Heartwood Extended Healthcare

Findings included.Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (disease that effects multiple nerves in the body), diabetes (too much sugar in the blood) and dysphagia (difficulty swallowing). Resident 9 was able to make needs known.

During an interview on 03/23/2026 at 11:29 PM, Resident 9 stated they were missing two pairs of jeans that were only worn once.

Observation on 03/26/2026 at 10:36 AM showed Resident 9 reported to Staff H, Registered Nurse, the missing jeans.

During an interview on 03/27/2026 at 11:56 AM, Resident 9 stated they had not been contacted regarding the missing jeans. Resident 9 stated the clothes they were wearing were from the facility's donation closet.

During a Resident Council meeting held on 03/26/2026 at 10:00 AM, Council members stated when they sent their clothes to the laundry sometimes, they did not get them back.

Council members stated the issues with laundry had been ongoing.

Review of the grievance logs from October 2025 through March 2026 showed a total of 27 grievances related to missing clothing.

During an interview on 03/30/2026 at 10:59 AM, Staff A, Administrator, stated the expectation was when residents had missing clothing a grievance should be completed by the staff it was reported to so it could be investigated or the resident could receive reimbursement.

Reference WAC 388-97-0880(2)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Findings included .Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (disease that effects multiple nerves in the body), diabetes (too much sugar in the blood) and dysphagia (difficulty swallowing). Resident 9 was able to make needs known.

During an interview on 03/23/2026 at 11:29 PM, Resident 9 stated they were missing two pairs of jeans that were only worn once. Resident 9 stated they had not reported the missing clothing to any members of staff.

Observation on 03/26/2026 at 10:36 AM showed Resident 9 reported to Staff H, Registered Nurse (RN), the missing jeans.

Review of the EHR showed no documentation related to Resident 9's concern.

During an interview on 03/27/2026 at 11:23 AM, Staff D, Social Services Director, stated they had not received any grievances related to Resident 9's missing clothing concern.

During an interview on 03/27/2026 at 11:56 AM, Resident 9 stated they had not been contacted regarding the missing jeans. Resident 9 stated the clothes they were wearing were from the facility's donation closet.

During an interview on 03/30/2026 at 10:59 AM, Staff H, RN, confirmed Resident 9 reported missing clothing and stated they did not complete a grievance.

During an interview on 03/30/2026 at 11:36 AM, Staff A, Administrator, stated the expectation was when residents had missing clothing a grievance should be completed by the staff it was reported to so it could be investigated or the resident could receive reimbursement.

Reference WAC 388-97-0460

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

During an interview and joint observation of Resident 105 on 03/26/2026 at 2:23 PM, Staff C,

03/11/2026 for exit seeking; however, it did not include an evaluation/assessment for a wander guard.

Staff C stated they were unable to locate provider orders, an assessment, an informed consent, or function and placement monitoring for the use of a wander guard, and these should have been in place.

Staff C stated Resident 105's wander guard was located on the left wrist and would be hard for the resident to remove due to being securely fastened.

During an interview on 03/27/2026 at 9:53 AM, Staff B, DNS, stated they were not aware that Resident 105 did not have provider orders, an assessment, an informed consent, or documentation to showed function and placement was checked for the use of the wander guard prior to or at the time of application of the device and there should have been.

Reference WAC 399-97-0620(1)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Review of the January 2026 accident and incident log showed an entry dated 01/19/2026 for a fall related to Resident 5 on 01/18/2026.

The fall was logged as unwitnessed with Small bruises occurring in places generally vulnerable to trauma.

The fall was said to be Reasonably related to the resident's condition.

The action taken was medical treatment and was not reported to the State Agency according to the incident log.

Review of the facility investigation dated 01/18/2026 showed, Floor nurse reported to CNA [Certified Nursing Assistant] that resident had bruising to the right side of the forehead. [Resident 5] had an unwitnessed fall potentially hit their head on the bottom of the overbed table. No pain or concerns noted.

Power of Attorney (POA) notified and requested side rails to be put back on resident's bed for safety.

Further review showed the facility concluded that the incident was reasonably related to Resident 5's Alzheimer's diagnosis with behavioral disturbances.

