Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hearthstone during CMS and state inspections, most recent first.
The facility failed to perform necessary nursing pre and post dialysis assessments and maintain completed dialysis communication transfer forms for residents on dialysis. This deficiency was observed in the clinical records of residents, where there was a lack of evidence of clinical assessments before, during, and after dialysis sessions. The Director of Nursing Services confirmed the missing and incomplete forms, acknowledging the expectation for complete documentation for every dialysis visit.
A resident experienced unprofessional behavior from an LPN during IV antibiotic administration. The LPN dropped the IV spike and tubing, intended to reuse them despite contamination, and used derogatory language towards the resident. The incident was witnessed by another LPN, and the facility confirmed the violation of the resident's right to dignity and respect.
A facility failed to ensure the accuracy of an MDS assessment for a resident discharged home. The resident, with various health conditions, was documented as discharged to the hospital instead. The MDS Coordinator confirmed the error, which contradicted the facility's policy requiring accurate MDS data transmission to CMS.
A facility failed to include a resident's threatening behaviors and another resident's medical condition in their care plans. One resident exhibited threatening behaviors towards staff, including physical and sexual violence, which were not addressed in their care plan. Another resident with edema was prescribed a diuretic, but their care plan did not reflect this condition or medication. The DON confirmed these omissions, which were against the facility's care planning policy.
A resident with COPD and CHF did not receive furosemide for edema due to a failure to enter the medication order into the EHR and MAR. Despite a provider's order, the medication was not administered, resulting in continued edema and discomfort. The DNS and APRN confirmed the oversight, which was against facility policy requiring immediate recording of orders.
A resident with a history of knee replacement experienced inadequate pain management due to the facility's failure to administer appropriate medication for moderate to severe pain levels. Despite the resident's reports of significant pain, the facility continued to administer acetaminophen prescribed for mild pain and did not contact the physician for further instructions. This resulted in unrelieved pain and discomfort for the resident.
The facility failed to conduct timely annual performance evaluations for two CNAs employed for over a year. One CNA did not have a documented evaluation by their anniversary date, while another had their evaluation conducted 55 days late. The HR Manager confirmed these deficiencies, noting that evaluations were required by the hire anniversary date, as per facility policy.
A resident with a history of alcohol dependence and schizoaffective disorder exhibited threatening behaviors towards staff, including profane language and threats of violence. Despite these incidents, behavior monitoring tasks indicated no behaviors were observed, and the resident's care plan lacked interventions for these behaviors. The DNS confirmed the need for documentation and care planning, which was not adhered to, resulting in a deficiency.
The facility failed to complete and document pre and post dialysis assessments and communication with the dialysis center, affecting all dialysis patients. The Executive Director confirmed the lack of a process to ensure proper documentation on the Dialysis Communication Record, as required by the facility's policy.
The facility failed to maintain complete medical records for residents undergoing dialysis and accurately document a resident's meal consumption amid significant weight loss. Hemodialysis Communication Forms were incomplete or missing vital information, such as vital signs and pain assessments, for several residents. Additionally, meal consumption logs for a resident with significant weight loss were incomplete, hindering effective nutritional management.
The QAPI committee at a facility failed to identify deficiencies in the dialysis process and medical records management. The Executive Director confirmed the lack of a process for ensuring pre and post dialysis assessments and communication with the dialysis center, as well as issues with filing and locating medical records. These deficiencies were not recognized by the QAPI committee, despite the facility's policy requiring systematic performance assessment.
The facility failed to ensure that resident rights training was completed by staff upon hire for two employees, a LPN and a CNA. Both employees' records lacked evidence of this training, which was confirmed by the Executive Director. The facility's policy requires all personnel to participate in in-service training classes, including those on patient rights.
The facility failed to provide annual QAPI training to 8 staff members, including the Executive Director, Activity Director, Registered Dietitian, CNAs, and LPNs. While initial training was documented upon hire in 2024, there was no evidence of the required annual training for 2025. Additionally, an LPN hired in 2024 lacked any QAPI training documentation. The facility's policy requires QAPI education at hire and annually.
The facility did not ensure that six employees, including the Executive Director and other key staff, received their required annual compliance and ethics training for 2025. Although these employees had completed the training upon hire in 2024, there was no documentation of annual training for the following year, as confirmed by the Executive Director.
The facility did not post the current nursing staff information as required. On a specific day, the nursing staff posting was outdated, and the current day's information was missing. The ADON confirmed that the Staffing Coordinator was responsible for daily postings, but the information was not updated, indicating a procedural lapse.
