Heartwood Extended Healthcare: Oxygen Safety Failures - WA
That discovery, made during a March 2026 federal inspection of Heartwood Extended Healthcare, was not an isolated slip. Inspectors found a second resident whose oxygen monitoring had gone undocumented across multiple shifts, whose care had never been formally planned despite active respiratory orders, and whose provider had never been called when oxygen saturation readings fell outside acceptable ranges.
The Director of Nursing Services said, of both residents, that the care did not meet expectations.
Resident 12 had been admitted to Heartwood with sleep apnea, chronic respiratory failure, and diabetes. A provider's order from August 2025 specified oxygen at 4 liters per minute via nasal cannula, continuously. The care plan, also from August 2025, reflected the same instruction.
Inspectors observed Resident 12 on three separate occasions between March 23 and March 26, 2026. Each time, the oxygen was running at 3.5 liters per minute. On March 27, it had dropped to 3 liters.
That same morning, at 9:32 AM, a licensed practical nurse looked at the equipment during an interview with inspectors and confirmed what they were seeing. The oxygen was set to 3 liters. It should have been 4. Staff were supposed to check the setting every shift.
The Director of Nursing, interviewed later that afternoon, said the expectation was that staff follow the provider's order and verify the oxygen settings each shift.
Nobody had.
The second resident, identified in the report as Resident 106, had a more complicated picture. An order dated November 20, 2025, called for weaning the resident off supplemental oxygen as tolerated, contingent on maintaining oxygen saturation above 90 percent. But the March 2026 treatment administration record, the document nurses use to track and confirm care, had only X marks where the actual liter-per-minute readings should have been recorded. There was no documentation of how much oxygen the resident was receiving or when.
Eight days after that order, on November 28, 2025, a sleep study found the resident was experiencing hypoxia during the night and required new oxygen parameters. That order, according to a staff member interviewed on March 30, did not include what those new requirements actually were. The order needed to be clarified with the provider. As of the inspection, it had not been. The March TAR showed X marks recorded every day for that order as well.
The staff member, identified in the report by the title indicating a clinical or charge role, told inspectors that oxygen saturation readings were not being documented consistently every shift, that they should have been, and that each time a reading fell outside the ordered parameters, the provider should have been notified. There was no evidence that had happened.
There was also no care plan for oxygen therapy for Resident 106, despite the active orders. The staff member said that was not acceptable. "These issues did not meet expectations," they said.
The Director of Nursing reviewed the oxygen orders, the March treatment records, and the saturation readings documented in the electronic health record before being interviewed at 2:01 PM on March 30. Her conclusion matched what the clinical staff had already said: Resident 106's respiratory care and services did not meet expectations.
Resident 106 had orders in place for months. The sleep study identified a problem. The follow-up order to address that problem was incomplete. And in the meantime, the nurses documenting care each shift were marking X's in boxes that were supposed to contain numbers.
Resident 12, who was able to communicate their needs, had been receiving less oxygen than ordered for at least four days before an inspector asked a nurse to look at the flow meter.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heartwood Extended Healthcare from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
HEARTWOOD EXTENDED HEALTHCARE in TACOMA, WA was cited for violations during a health inspection on March 30, 2026.
That discovery, made during a March 2026 federal inspection of Heartwood Extended Healthcare, was not an isolated slip.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.