Heartwood Extended Healthcare: Wander Guard Violations - WA

Inspectors from the Centers for Medicare and Medicaid Services documented the violation at Heartwood Extended Healthcare, a long-term care facility at 1649 East 72nd Street, during a survey completed March 30, 2026.

The device was on the left wrist of Resident 105, a person the facility had already identified as an elopement risk. An elopement risk evaluation dated March 11, 2026 was in the record. It noted exit-seeking behavior. What it did not include was any evaluation or assessment for the use of a wander guard, the device that was already on the resident's wrist when inspectors arrived.

Staff C, a registered nurse and unit manager, walked inspectors through what was missing. No provider orders. No assessment. No informed consent. No documentation showing anyone had checked whether the device was functioning correctly or placed properly. Staff C said all of those things should have been in place. They weren't.

The wander guard, Staff C told inspectors, was fastened tightly enough that the resident would have had difficulty removing it.

A wander guard is not a passive safety measure. It is a device attached to a person's body, typically triggering an alarm at exits if the resident attempts to leave. Applying one without a physician's order, without assessing the resident's specific needs, and without obtaining consent means a resident is being physically monitored and restricted, on someone's informal judgment alone, with no medical oversight and no record that the person ever agreed to it.

The facility's own quarterly minimum data set assessment, a standardized federal evaluation completed on a rolling basis for every resident, showed no wander guard in use for Resident 105. The device was on the wrist. The paperwork said otherwise.

On March 27, 2026, inspectors sat down with Staff B, the director of nursing services. She said she was not aware that Resident 105 lacked provider orders, a formal assessment, informed consent, or any documentation confirming the device had been checked for function and correct placement before or at the time it was applied. She said there should have been documentation. There wasn't.

The gap between what the DNS said should exist and what actually existed is the whole of the violation. The facility had already flagged this resident as someone who might try to leave. It had gone so far as to put a device on the resident's wrist to prevent that. It had not, apparently, taken the additional steps of asking a doctor to order it, assessing whether it was appropriate, or telling the resident it was happening.

CMS rated the harm level as minimal, with potential for actual harm, affecting some residents.

Heartwood Extended Healthcare has a facility identification number of 505326. The inspection was a standard health survey. The deficiency references Washington Administrative Code 399-97-0620(1), the state's regulations governing the use of devices like wander guards in licensed care settings.

The facility was given the opportunity to submit a plan of correction. As of the report's printing date of June 12, 2026, anyone seeking information on that plan was directed to contact the nursing home or the state survey agency directly.

Resident 105 remained in the facility with a wander guard fastened to their wrist, placed there by staff who could not say when it went on, whether a doctor had ever approved it, or whether the person wearing it had ever been asked.

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

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