Abuse and neglect were ruled out.

Review of a progress note within the investigation dated 01/18/2026 showed Resident 5 was sent to the hospital due to a black and blue bruise observed on the right side of Resident 5's forehead.

Review of a document titled Post-fall Huddle dated 01/18/2026 showed Resident 5 was found with bruising to forehead while sitting in their wheelchair in their room. Resident 5 was unable to recall what happened.

The box for unwitnessed fall was checked.

During an interview on 03/30/2026 at 10:20 AM, Staff B, Director of Nursing Services (DNS), stated after contacting the staff who worked on the day of the incident it was confirmed that Resident 5 did not have a fall.

Staff B stated the incident was an injury of unknown origin and should have been documented on the incident log correctly and reported to the State Hotline.

Reference WAC 388-97-0640(5)(a)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

During an interview on 03/23/2026 at 11:24 AM, Resident 9 stated they pressed their call light and after 15 minutes Collateral Contact went to the nurse's station to request assistance which took an additional 30 minutes.

During an interview on 03/23/2026 at 11:28 AM, Collateral Contact (CC), stated they were unhappy with the care Resident 9 was receiving. CC stated they worked in long term care and Resident 9's long wait time for a brief change was neglect.

Allegation was reported to Staff A, Administrator, on 03/24/2026 at 10:30 AM.

Review of the EHR on 03/24/2026 at 3:00 PM, 03/25/2026 at 12:47 PM and 03/26/2026 at 10:40 PM showed no alert charting or documentation related to the allegation neglect.

During a joint interview on 03/27/2026 at 11:22 AM, Staff B, Director of Nursing Services (DNS), and Staff A, Administrator, stated Resident 9 was not put on alert for psychosocial well-being to monitor for psychosocial harm but should have been.

Staff A, Administrator, stated this did not meet their expectations.

Reference WAC 388-97-0640 (6)(a-c)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Findings included.

Resident 5

Review of the electronic health record (EHR) showed Resident 5 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (progressive disorder that destroys memory and thinking skills), depression, and atrial fibrillation (heart rhythm disorder where the upper chambers are out of sync with the lower chambers). Resident 5 was transferred to the hospital on [DATE] for injuries to their head.

Review of the EHR showed Resident 5 did not have Nursing Home Transfer and Discharge Notice or bed hold notice for the 01/18/2026 transfer.

Resident 6

Review of the EHR showed Resident 6 was admitted to the facility on [DATE] with diagnoses to include dementia (brain disorder that impairs memory, thinking and interferes with activities of daily life), diabetes (high blood sugar), and high blood pressure. Resident 6 was transferred to the hospital on [DATE] for vomiting.

Review of the EHR showed Resident 6 did not have Nursing Home Transfer and Discharge Notice or bed hold notice for the 12/13/2025 transfer.

Resident 66

Review of the EHR showed Resident 66 was admitted to the facility on [DATE] with diagnoses to include atrial fibrillation, heart failure and dementia. Resident 66 was transferred to hospital on [DATE] for hip pain.

Review of the EHR showed Resident 66 did not have Nursing Home Transfer and Discharge Notice or bed hold notice for the 12/05/2025 transfer.

Resident 110

Review of the EHR showed Resident 110 was admitted to the facility on [DATE] with diagnoses to include diabetes, traumatic subdural hemorrhage (brain injury causing bleeding in the brain), and high blood pressure. Resident 110 was transferred to hospital on [DATE] for critical blood test results.

Review of the EHR showed Resident 110 did not have Nursing Home Transfer and Discharge Notice or bed hold notice for the 01/27/2026 transfer.

During an interview on 03/25/2026 at 10:36 AM, Staff D, Social Service Director, stated when a resident was transferred to the hospital, the nurses sent a copy of the transfer notice and bed hold and the next day the business office manager would follow up.

Staff D presented copies of Nursing Home Transfer and Discharge Notices for Residents 110 and 5.

The notices had not applicable (n/a) written on the date when the notice was given and not applicable on the space that said notice provided to.

