Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hearthstone Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to provide bed hold notices and notify the Ombudsman of hospital transfers. Four residents were emergently transferred for issues including vaginal bleeding, chills and shivering, COPD exacerbation, and a fall with head injury, but the record showed no written bed hold notice for three residents and no documentation that the Ombudsman was notified of any of the transfers. The Administrator confirmed the notices were not issued and the Ombudsman was not informed.
Failure to Protect Residents from Verbal Abuse: Two residents were subjected to verbal abuse, including a cognitively impaired resident who was yelled at and cursed by her roommate over TV volume and another resident who was yelled at by a CNA after reporting she had not been changed timely. Facility records and interviews substantiated both incidents as verbal abuse.
Failure to Report Substantiated Verbal Abuse to Law Enforcement: The facility substantiated verbal abuse involving two residents, including abuse by a CNA toward a cognitively intact resident and abuse by one resident toward another resident who felt scared to return to her room. The DON and Administrator confirmed there was no documentation that law enforcement was notified, and the Administrator stated the facility decided whether the incidents were crimes before reporting.
The facility did not complete thorough investigations of abuse and neglect allegations involving multiple residents. One resident reported verbal abuse during a TV dispute, another resident with severe cognitive impairment left the facility without staff notification, and a cognitively intact resident alleged a CNA was verbally abusive during care. Investigation files were missing key resident and staff statements, lacked dates and times for some interviews, and did not show that all relevant witnesses, staff, or residents were interviewed as required by policy.
Inaccurate MDS coding affected three residents. One resident was coded for IV feeding even though there was no facility order and the IV feeding occurred in the hospital, another resident’s hospice status was not checked despite an active hospice order, and a third resident was coded with MDRO as an active diagnosis even though staff said the resident only had a history of ESBL and no active infection during the review period.
Incomplete Person-Centered Care Plans: The facility failed to develop person-centered care plans based on comprehensive assessments for two residents. One resident with generalized weakness, cognitive communication deficit, and major depressive disorder was documented as incontinent of bowel and bladder and dependent for toileting, but the care plan did not address incontinence. Another resident with dementia, generalized weakness, and complete loss of teeth required help with bathing and oral care, but the care plan did not include bathing, shaving, or denture care. The DON confirmed the missing care plan items.
Failure to instruct two residents to rinse their mouths after inhaled steroid use. An LPN administered Breo Ellipta to one resident with COPD and Breyna to another resident with COPD without telling them to rinse afterward; both LPNs confirmed the residents did not rinse and acknowledged the inhaler labels stated to rinse the mouth after use. The DON stated residents need to rinse after using these inhalers and that nurses are expected to instruct them to do so.
A resident with dementia, generalized weakness, and cognitive communication deficit was assessed as needing help with bathing. Staff documentation showed the resident was scheduled for showers twice weekly, but the record did not show the resident was offered a shower/bath as scheduled, and the last documented shower offer was a refusal. During observations, the resident had an unkept beard and stated he had not had a shower or bath for 2 weeks and later said he still had not had a shower. CNAs and the DON confirmed the shower schedule and the lack of documentation showing the resident was offered bathing twice per week.
Improper Catheter Care and Perineal Cleansing: A CNA provided incomplete catheter care for a resident with neuromuscular dysfunction of the bladder and an indwelling urinary catheter. During observation, the CNA cleaned the perineal area and glans of the penis but did not clean the shaft of the penis, catheter, or tubing, and also wiped the buttocks after the resident had a BM. The CNA, DON, and IP all described expected front-to-back cleansing and catheter care steps that were not fully followed.
A resident who required continuous oxygen had a heavily soiled exterior oxygen concentrator filter that was observed dirty despite a recent cleaning entry on the TAR. The resident had COPD, chronic bronchitis, asthma, and chronic respiratory failure, and staff, including the ADON and DON, acknowledged the filter needed attention; the facility policy required the filter to be cleaned every 7 days or when visibly soiled.
A CNA failed to follow EBP during catheter care for a resident with an indwelling urinary catheter by not wearing the required gown, reusing gloves across dirty and clean tasks, and not performing hand hygiene at key points. In a separate event, an LPN failed to follow contact precautions for a resident with bacterial conjunctivitis by entering without a gown, leaving the room with contaminated gloves, and touching the medication cart, creating cross contamination during care.