Failure to Ensure Complete Dialysis Care Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for residents requiring such services. Specifically, the facility did not perform necessary nursing pre and post dialysis assessments and failed to maintain completed dialysis communication transfer forms in collaboration with the dialysis provider for all six sampled residents on dialysis. This deficiency was observed in the clinical records of residents who were transported to dialysis, where there was a lack of evidence of clinical assessments before, during, and after dialysis sessions. For Resident #9, the clinical record lacked a Hemodialysis Communication Form and evidence of clinical assessments for multiple documented dialysis transportation dates. The forms that were present were incomplete, missing critical information such as pre and post dialysis assessments, pain assessments, and vital signs. Similar deficiencies were noted for Resident #20, whose clinical record also lacked complete Hemodialysis Communication Forms, missing vital information from both the facility and the dialysis center. The Director of Nursing Services (DNS) confirmed the missing and incomplete forms, acknowledging that the expectation was for the forms to be filled out for every dialysis visit. The DNS also confirmed that if the dialysis center did not complete their portion of the form, the charge nurse was responsible for obtaining the missing information. Despite these expectations, the facility failed to ensure proper documentation and communication, potentially placing residents at risk for improper coordination of care between the facility and the dialysis provider.
Resident Dignity and Respect Violation by LPN
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) treated a resident with dignity and respect, as evidenced by an incident involving Resident #251. The resident, who had been admitted with diagnoses including cognitive communication deficit, anxiety disorder, and sepsis, experienced unprofessional behavior from LPN1. During the administration of an intravenous (IV) antibiotic, LPN1 dropped the IV spike into the garbage and intended to reuse it, despite the resident's objection. LPN1 also dropped the IV tubing on the floor and planned to use it after cleaning it with an alcohol pad, which the resident refused. LPN1 then left the room, returned with new tubing, but the resident expressed fear and distrust towards LPN1, suspecting potential tampering with the IV bag. Further investigation revealed that LPN1 referred to the resident using derogatory language and displayed anger and unprofessionalism. LPN2, who witnessed the incident, confirmed LPN1's inappropriate conduct. The Director of Nursing Services acknowledged that using the contaminated IV tubing was unacceptable. The facility substantiated the allegations, confirming that the resident's right to be treated with respect and dignity was violated, potentially causing psychosocial harm or mental anguish.
Inaccurate MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for a resident who was discharged from the facility. The resident, who had been admitted with diagnoses including surgical aftercare, cognitive communication deficit, prediabetes, and mobility issues, was discharged home with all medications and belongings. However, the discharge MDS assessment inaccurately documented that the resident was discharged to the hospital. The MDS Coordinator confirmed this error, acknowledging that the assessment should have correctly indicated the resident was discharged home. The facility's policy required accurate and complete MDS data transmission to the Centers for Medicare & Medicaid Services (CMS), which was not adhered to in this instance.
Failure to Address Resident Behaviors and Medical Conditions in Care Plans
Penalty
Summary
The facility failed to ensure that a resident's threatening behaviors were included in their care plan. Resident #78, who was diagnosed with alcohol dependence with alcohol-induced persisting dementia, schizoaffective disorder, and unspecified hallucinations, exhibited behaviors of threatening staff with physical and sexual violence. Despite multiple documented incidents where the resident used profane language, made derogatory remarks, and threatened to harm and sexually assault staff members, these behaviors were not addressed in the resident's care plan. The Director of Nursing Services acknowledged that the resident's threatening behaviors should have been included in the care plan to ensure the safety of staff, residents, and visitors. Additionally, the facility failed to care plan for another resident's medical condition. Resident #83, diagnosed with chronic obstructive pulmonary disease, acute on chronic diastolic heart failure, and chronic kidney disease, complained of significant edema. A provider noted the edema and prescribed furosemide, a diuretic medication, but the resident's care plan did not reflect this condition or the medication use. The resident continued to experience edema and expressed concerns about not receiving the prescribed medication. The Director of Nursing Services confirmed that the care plan did not include the necessary information regarding the resident's edema and diuretic medication, which was a requirement according to the facility's policy on comprehensive person-centered care planning.