During an interview on 03/26/2026 at 8:41 AM, Staff S, Licensed Practical Nurse, stated when a resident was transferring to the hospital, the nurses made a packet that included medical record information plus Nursing Home Transfer or Discharge Notice and bed hold.

Staff S stated that it was mandatory and copies were available at the station.

Upon reviewing the folder of copies, only Nursing Home Transfer or Discharge Notice forms were available (there were no bed hold form).

During an interview on 03/30/2026 at 10:19 AM, Staff A, Administrator, stated the nurses were to present the Nursing Home Transfer or Discharge Notice with a bed hold and then the business office manager was to follow up on completing them.

Staff A stated lack of documentation and bed hold for the above four residents did not meet expectations.

Reference WAC 399-97 -0120(1)(2)(a)-(d)(3)(a)(4)(b)(5), -0080 -0140(1)(a)-(c)(i)-(iii)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Review of the dental visit form dated 08/11/2025 showed Resident 10 had broken teeth or root tips and missing upper and lower teeth and red/irritated gum tissue. It showed handwritten on the form that tooth #4 caused pain and Resident 10 would like tooth extraction/removed.

Review of a significant change MDS dated [DATE] that was coded No, for obvious or likely cavity or broken natural teeth and No, for mouth or facial pain, discomfort or difficulty with chewing.

Review of the quarterly MDS dated [DATE] showed Resident 10 was coded No for mouth or facial pain, discomfort or difficulty with chewing.

During an interview on 03/30/2026 at 2:30 PM, after reviewing Resident 10's EHR, Staff B, DNS, stated the MDS should have been coded for broken and missing teeth. Resident 105 Review of the EHR showed Resident 105 admitted to the facility on [DATE] with diagnoses to include dementia, unsteadiness on feet, and cognitive communication deficit (difficulty communicating, speaking, listening, reading, or writing, because of underlying thinking problems rather than language issues).

Observation on 03/26/2026 at 1:25 PM showed Resident 105 with a wander guard wrist band (a device used to prevent from wandering or eloping by triggering an alarm when approaching an exit) securely fastened to the left wrist.

During an interview on 03/26/2026 at 2:23 PM, Staff O, RN/MDS, stated Resident 105's care plan had an intervention for a wander guard that was initiated on 03/13/2026.

Staff O stated Resident 105's quarterly MDS dated [DATE] was not coded accurately and should have been coded Used daily, for wander/elopement alarm.

Staff O stated the MDS needed to be modified.

During an interview on 03/27/2026 at 9:53 AM, Staff B, DNS, stated they were not aware that Resident 105's quarterly MDS dated [DATE] was coded Not used for wander/elopement alarm and should have been coded Used daily.

Reference WAC 399-97- 1000(1)(a)(b)(4)(a)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

assessment Resident 1's oral needs should have been care planned with clear goals and

Reference WAC 388-97-1020(1), (2)(a)(b)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Findings included.Resident 87

Review of the electronic health record (EHR) showed Resident 87 readmitted to the facility on [DATE] with diagnoses to include dependence on renal dialysis (the process of filtering blood to remove waste and excess fluids due to kidney failure), high blood pressure, and encephalopathy (the brain does not work properly, often causing confusion, altered mental state, or personality changes). Resident 87 was able to make needs known.

During an interview on 03/24/2026 at 11:52 AM, Resident 87 stated they did not remember going to a care conference.

Review of Resident 87's EHR showed a care conference document dated 11/17/2025 that Resident 87 had attended and participated in the conference; however, there were no other documented care conferences located in the EHR.

During an interview on 03/27/2026 at 1:18 PM, Staff D, Social Services Director (SSD), stated Resident 87 had a care conference on 11/17/2025 and should have had a quarterly care conference in February 2026; however, they were unable to locate documentation that another care conference had occurred.

During an interview on 03/20/2026 at 9:30 AM, Staff A, Administrator, stated care conferences were to be held upon admission, quarterly, as needed with a significant change in condition, and per resident and/or responsible party request.

Staff A stated they were not aware Resident 87 did not have a quarterly care conference conducted and this did not meet their expectations.