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 Provide Bed Hold Notices and Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure that 4 of 5 residents reviewed for hospitalization were given a bed hold notice prior to or within 24 hours of emergency transfer to the hospital and/or that the Ombudsman was notified of the emergent transfers. Review of the medical records for R35, R90, and R97 showed each resident was sent to the hospital for an acute change in condition, including vaginal bleeding, increased chills and shivering from the dialysis center, and COPD exacerbation, respectively. The records contained no documented evidence that a bed hold notice was issued to the resident and/or responsible party at the time of transfer or the next day, and no documented evidence that the Ombudsman was notified of the transfers. Review of R1's record showed the resident was transferred to the ER after falling and hitting his head, with the transfer made to rule out a subdural hematoma. The record contained no documented evidence that the Ombudsman was notified of R1's emergent transfer. During interviews on 03/04/2026, the Administrator stated that R35, R90, and R97 and/or their responsible parties were not issued a written bed hold notice when they were emergently transferred to the hospital, and that the Ombudsman was not made aware of R1, R35, R90, or R97's emergent transfers. The facility policy titled, Criteria for Transfer and Discharge, revised April 2025, stated that prior to transfer or discharge, the facility shall notify the resident and the resident's representative in writing and send a copy of the notice to the State Long-Term Care Ombudsman.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to ensure two residents were free from verbal abuse. One resident, who had diagnoses including cognitive communication deficit, anxiety disorder, and unspecified dementia and a BIMS score of 6 out of 15, reported that her roommate was too loud and then began yelling and cursing at her to turn the TV down. The resident stated she was afraid to go back into the room. The roommate, who had a BIMS score of 13 out of 15 and no behaviors directed toward others on admission MDS, was documented in progress notes as yelling at the roommate and telling her to shut the TV off using profane language. The facility’s incident report for the roommate conflict identified the event as verbal abuse and stated the residents were separated. A written statement from an RN described the roommate yelling profanities after the resident returned to the room and noted the resident said the roommate cussed her out anytime she went into the room. The resident’s statement also described being threatened with physical harm if she did not turn her TV down. The DON and Administrator later acknowledged the incident was substantiated as verbal abuse. The facility also failed to protect another resident, who was cognitively intact with a BIMS score of 15 out of 15 and dependent on staff for incontinent care, from verbal abuse by a CNA. The facility’s investigation stated the CNA yelled at the resident after the resident said she had not been changed timely, and the resident reported the CNA was very mean, yelled at her, and would not change her. A witness confirmed hearing the CNA screaming at the resident, continuing to yell, and making threatening statements. The investigation was substantiated, and the CNA was terminated.
Failure to Report Substantiated Verbal Abuse to Law Enforcement
Penalty
Summary
The facility failed to report substantiated verbal abuse to local law enforcement for 2 of 4 residents reviewed for abuse, involving R9 and R120. For R9, the record showed the resident was cognitively intact with a BIMS score of 15 out of 15 and dependent on staff for incontinent care. The facility’s investigation substantiated that CNA9 verbally abused R9 by making intimidating and threatening statements, including statements the Administrator described as a threat. During interview, R9 recalled that CNA9 was very mean, yelled at her, and would not change her. CNA8 stated she witnessed CNA9 verbally abusing R9 and making intimidating and threatening statements. Despite this, the Administrator stated the Police Department had not been notified for verbal abuse because the facility determines whether a crime has been committed before notifying police. For R120, the facility incident report documented verbal abuse by another resident, R119, who yelled profanities at R120, called her a liar, and threatened her, and the report stated R120 felt scared to go back into her room while the other resident was there. The facility’s investigation file contained no documented evidence that the abuse was reported to local law enforcement. The DON stated there was no documentation that law enforcement was notified, and the Administrator stated law enforcement was not notified because the facility decided whether it felt the incident was a crime. The facility policy on abuse stated allegations of abuse, neglect, misappropriation of resident property, or exploitation would be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes.
Incomplete Abuse and Neglect Investigations
Penalty
Summary
The facility failed to complete thorough investigations of allegations of abuse and neglect involving three residents. The report states that the facility did not fully investigate a verbal abuse allegation involving two residents, a neglect allegation involving a resident who left the facility without staff notification, and an allegation that a CNA verbally mistreated a cognitively intact resident during care. In each case, the investigation files lacked complete documentation and did not include all relevant interviews or statements described in the facility’s own abuse and neglect policy. For the verbal abuse incident, a resident with severe cognitive impairment and a cognitively intact roommate were involved in a dispute over TV volume. The cognitively intact resident was reported to have yelled profanities and threatened the other resident, who stated she was scared to return to the room. The investigation file contained only one undated RN statement and an interview with one resident without date, time, or interviewer identification. There was no statement from the other resident, no documentation identifying which staff intervened, and no evidence that additional staff or other residents were interviewed, despite the facility’s policy requiring interviews with the reporting person, residents, witnesses, staff members on all shifts, and other residents who may have information. For the neglect allegation, a resident with severe cognitive impairment was found to have left the facility with a visitor without nursing staff being notified. The facility’s incident report stated the allegation was verified and that interviews were conducted with involved staff, the DON, the resident, and the roommate. However, the investigation file did not contain written statements from the roommate, the receptionist who saw the resident leave, the LPN involved, or other staff who were present. During interviews, staff confirmed they were not asked to provide written statements, and the Administrator acknowledged that no statements had been obtained from the roommate, LPN, receptionist, or other staff. For the third allegation, a cognitively intact resident reported that a CNA told her to shut up and did not change her. The facility interviewed some residents and staff, but there was no written statement from the resident, no documentation that all staff with the same first name were identified and interviewed, and the Administrator stated the investigation was not complete and that more schedules and staff interviews should have been reviewed.
