

D-51-75 percent consumed

-02/12/2025

B-no documentation found

L-no documentation found

D-76-100 percent consumed

-02/13/2025

B-no documentation found

L-no documentation found

D-no documentation found

-02/14/2025

B-76-100 percent consumed

L-76-100 percent consumed

D-no documentation found

-02/15/2025

B-76-100 percent consumed

L-51-75 percent consumed

D-76-100 percent consumed

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -02/16/2025

Level of Harm - Minimal harm or B-76-100 percent consumed potential for actual harm L-no documentation Residents Affected - Few D-76-100 percent consumed

-02/17/2025

B-0-25 percent consumed

L-26-50 percent consumed

D-76-100 percent consumed

-02/18/2025

B-no documentation found

L-no documentation found

D-76-100 percent consumed

-02/19/2025

B-76-100 percent consumed

L-76-100 percent consumed

D-76-100 percent consumed

-02/20/2025

B-no documentation found

L-no documentation found

D-51-75 percent consumed

-02/21/2025

B-26-50 percent consumed

L-26-50 percent consumed

D-no documentation found

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -02/22/2025

Level of Harm - Minimal harm or B-76-100 percent consumed potential for actual harm L-no documentation found Residents Affected - Few D-no documentation found

-02/23/2025

B-51-75 percent consumed

L-76-100 percent consumed

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 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 Level of Harm - Minimal harm or range, usual body weight, current diet order, percentage of food eaten, possible dental problems, current potential for actual harm illness, resident likes and dislikes, psychosocial needs, and any other changes in medical conditions that may have an impact on weight loss. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 43310 potential for actual harm Based on interview and document review, the facility's Quality Assurance and Performance Improvement Residents Affected - Few (QAPI) committee failed to identify the facility lacked a process to ensure 1) pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center were completed and correctly documented, and 2) medical records were completed and filed in 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-F740

43310

Resident #83

Resident #83 was admitted to the facility on [DATE REDACTED] 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-F842

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0942 Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Level of Harm - Minimal harm or potential for actual harm 40377

Residents Affected - Few Based on personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff upon hire for 2 of 16 sampled employees (Employee #13 and #15).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 40377

Residents Affected - Few Based on interview and document review, the facility failed to ensure facility staff received training on the facility's quality assurance and performance improvement (QAPI) program for 8 of 16 sampled employees (Employee #1, #3, #4, #7, #8, #9, #13, and #16).

Findings include:

Employee #1

Employee #1 was hired as the Executive Director with a start date on 01/01/2024.

Employee #1's personnel record documented QAPI training dated 01/14/2024 and lacked documented evidence of annual QAPI training for 2025.

Employee #3

Employee #3 was hired as the Activity Director with a start date on 01/01/2024.

Employee #3's personnel record documented QAPI training dated 01/14/2024 and lacked documented evidence of annual QAPI training for 2025.

Employee #4

Employee #4 was hired as the Registered Dietitian with a start date on 01/01/2024.

Employee #4's personnel record documented QAPI training dated 01/15/2024 and lacked documented evidence of annual QAPI training for 2025.

Employee #7

Employee #7 was hired as a Certified Nursing Assistant (CNA) with a start date on 01/01/2024.

Employee #7's personnel record documented QAPI training dated 01/29/2024 and lacked documented evidence of annual QAPI training for 2025.

Employee #8

Employee #8 was hired as a CNA with a start date on 01/01/2024.

Employee #8's personnel record documented QAPI training dated 01/14/2024 and lacked documented evidence of annual QAPI training for 2025.

Employee #9

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Employee #9 was hired as a Licensed Practical Nurse (LPN) with a start date on 01/01/2024.

Level of Harm - Minimal harm or Employee #9's personnel record documented QAPI training dated 01/21/2024 and lacked documented potential for actual harm evidence of annual QAPI training for 2025.

Residents Affected - Few Employee #13

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or 40377 potential for actual harm Based on personnel record review, interview and document review, the facility failed to ensure facility staff Residents Affected - Few received compliance and ethics training for 6 of 16 sampled employees (Employee #1, #3, #4, #6, #7, and #8).

Findings include:

Employee #1

Employee #1 was hired as the Executive Director with a start date on 01/01/2024.

Employee #1's personnel record documented compliance and ethics training dated 01/10/2024 and lacked documented evidence of annual training for 2025.

Employee #3

Employee #3 was hired as the Activity Director with a start date on 01/01/2024.

Employee #3's personnel record documented compliance and ethics training dated 01/10/2024 and lacked documented evidence of annual training for 2025.

Employee #4

Employee #4 was hired as the Registered Dietitian with a start date on 01/01/2024.

Employee #4's personnel record documented compliance and ethics training dated 01/14/2024 and lacked documented evidence of annual training for 2025.

Employee #6

Employee #6 was hired as the Dietary Supervisor with a start date on 01/01/2024.

Employee #6's personnel record documented compliance and ethics training dated 01/17/2024 and lacked documented evidence of annual training for 2025.

Employee #7

Employee #7 was hired as a Certified Nursing Assistant (CNA) with a start date on 01/01/2024.

Employee #7's personnel record documented compliance and ethics training dated 01/28/2024 and lacked documented evidence of annual training for 2025.

Employee #8

Employee #8 was hired as a CNA with a start date on 01/01/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 47 295044 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946 Employee #1's personnel record documented compliance and ethics training dated 01/12/2024 and lacked documented evidence of annual training for 2025. Level of Harm - Minimal harm or potential for actual harm On 03/03/2025 at 12:22 PM, the Executive Director (ED) verbalized all staff were required to take compliance and ethics training upon hire and annually. The ED confirmed Employee #1, #3, #4, #6, #7, and Residents Affected - Few #8 did not receive annual compliance and ethics training in 2025.

The facility policy titled Compliance Training, last revised May 2019, documented the policy outlines the process and scope of new hire and annual compliance related training for all employees. All 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 47 295044