Heartwood Extended Healthcare: Wheelchair Safety Failures - WA
The resident, identified in inspection records as Resident 66, had a weak left side and could not unlock the left brake on their wheelchair without a handle extension. An occupational therapist had documented that recommendation in a discharge summary. Nobody ordered the extension.
Instead, maintenance installed an anti-rollback device.
On March 3, Resident 66 fell while trying to transfer from the wheelchair to their bed and was taken to the hospital with a hematoma on their head, pooling of blood outside the blood vessels. The facility's plan to prevent another fall was to assess for safety when the resident returned. No reassessment of the wheelchair device was documented.
Eleven days later, on March 14, Resident 66 was found on the floor of the bathroom. They could not say what had happened. An incident report attributed the fall to the resident's preference to not use the call light and to self-transfer to the toilet. Resident 66 was taken to the hospital again, this time with a fractured distal clavicle.
When an occupational therapist observed Resident 66 on March 27, she watched the resident try to roll their wheelchair backward and fail. The anti-rollback device stopped them. Staff J, the occupational therapist, told inspectors the device was not safe or appropriate for this resident. When Resident 66 could not roll backward, their impulse was to stand. The device the facility had installed to improve safety was triggering the behavior most likely to cause a fall.
Staff J said nursing was responsible for ordering equipment once a resident was discharged from therapy services.
Resident 66 had been discharged from therapy in January 2026. Staff K, the Director of Rehabilitation, told inspectors on March 30 that Resident 66 should have been evaluated for therapy again after falls on January 18, January 26, and February 11. None of those evaluations happened. Staff K said the resident had been in and out of the hospital and that they were "unaware of where the ball was dropped."
The Director of Nursing Services told inspectors she had no knowledge of the brake extender recommendation. She said she did not believe that gap contributed to Resident 66's injuries.
The occupational therapist's assessment told a different story. Resident 66 had a weak left side. The left brake required a handle extension to operate. Without it, the resident could not reliably stop the wheelchair before standing. The device that was installed stopped backward movement entirely, which made the problem worse.
The brake extender the therapist recommended was listed in the discharge summary as unable to locate.
Federal inspectors rated the violation as causing actual harm.
What the record shows is a resident who fell in January, fell again in January, fell again in February, fell in early March and bled into their skull, and fell again two weeks later and broke their collarbone, while the device a therapist had prescribed sat unordered somewhere in a paperwork chain nobody followed to its end. Resident 66's wheelchair was last assessed for the anti-rollback device, according to the Director of Rehabilitation, at the moment it was installed. It was never assessed again.
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.
An occupational therapist had documented that recommendation in a discharge summary.
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.