Failure to Administer Ordered Medication for Edema
Penalty
Summary
The facility failed to ensure that a medication ordered for edema was entered into a resident's order set and Medication Administration Record (MAR), resulting in the resident not receiving the necessary medication. Resident #83, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and acute on chronic diastolic congestive heart failure (CHF), complained of significant edema. A provider had documented a new order for furosemide 20 mg daily for edema on 02/21/2025, but this order was not entered into the resident's electronic health record (EHR) or MAR. The Licensed Practical Nurse (LPN) confirmed that the order for furosemide was not included in the resident's orders, and the Director of Nursing Services (DNS) verified the absence of the order in the EHR. The DNS and the Advanced Practice Registered Nurse (APRN) both acknowledged that the order should have been entered and implemented on 02/21/2025. The facility's policy required nurses to record orders immediately, but this was not followed, leading to the resident experiencing continued edema and discomfort.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to manage the pain of Resident #83 effectively, as evidenced by the administration of acetaminophen for pain levels that exceeded the medication's prescribed parameters. Resident #83, who had a history of knee replacement and frequent knee pain, was prescribed acetaminophen 325 mg for mild pain (1-3/10 on a numeric scale). However, the resident was administered this medication for pain levels ranging from 4 to 10 out of 10, which indicated moderate to severe pain. The facility did not reassess the resident's pain to ensure the efficacy of the medication, nor did they contact the physician for further instructions or new orders when the pain levels exceeded the prescribed parameters. Interviews with the resident and staff confirmed that the resident's pain was not effectively managed. The resident reported that the acetaminophen did not alleviate the pain, which was severe enough to interfere with sleep and daily activities. The LPN and the Director of Nursing Services acknowledged that the pain levels documented were outside the prescribed range for the medication, and the facility's policy required contacting the provider for further instructions in such cases. Despite this, the facility did not take appropriate action to address the resident's pain, leading to unrelieved discomfort and inadequate pain management.
Failure to Conduct Timely Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), employed for over a year, received timely annual performance evaluations. Employee #7, hired on January 1, 2024, did not have any documented evidence of an annual performance review by their anniversary date of January 1, 2025. Employee #8, also hired on January 1, 2024, had their annual performance review conducted 55 days late, on February 25, 2025. The Human Resources Manager confirmed these deficiencies, acknowledging that all CNAs were required to have evaluations completed by their hire anniversary date, as per facility policy revised in July 2010. The evaluations were to be conducted by the Director of Nursing.
Failure to Monitor and Document Resident's Threatening Behaviors
Penalty
Summary
The facility failed to monitor and document a resident's threatening behaviors as per their policy, which led to a deficiency in behavioral health care and services. Resident #78, who was diagnosed with alcohol dependence with alcohol-induced persisting dementia, schizoaffective disorder, and unspecified hallucinations, exhibited threatening behaviors towards staff members. On multiple occasions, the resident used profane and derogatory language, made threats of physical and sexual violence, and blocked staff from leaving the area. Despite these incidents, the behavior monitoring tasks documented that no behaviors were observed on the days these incidents occurred. Additionally, the resident's care plan did not include interventions for the threatening behaviors, which was confirmed by the Director of Nursing Services (DNS). The DNS acknowledged that the resident's behavior should have been care planned with appropriate interventions for the safety of residents, visitors, and staff. The facility's policy required that behaviors be documented and tracked as they occurred, but this was not followed, leading to the deficiency.
Failure in Dialysis Assessment and Communication
Penalty
Summary
The facility failed to ensure effective administration by not completing and correctly documenting pre and post dialysis assessments, as well as communication with the dialysis center. This deficiency was identified through observation, document review, and interviews. The Executive Director confirmed the absence of a process to ensure these assessments and communications were properly documented on the facility's Dialysis Communication Record. The facility's policy, revised in 2016, required ongoing communication with the dialysis center using this form, which was to be filed in the resident's medical record. The deficiency affected all dialysis patients in the facility, indicating a systemic failure in the dialysis process.
Incomplete Medical Records and Monitoring in Dialysis and Weight Loss Cases
Penalty
Summary
The facility failed to ensure the completeness of medical records for six residents undergoing hemodialysis, as well as accurately document the monitoring of a resident with significant weight loss. For residents undergoing dialysis, the facility did not maintain complete Hemodialysis Communication Forms, which are crucial for tracking the residents' clinical status before, during, and after dialysis sessions. The forms were missing vital information such as vital signs, pain assessments, access site assessments, and medication administration details. This lack of documentation was confirmed by the Director of Nursing Services (DNS) and the Licensed Practical Nurse (LPN)/Charge Nurse, who acknowledged the importance of these forms in monitoring the residents' metabolic status and ensuring proper communication between the facility and the dialysis center. The report highlights specific instances where the Hemodialysis Communication Forms were incomplete or missing for multiple residents. For example, one resident's records lacked documentation for several dialysis sessions, including vital signs and access site assessments. Another resident's records were missing similar information, and the DNS confirmed that the forms were not present in the clinical charts. The DNS also explained that if the dialysis center did not complete their portion of the form, the charge nurse was responsible for obtaining the missing information. However, this process was not consistently followed, leading to incomplete records. Additionally, the facility failed to accurately document the meal consumption of a resident experiencing significant weight loss. The Registered Dietician and DNS confirmed that the meal consumption logs were incomplete, missing documentation for several days and meals. This lack of documentation hindered the ability to assess the resident's nutritional intake and address the weight loss effectively. The facility's policy required detailed documentation of food consumption for residents with weight loss, but this was not adhered to, resulting in incomplete records that could impact the resident's health management.