Resident 99

Review of the EHR showed Resident 99 admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), chronic obstructive pulmonary disease (COPD, a lung disease making it difficult to breathe), and peripheral vascular disease (a circulation disorder, blood vessels outside the heart and brain become narrowed, blocked, or damaged). Resident 99 was able to make needs known.

During an interview on 03/25/2026 at 9:43 AM, Resident 99 stated they did not remember going to a care conference.

During an interview on 03/27/2026 at 1:26 PM, Staff D, SSD, stated Resident 99 admitted to the facility on [DATE] and should have had a care conference upon admission; however, they saw no documentation that one had occurred.

Staff D stated a care conference needed to be scheduled and conducted for Resident 99.

During an interview on 03/30/2026 at 9:34 PM, Staff A, Administrator, stated they were not aware that Resident 99 had not had a care conference upon admission and this did not meet their expectations.

Reference WAC 388-97-1020(2)(e)(f)(4)(b)(d)-(f)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

stated the facility requested the order be written two times a day for documentation purposes.

obtain the correct administration did not meet their expectations.

Reference WAC 388-97-1620 (2)(d)(i)(ii),(6)(b)(i)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

During an interview on 03/23/2026 at 11:46 AM, Resident 9 stated they were not receiving their showers consistently because there was only one shower aid.

Review of the shower EHR showed Resident 9 received four showers in the past 30 days.

During an interview on 03/25/20206 at 2:41 PM, Staff L, Certified Nursing Assistant, stated they were responsible for all showers in the building and did not always get to every resident but would try to offer on an alternate day.

Staff L stated they did not always have time to turn in their shower sheets or did not always enter showers in the EHR due to internet issues.

During an interview on 03/30/2026 at 10:32 AM, Staff B, Director of Nursing Services (DNS), stated the facility was in the process of hiring another shower aid and revising the shower schedule to accommodate resident needs.

Staff B, DNS stated the expectation was that showers were offered to residents on their shower days or offered a make a shower if there were no staff to provide the shower on the scheduled day.

Resident 1

Review of the EHR showed Resident 1 admitted to the facility on [DATE] with diagnoses that included cholecystitis (inflammation of the gallbladder), chronic kidney disease and rectal cancer (cancer of the anus). Resident 1 was able to make needs known.

During an interview on 03/24/2026 at 10:08 AM, Resident 1 pointed to a package of drugstore-brand briefs on their chair and stated they had requested incontinence briefs from the staff but never received any.

During an interview on 03/30/2026 at 12:17 PM, Staff G, Central Supply, stated the facility did not have a formal process for residents to request briefs.

Staff G stated staff would verbally inform them if a resident needed briefs.

Staff G stated they did not keep documentation on if a resident received incontinent briefs and was not aware of when and if Resident 1 had received any.

Staff G stated the facility was low on briefs in the last month due to the supplier.

During an interview on 03/30/2026 at 12:32 PM, Staff B, DNS, stated Resident 1 not receiving incontinent briefs did not meet their expectations.

Staff B stated briefs were always available for residents who needed them.

Reference WAC 388-97-1060 (2)(a)(ii)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Review of the quarterly minimum data set (MDS, a required assessment) dated 01/01/2026 showed Resident 8 was dependent on staff for eating, oral care, hygiene, toileting, dressing and moving in and out of bed or chair.

Observation on 03/23/2026 at 9:33 AM, showed Resident 8 was in bed with fan on. Resident 8 had a contracture (permanent tightening of muscle, tendon or skin tissue) to their right hand and the left hand was under the blanket. Resident 8 stated they were unable to move their extremities.

Observation on 03/27/2026 at 9:24 AM showed Resident 8 was lying in their bed and the breakfast tray was placed on the table next to them.

During an interview on 03/27/2026 at 9:25 AM, Resident 8 stated they were waiting for staff to come and help them eat.

Roommate of Resident 8 stated breakfast arrived about 10-15 minutes ago.

During an interview on 03/27/2026 at 9:43 AM, Staff U, Registered Nurse, was called to Resident 8's room and Staff U stated they would find out what was going on.

Review of facility mealtime schedule on 03/27/2026 showed Resident 8's meal tray for breakfast was scheduled for delivery at 8:45 AM.