Inaccurate MDS Coding for IV Feeding, Hospice, and MDRO
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for 3 sampled residents. For one resident, the quarterly MDS with an assessment reference date of 12/26/2025 indicated parenteral/IV feeding as present, but the physician order summary and MAR showed no order for parenteral/IV feedings at the facility. During interview, the MDS Director confirmed the resident received IV feedings in the hospital, not at the facility, and stated the quarterly MDS was miscoded. For another resident, the quarterly MDS with an assessment reference date of 01/22/2026 did not check hospice care even though the resident had an order for hospice services and was admitted to hospice services in July 2025. For a third resident, the quarterly MDS with an assessment reference date of 01/08/2026 marked multidrug-resistant organism (MDRO) as an active diagnosis, but the Infection Preventionist and MDS Director stated the resident had a history of ESBL-related MDRO and did not have an active infection during the review period. The facility policy required accurate and timely MDS assessments, and the RAI Manual stated items should be validated for accuracy based on the resident's actual status during the observation period.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans based on comprehensive assessments for 2 of 31 sampled residents, R14 and R27. R14 was admitted with diagnoses including generalized muscle weakness, cognitive communication deficit, and major depressive disorder. Her quarterly MDS with an ARD of 01/19/2026 showed a BIMS score of 15 out of 15, indicating she was cognitively intact, and also indicated she was dependent on staff for toileting and was incontinent of bowel and bladder. Documentation Survey Reports for December 2025 and January 2026 also showed bowel and bladder incontinence, but the care plan did not include incontinence. R27 was admitted with diagnoses including complete loss of teeth, cognitive communication deficit, generalized muscle weakness, dementia, and generalized anxiety disorder. Her annual MDS with an ARD of 02/13/2026 showed a BIMS score of 14 out of 15, indicating she was cognitively intact, and also showed she required assistance with oral hygiene and bathing. The care plan did not include assistance with bathing, shaving, or dentures. During interview, the DON confirmed that urinary and bowel incontinence for R14 and bathing, shaving, and denture care for R27 were not included on the care plans and stated these should have been care planned.
Failure to Instruct Residents to Rinse Mouth After Inhaled Steroid Use
Penalty
Summary
The nursing facility failed to ensure that two residents receiving inhaled steroid medications were instructed to rinse their mouths after administration. One resident with COPD had an order for Breo Ellipta inhalation aerosol powder, and during an observed medication pass, an LPN administered the inhaler in the resident’s room without instructing him to rinse his mouth afterward. During interview, the LPN confirmed the resident did not rinse his mouth and stated uncertainty about whether rinsing was needed, then reviewed the inhaler box and confirmed the label stated to rinse the mouth after each use. A second resident with COPD had an order for Breyna inhalation aerosol, and during an observed medication pass, an LPN administered the inhaler in the resident’s room without instructing her to rinse her mouth afterward. During interview, the LPN confirmed the resident did not rinse her mouth and stated she did not think residents had to rinse after using the inhaler, then reviewed the Breyna box and confirmed the label stated to rinse the mouth after use. The DON later stated that residents need to rinse their mouths after using Breyna and Breo Ellipta inhalers and that the expectation is for the nurse to instruct residents to rinse after use.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
The facility failed to provide staff assistance with ADLs for one resident, R27, who had diagnoses including cognitive communication deficit, generalized muscle weakness, dementia, and generalized anxiety disorder. The annual MDS dated 02/13/2026 showed a BIMS score of 14 out of 15, indicating the resident was cognitively intact, and also indicated that R27 required assistance with showering/bathing. During an observation and interview on 03/02/2026, R27 was lying in bed with an unkept beard and stated that staff help him shave when they give him a shower. R27 also stated he had not had a shower or bath for 2 weeks. During a later observation and interview on 03/04/2026, R27 still had facial hair and stated he still had not had a shower. The EMR shower schedule showed R27 was scheduled for showers on Mondays and Thursdays during day shift, and the last documented shower offer was a refusal on 02/19/2026. The documentation survey report for February 2026 showed CNA1 documented "NA" for a shower scheduled on 02/26/2026. CNAs stated residents were showered twice per week and that refusals were documented on shower sheets, while the DON stated the facility did not have documentation showing R27 was offered a shower/bath twice per week and confirmed the last documented shower offer was 02/19/2026.