QAPI Committee Fails to Identify Deficiencies in Dialysis Process and Medical Records Management
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify a lack of process regarding pre and post dialysis assessments, documentation, and communication with the dialysis center. This deficiency was confirmed by the Executive Director, who acknowledged that the QAPI committee had not recognized the absence of a process to ensure these assessments and communications were completed and correctly documented on the facility's Dialysis Communication Record. The Executive Director emphasized the importance of following this process to maintain continuity of care between the facility and the dialysis center. Additionally, the QAPI committee did not identify issues related to the management of medical records, which resulted in incomplete records being filed, difficulty in locating records, and the potential for records to be lost. The Executive Director confirmed these concerns and stressed the importance of maintaining accurate records to provide appropriate care to residents. The facility's policy on Quality Assurance and Performance Improvement, revised in December 2023, stated that the QAPI committee should continually assess the facility's performance using a systematic approach to maintain and improve safety and quality, but this was not effectively implemented in these areas.
Failure to Provide Resident Rights Training Upon Hire
Penalty
Summary
The facility failed to ensure that resident rights training was completed by staff upon hire for two employees. Employee #13, a Licensed Practical Nurse, was hired on May 7, 2024, and Employee #15, a Certified Nursing Assistant, was hired on January 8, 2025. Both employees' personnel records lacked documented evidence of having received resident rights training. The Executive Director confirmed that all staff were required to take resident rights training upon hire and acknowledged that these two employees did not receive the training. The facility's policy, last revised in April 2024, mandates that all personnel must participate in regularly scheduled in-service training classes, including those on patient rights and civil rights.
Failure to Provide Annual QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that its staff received the required training on the Quality Assurance and Performance Improvement (QAPI) program. Specifically, 8 out of 16 sampled employees did not have documented evidence of annual QAPI training for 2025. These employees included the Executive Director, Activity Director, Registered Dietitian, Certified Nursing Assistants, and Licensed Practical Nurses. The personnel records for these employees showed that while they had received initial QAPI training upon hire in 2024, there was no documentation of the required annual training for the following year. Additionally, one employee, hired as an LPN in May 2024, lacked any documented evidence of QAPI training upon hire. The Executive Director confirmed that these employees did not receive the necessary annual QAPI training, and the facility's policy, last revised in December 2023, mandates that staff be educated on QAPI at the time of hire and annually thereafter. This oversight in training compliance was identified through interviews and document reviews conducted by the surveyors.
Failure to Provide Annual Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that six out of sixteen sampled employees received their required annual compliance and ethics training for the year 2025. These employees included the Executive Director, Activity Director, Registered Dietitian, Dietary Supervisor, and two Certified Nursing Assistants. Each of these employees had documented evidence of receiving compliance and ethics training upon hire in January 2024, but there was no documented evidence of them receiving the required annual training for 2025. The Executive Director confirmed that all staff were required to take compliance and ethics training upon hire and annually, acknowledging that the six employees did not receive their annual training in 2025. The facility's policy, last revised in May 2019, outlined the process for new hire and annual compliance-related training, which includes the Code of Conduct, the Compliance Program, and concepts of fraud, waste, and abuse. Despite this policy, the facility did not adhere to its own guidelines, resulting in the deficiency.
Failure to Post Current Nursing Staff Information
Penalty
Summary
The facility failed to ensure that the current nursing hours were posted daily, as required. On February 26, 2025, at 11:11 AM, it was observed that the nursing staff posting was dated for the previous day, February 25, 2025, and the current day's posting was not available. The Assistant Director of Nursing (ADON) stated that the Staffing Coordinator was responsible for posting the direct care staff information daily at shift change. At 11:16 AM, the ADON confirmed that the nursing staff information for February 26, 2025, was not posted, indicating a lapse in the facility's procedure for maintaining up-to-date staffing information.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sparks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northern Nevada State Veterans Home | 1.3 mi | — | 13 | 0 |
| Wingfield Skilled Nursing And Rehabilitation Cente | 3.7 mi | — | 14 | 0 |
| Rosewood Rehabilitation Center | 3.8 mi | — | 30 | 0 |
| Advanced Health Care Of Reno | 5.2 mi | — | 12 | 0 |
| Caremeridian Llc, Dba Neurorestorative | 5.6 mi | — | 6 | 0 |
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