During an interview on 03/27/2026 at 1:42 PM, Staff B, Director of Nursing Services, stated residents dependent on staff for assistance with meals should be assisted timely, and Resident 8's delay of breakfast did not meet expectation.

Reference WAC 399-97- 1060(2)(c)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Findings included.

Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include quadriplegia with incomplete damage to the neck (spinal cord damaged causing partial paralysis/partial or complete loss of muscle function and/or feeling to all four limbs and torso/trunk of the body), high blood pressure, and depression. Resident 10 was able to make needs known.

During an interview on 03/24/2026 at 9:01 AM, Resident 10 stated their vision had become blurry quite a while ago and the last time they saw an eye doctor was about six months ago and were told they needed glasses. Resident 10 stated staff were aware they needed glasses; however, they never received any.

Review of the focus care plan initiated on 05/15/2025 showed Resident 10 had moderate impaired visual function related to age related decline. It further had an intervention dated 05/15/2025 that showed, Arrange consultation with eye care practitioner as required.

Review of the eye exam form titled, Summary Ocular Progress Notes, dated 05/15/2025 showed Resident 10's chief complaint was Blurred Vision. It showed Resident 10 was prescribed a new prescription for glasses. It further showed, Deliver glasses prescribed today 2 weeks from receipt of payment.

This document was signed by the Examining Doctor.

This form showed, Noted 5/29/25, and an initial, handwritten on the right lower corner of the form.

During an interview on 03/30/2026 at 11:54 AM, Staff F, Scheduling/Transportation, stated Resident 10 had an eye exam document dated 05/15/2025 that showed a prescription for glasses and that they would be delivered in two weeks upon payment receipt; however, they should have gotten their glasses mailed to them by now.

Staff F stated they were not aware that Resident 10 had not received their glasses and they needed to be followed up on.

Staff F stated this did not meet their expectations.

During an interview on 03/30/2026 at 2:18 PM, Staff B, Director of Nursing Services (DNS), stated they were not aware that Resident 10 had a prescription for glasses dated 05/15/2025 and that glasses had not been provided to the resident.

Staff B stated that Resident 10 should have been provided with glasses prior to now and this did not meet their expectations.

Reference WAC 388-97-1060 (3)(a)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Review of Resident 10's restorative program documentation from 02/26/2026 - 03/27/2026 for

3-6x per week as tolerated and was documented as completed and no other programs were noted as

Prafos boots.

Review of the Restorative Programs overview progress note dated 03/26/2026 showed the interdisciplinary (IDT) restorative meeting was held on 03/26/2026 with overview of participation of programs PROM BUE/BLE, B [bilateral] PRAFOS boots (4hrs), fine motor tasks. It showed, Progress towards goal(s): upon look back participation with programs noted.

Changes to program(s): no changes at this time and would continue with IDT Intervals of evaluations for participation.

This review was inaccurate due to Resident 10 had not had Prafos boots applied to BLE and no fine motor tasks were documented as provided and/or completed.

During an interview and observation on 03/27/2026 at 12:42 PM, Staff Q, Restorative Aide, stated that they provided PROM to all joints of Resident 10's BUE and BLE and was able to show documentation in the computer system.

Staff Q stated Resident 10 had not been applied splint/brace Parfos boots and documentation showed, Activity did not occur, Staff Q stated the splint brace program should have been discontinued because the resident refused to have them put on.

Staff Q stated those were the programs being provided and documented on.

During an interview on 03/30/2026 at 2:44 PM, Staff B, Director of Nursing Services, stated Resident 10 did not have an order for splints/braces or Prafos; however, it was care planned.

Staff B stated Resident 10's restorative programs should have been documented and reviewed appropriately because the resident was not getting the Parfos/boots applied and restorative documentation showed activity did not occur.

Staff B stated the IDT restorative meetings should have thoroughly reviewed Resident 10's nursing restorative programs and addressed these issues and that did not happen.

Staff B stated this did not meet their expectations.

