Resident 83 complained repeatedly about bilateral lower extremity edema starting February 24, telling staff they weren't receiving medication for the swelling. The resident had notable edema to both legs.
Three days earlier, on February 21, an Advanced Practice Registered Nurse had examined the resident, documented significant edema, and ordered furosemide 20 milligrams daily specifically for the swelling. But the order never made it into Resident 83's electronic health record or medication administration record.
"The resident was not being provided medication for edema," the inspection report documented, quoting the patient's own words.
On February 26, a Licensed Practical Nurse confirmed the resident's orders contained no furosemide prescription, despite the provider's written documentation. The next day, the Director of Nursing Services assessed the resident's legs and confirmed "1 to 2 plus pitting edema," describing the feet and legs as feeling tight.
The Advanced Practice Registered Nurse told inspectors the order should have been entered into the system by the resident's nurse on February 21 and administered immediately. The Director of Nursing Services acknowledged that failing to implement the order "could have led to increased edema, an exacerbation of congestive heart failure and/or chronic obstructive pulmonary disease, increased pain and discomfort."
Facility policy required nurses to record provider orders "immediately" into residents' medical records.
The medication failure was part of a broader pattern of care breakdowns at Hearthstone that left vulnerable residents without proper medical attention.
Another resident endured severe pain for weeks while receiving only mild medication designed for headaches and minor discomfort. Resident 83 — who had diagnoses including pain in both hips, cellulitis, and restless leg syndrome — was prescribed acetaminophen 325 milligrams for pain levels of 0-3 on a 10-point scale.
But medication records show staff repeatedly gave the mild pain reliever to the resident when pain levels reached 4, 5, 6, 7, and even 10 out of 10 — far exceeding what the medication was prescribed to treat.
On February 23, staff administered one acetaminophen tablet for a pain level of 10 out of 10. The next day, they gave the same mild medication for pain levels of 5 out of 10. Staff continued this pattern through February 26, when the resident reported pain levels of 6 out of 10 — twice giving the inadequate medication within hours.
The resident told inspectors on February 24 about a history of knee replacement surgery and frequent knee pain. "The resident's only ordered pain medication was acetaminophen and the medication did not effectively manage the resident's pain," the report documented.
A Licensed Practical Nurse explained to inspectors that pain levels of 1-3 were considered mild, 4-6 were moderate, and 7-10 were severe. When residents reported pain levels outside their medication's prescribed range, nurses were expected to contact the provider for new orders.
But no such contact occurred.
On February 27, the resident complained of 10 out of 10 knee pain and 8 out of 10 neck and shoulder pain at rest, increasing to 10 out of 10 with movement. The resident said the pain was keeping them awake at night, limiting range of motion, and preventing them from doing activities they enjoyed.
"The resident verbalized the facility was aware of the resident's pain but had not done anything to help alleviate the pain," inspectors wrote.
The Director of Nursing Services confirmed that pain rated 4-10 out of 10 was moderate to severe pain and "was not to be considered mild pain." The expectation was for nurses to contact providers when residents reported pain levels outside their prescribed medication's parameters.
Medication administration records showed no evidence that staff reassessed residents' pain after giving medication to determine if it was effective.
The facility's most serious problems involved dialysis care, where staff failed to properly monitor six residents receiving life-sustaining kidney treatments. All six residents — numbers 9, 20, 151, 51, 61, and 60 — had missing or incomplete dialysis communication forms that are supposed to track vital signs, medication administration, and access site assessments before and after each treatment.
Resident 9 went to dialysis on December 2, December 27, December 31, January 17, and January 27 with no communication forms documenting clinical assessments. Additional forms from November through January were missing critical information including pre-dialysis access site assessments, pain evaluations, medication documentation, vital signs, and post-dialysis monitoring.
The problems weren't isolated incidents. Resident 20's forms from November through February lacked dialysis center access site assessments, pain evaluations, and facility nurse signatures. One form from January 16 was missing both pre- and post-dialysis signatures, departure times, and post-dialysis assessments.
Resident 51 went to dialysis on February 3, 5, and 7 with no communication forms at all. Other forms lacked essential information, with one notation stating "Dialysis Center did not fill out."
A Licensed Practical Nurse explained the communication forms were critical because "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."
The Director of Nursing Services, who served as the facility's Dialysis Coordinator, confirmed that missing forms meant no documentation existed for those dialysis visits. When dialysis centers failed to complete their portions, charge nurses were supposed to call for the information or have it faxed to the facility.
Medical literature cited in the inspection report noted that dialysis patients face extremely high mortality rates due to cardiovascular causes, with sudden cardiac death being the most common form of death. Dialysis can cause "significant sudden shifts in electrolytes and fluid volume" that can trigger life-threatening heart rhythm problems.
The facility's dialysis transfer agreement required comprehensive communication about residents' conditions, medications, and any changes in physical or mental status.
Beyond medical care failures, the facility couldn't keep track of basic administrative requirements. Two certified nursing assistants hired on January 1, 2024, either had no annual performance evaluation or received it 55 days late. Employee 7 had no documented performance review by the required anniversary date, while Employee 8's evaluation was completed on February 25, nearly two months after it was due.
The Human Resources Manager confirmed both employees should have had evaluations completed by their hire anniversary dates.
Staff also failed to post daily nursing staffing information as required. On February 26, the nursing staff posting displayed information from the previous day, leaving residents and visitors without current information about how many nurses and direct care staff were on duty.
The Assistant Director of Nursing confirmed the staffing information wasn't posted for February 26, despite facility policy requiring daily updates at shift change.
In another case involving behavioral health, staff failed to properly monitor a resident who made violent and sexual threats against a Licensed Practical Nurse. Resident 78, diagnosed with alcohol dependence, dementia, and schizoaffective disorder, threatened to "break the LPN's face" and "catch the LPN off-guard and rape the LPN" on January 6.
Despite documenting these threats in nursing notes, staff marked "no behaviors observed" on the facility's behavior monitoring forms for January 6, 9, and 15 — dates when threatening incidents occurred.
The resident continued making violent threats, telling the LPN on January 15 that he would "wait for the LPN outside and would torture the LPN." Again, staff documented no behaviors on monitoring forms.
The Director of Nursing Services acknowledged the resident's threatening behavior should have been included in the care plan with safety interventions, and that behavior monitoring should have documented each incident as it occurred.
The resident's care plan contained no mention of the threatening behaviors toward staff.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hearthstone from 2025-03-03 including all violations, facility responses, and corrective action plans.