Improper Catheter Care and Perineal Cleansing
Penalty
Summary
The facility failed to ensure proper catheter care for one resident with neuromuscular dysfunction of the bladder who had an indwelling urinary catheter. During observation of catheter care, a CNA wiped the resident’s perineal area in a downward motion, retracted the foreskin, and wiped the glans of the penis in a circular motion, but did not clean the urinary catheter, the catheter tubing, or the body of the penis. The CNA then assisted the resident to roll onto his right side and wiped the buttocks with a disposable wipe using a downward motion. During the observation, the resident had a bowel movement, and the CNA was observed wiping stool off her gloves. In interview, the CNA stated catheter care included cleaning downward, retracting the foreskin, and cleaning the glans of the penis in a circular motion, and confirmed the body of the penis, catheter, and catheter tubing should also be cleaned. The DON stated staff were expected to wipe front to back when cleaning the perineal area and to include the shaft of the penis, catheter, and catheter tubing. The IP also stated cleaning should occur from front to back. The facility policy for indwelling urinary catheter care required cleaning the catheter in a downward motion beginning at the urinary meatus and at least four inches down, using a clean portion of the washcloth or fresh disposable wipe for one cleansing motion.
Dirty Oxygen Concentrator Filter Not Cleaned as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for R9, who was admitted and readmitted with asthma, mucopurulent chronic bronchitis, COPD, dependence on supplemental oxygen, anxiety disorder, and chronic respiratory failure. R9’s MDS showed a BIMS score of 15 out of 15 and indicated the resident received oxygen therapy in the facility. Physician orders directed that the oxygen tubing, humidifier bottle, and concentrator filter be changed and cleaned on a scheduled basis, including cleaning the concentrator filter every week and as needed. Review of the TAR showed the concentrator filter was documented as cleaned on 02/25/2026, but there was no indication it was cleaned again before it was observed on 03/02/2026 to be very dirty. During observation, R9 was in bed with oxygen in place, and the exterior filter on the oxygen concentrator was gray with a heavy build-up of dust and dirt. R9 stated the oxygen had to be on always and said they did not know when the filter was cleaned. The ADON observed the filter and stated it needed to be changed, and the DON stated the facility needed to check that it was being done. The facility’s oxygen administration policy stated the external filter was to be cleaned every seven days or when visibly soiled.
Failure to Follow EBP and Contact Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions and Transmission-Based Precautions, and failed to provide care in a manner to prevent cross contamination for two residents. One resident had neuromuscular dysfunction of the bladder and was on Enhanced Barrier Precautions with an indwelling urinary catheter. During observation, a CNA entered the room without a gown, double-gloved, and performed catheter care, peri-care, and repositioning activities while using the same gloves across dirty and clean tasks. The CNA removed gloves at times without performing hand hygiene, left the room without hand hygiene, returned without hand hygiene or the required gown and gloves, and continued care after handling contaminated items and supplies. The CNA stated she was not sure what Enhanced Barrier Precautions were or what PPE to use for catheter care, and said she thought PPE was only needed for a wound. The DON stated that any resident with a catheter was on Enhanced Barrier Precautions and that staff providing catheter care should wear at least a gown and gloves, with glove changes when moving from dirty to clean tasks. The Infection Preventionist stated the CNA should have worn the proper PPE, changed gloves after moving from a dirty area to a clean area, and performed hand hygiene between glove changes. The facility policy stated staff will wash hands after direct resident contact when indicated and use alcohol-based hand sanitizer when moving from a dirty task or area to a clean task or area if hands are not visibly contaminated. A second resident had acute conjunctivitis and was on contact precautions for bacterial conjunctivitis. A contact precautions sign outside the room directed staff to clean hands before entering and when leaving, and to put on gloves and a gown before room entry and discard them before room exit. An LPN performed hand hygiene, donned gloves, and entered the room to administer eye drops, but did not don a gown. The LPN leaned across the resident’s bed, left the room wearing the same gloves, and touched the medication cart with gloved hands. The LPN stated she wore gloves but not a gown because she was only administering eye drops, and she did not sanitize her hands. The DON stated gloves and gown are worn when entering a room on contact precautions, and the facility policy stated to wear a gown and gloves for all interactions that may involve contact with the patient or the patient’s environment and to perform hand hygiene before exiting the room.
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 | ★★★★★ | 28 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.