Reference WAC 388-97-1060 (3)(d)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Review of the facility incident report, dated

to transfer from their wheelchair to the bed. Resident 66 was transfered to the hospital and treated for a hematoma (pooling of blood outside of blood vessels) on their head.

Planned interventions to prevent recurrence was to assess for safety upon return from the hospital.

Review of Resident 66's Occupational Discharge summary, dated [DATE], showed a recommendation for a Left side brake handle extension, unable to locate.

Review of the facility incident report, dated 03/14/2026, showed Resident 66 was found on the floor in the bathroom and unable to state what happened.

The incident report concluded the fall was related to Resident 66's preference to not use their call light for assistance and self-transfer to the toilet. A staff witness statement noted Resident 66's bed was locked and in the lowest position. Resident 66 was taken to the hospital and treated for a fracture of their distal clavicle.

During an observation and interview on 03/27/2026 at 11:28 AM, Staff J, Occupation Therapist (OT), observed Resident 66 attempted to roll their wheelchair backwards, but they were unable to.

Staff J stated the anti-rollback device was not safe or appropriate due to Resident 66's impulse to stand when they could not roll backwards.

Staff J stated their recommendation was for a brake handle extension as Resident 66 had a weak left side and was unable to unlock the left side wheelchair brake.

Staff J stated nursing was responsible for ordering devices when a resident was not on therapy services.

Observation and interview at 03/30/2026 at 9:31 AM, Staff K, Director of Rehabilitation, stated Resident 66 was discharged from therapy in January 2026 but should have been evaluated for therapy after the 01/18/2026, 01/26/2026 and 02/11/2026 falls.

Staff K stated Resident 66 was in and out of the hospital and they were unaware of where ball was dropped.

Staff K stated Resident 66 was not assessed in the wheelchair after the anti-rollback device was installed on the wheelchair for safety and to determine if the device was appropriate but should have been.

During an interview on 03/27/2026 at 2:11 PM, Staff B, Director of Nursing Services (DNS), stated they were unaware of the recommendation for the brake extender; however, they did not believe that contributed to Resident 66's injury.

Reference WAC 388-97-1060 (3)(g)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

During an interview on 03/30/2026 at 2:01 PM, after reviewing O2 orders, March 2026 TAR, and O2 Sats documented in the EHR, Staff B, Director of Nursing Services, stated Resident 106's respiratory care and services did not meet their expectations. Resident 12 Review of the EHR showed Resident 12 admitted to the facility on [DATE] with diagnoses that included sleep apnea (condition that makes one stop breathing while sleeping), chronic respiratory failure (inability of lungs to provide adequate oxygen) and diabetes (too much sugar in the blood). Resident 12 was able to make needs known.

Review of Resident 12's admission minimum data set assessment (MDS) dated [DATE] showed the resident received O2 therapy.

Observations on 03/23/2026 at 9:36 AM, 03/25/2026 at 10:48 AM and 03/26/2026 at 2:46 PM showed Resident 12 received O2 set to 3.5 L/min via a nasal canula.

Observations on 03/27/2026 at 9:31 AM showed Resident 12 received O2 set to 3 liters L/min via a nasal canula.

Review of a 08/25/2025 provider's order showed Oxygen 4 L/min via nasal canula.

Review of Resident 12's care plan initiated 08/25/2025 showed an intervention for oxygen settings at 4 L continuously.

During an interview and observation on 03/27/2026 at 9:32 AM, Staff N, Licensed Practical Nurse (LPN), observed Resident 12's O2 and stated it was set at 3 L but should have been on 4 L.

Staff N stated staff were to check the O2 setting on every shift.

During an interview on 03/27/2026 at 1:28 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that staff follow the providers order and check the O2 settings every shift.

Reference WAC 388-97-1060 (3)(j)(vi)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Findings included .

Review of the electronic health record (EHR) showed Resident 106 initially admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis (the process of filtering blood to remove waste and excess fluids due to kidney failure), anxiety disorder, and dorsalgia (a group of condition that produce moderate to intense pain in the muscles, nerves, bones, joints, or other structures associated with the spinal column/back bone of the body). Resident 106 was able to make needs known.

Review of the provider order dated 12/31/2025 showed Resident 106 was prescribed oxycodone HCI (narcotic medication used to relieve severe pain) 5 milligrams (mg) 1 tablet by mouth every four hours as needed (PRN) for pain.

Review of Resident 106's March 2026 medication administration records (MAR) from 03/01/2026 - 03/23/2026 showed oxycodone was provided one to four times a day with pain levels ranging from 4 - 10 (0 = no pain and 10 = worst pain imaginable); however, usually the pain level was 7 or higher.

Review of Resident 106's focused care plan for identified pain related to disease process initiated on 11/05/2025 showed an intervention for non-pharmaceutical (treatment without drug use) pain interventions which was to Report verbal or physical signs of pain, initiated on 11/05/2025.

There were no NPI documented on Resident's 106's care plan for pain management.

During an interview on 03/25/2026 at 1:19 PM, Staff C, Registered Nurse/Unit Manager (RN/UM), stated a resident's care plan was built from the admission assessment.

Staff C stated there was a section on the assessment that addressed NPIs and if a resident had a NPI preference, it would be care planned and offered/provided prior to giving a PRN pain medication.

Staff C stated if a resident had no NPI preference then they would be provided the pain medication as ordered.

Staff C stated licensed nurses were to review a resident's care plan prior to giving PRN pain medications.

Staff C stated resident pain assessments were conducted quarterly and PRN.

Continued interview on 03/25/2026 at 1:19 PM, Staff C stated Resident 106's admission nursing evaluation, effective date of 11/03/2025, showed not all areas of the Pain Evaluation on the form were filled in, including the question Are there any non-medication interventions that improve your pain? was left blank and should have been documented yes or no.

Staff C stated this did not meet their expectations.

Review of the pain interview evaluation dated 11/05/2025 showed Resident 106's pain numeric rating was 8 out of 10. It further showed the form had blanks/areas not filled out completely.

Review of the pain interview evaluation dated 02/09/2026 showed Resident 106's pain numeric rating was 9 out of 10.

Review showed four answered questions revealed four areas had increase in pain frequency. It further showed the form had blanks/areas not filled out completely.

During an interview on 03/27/2026 at 10:36 AM, Staff B, Director of Nursing Services, stated pain and NPIs were to be asked about as part of the admission assessment process and then care planned.

Staff B stated pain was assessed quarterly and as needed.

Staff B stated Resident 106's admission assessment dated [DATE] had several blank areas, was incomplete, and did not address NPIs.

Staff B stated Resident 106's 11/05/2025 pain interview assessment was incompletely filled out.

Staff B stated the pain interview assessment dated [DATE] showed Resident 106's pain had increased and the form was not completely filled out and should have been.

Staff B stated they needed to do a better job with assessments and pain management documentation, and this did not meet their expectations.

Reference WAC 388-97-1060(1), -1620(2)(b)(i)(ii)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Findings included.Observations on 03/23/2026 at 10:00 AM showed the front entrance, receptionist desk, and lobby areas with no daily nurse staffing data posted.

Observations on 03/24/2026 at 9:30 AM, 03/25/2026 at 8:50 AM, 03/26/2026 at 10:41 AM, 03/27/2026 at 9:07 AM, and 03/30/2026 at 8:33 AM showed the daily nurse staff data postings with no actual nursing staff hours documented, located on a window to the right of the staffing scheduler's office door, after walking through the front entrance and then taking a right towards the [NAME] Wing nurses' station.

If a person were to take a left towards the Emerald Wing nurses' station, they would not have been able to view the daily nurse staff data.

During an interview on 03/30/2026 at 10:42 AM, Staff KK, Staffing Coordinator, stated they were responsible for posting the daily nurse staff data; however, they did not post the actual hours even though they were being monitored and tracked.

Staff KK stated postings were not updated the day they were posted but could be revised the next day.

Staff KK stated people would not be able to see the daily nurse postings unless they took a right after entering the facility and went by their office window because it was the only location they were posted.

During an interview on 03/30/2026 at 10:56 AM, Staff B, Administrator, stated nurse staffing postings would not be visible unless one went to the east side of the facility.

Staff B stated the daily nursing staff postings should have been posted in a location for all to see.

Staff B stated that daily nurse data should be updated every shift to reflect the actual hours worked and any needed changes and they were not aware they were not being posted/updated, and this did not meet their expectations.

Reference WAC 388-97-1620(2)(b)(i)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

any referrals for Resident 1.

expectation was that upon assessment Resident 1 should have been referred for dental services and

Reference WAC 388-97-1060(2)(c), (3)(j)(vii)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Findings included.Observation and record review on 03/26/2026 at 11:23 AM showed the facility menu for the week with entries for breakfast, lunch, and dinner daily hung in the facility's cafeteria.

Review showed beef tip au jus, rice, seasoned peas, wheat roll, margarine, and frosted marble cake were scheduled to be served for lunch on 03/26/2026.

Observation showed a sticky note was placed over the lunch menu entry for 03/26/2026 with carrots written by hand.

Observation showed similar sticky notes placed over the lunch for 03/25/2026 with No apples, change to pineapple and peaches over the 03/25/2026 lunch entry and Diced potatoes not mashed over the dinner menu for 03/25/2026.

Observation on 03/26/2026 at 12:52 PM showed residents were served beef tip au jus, rice, carrots, a piece of bread, and yellow cake for lunch (seasoned peas, wheat roll, and marble cake were not provided per menu).

Review of the lunch menu for 03/27/2026 showed chicken fried rice, broccoli, egg roll, and tropical fruit.

Observation on 03/27/2026 at 12:06 PM showed apricot was served in lieu of tropical fruit.

During an interview on 03/27/2026 at 12:07 PM, Staff JJ, Dietary Manager, stated any substitutions to the menu were reviewed by the facility's registered dietician to ensure nutritional needs were still met and recorded on a substitution log.

During an interview on 03/27/2026 at 12:31 PM, Staff JJ, Dietary Manager, stated the facility offered an alternative meal to the posted menu for the day.

Staff JJ stated this alternative meal was not posted for residents to view and was based on what extra food was available in the kitchen.

Review of the Menu Substitution Record showed on 03/26/2026 carrots were substituted for peas but did not show the substitutions of piece of bread for wheat roll or yellow cake for marble cake.

Review showed on 03/25/2026 peaches and pineapple were substituted for baked apples but did not show diced potatoes were substituted for mashed potatoes.

Review showed 10 substitutions were recorded for the month of March 2026 and 9 of 10 were due to a lack of product.

During an interview on 03/30/2026 at 10:00 AM, Staff JJ, Dietary Manager, stated when a substitute needed to occur, they would have it reviewed by the registered dietician, record it in the Menu Substitution Record, and a sticky note would be put on the menu posted in the facility's cafeteria.

Staff JJ stated residents were not informed of substitutions except by this sticky note.

Staff JJ stated the alternative meal was not posted for residents, and residents would receive the alternative if the main menu contained items recorded as Dislikes on their tray card.

Staff JJ stated the alternative menu was decided by whatever we have in stock and decided on the day it would be served.

Staff JJ stated there was no system for residents to choose between the main or alternate meal.

During an interview on 03/30/2026 at 10:38 AM, Staff A, Administrator, stated residents should be informed of substitutions to the menu and residents should be able to choose between the main course and the alternative menu item.

Staff A stated the facility's menu system did not meet expectations.

Reference WAC 388-97-1160(1)(a)(b), -1120(3)(c)(4)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404

Findings included.TrackingReview of the infection control logs for the month of January 2026 showed no infectious organisms were identified and included on the log.

Further review showed an entry for Resident 110 dated 01/30/2026 which showed it was not a multidrug resistant organism (MDRO) and did not require special infection control precautions.

Review of Resident 110's electronic health record (EHR) showed a laboratory test dated 01/20/2026 which identified Escherichia coli ESBL positive organism [an MDRO] confirmed, contact precautions should be observed with this patient.

During an interview on 03/27/2026 at 1:37 PM, Staff E, Infection Preventionist/Registered Nurse (IP/RN), stated the month of January did not include the identified organisms and should have.

Staff E stated they did not have access to hospital records and did not know which organisms were present for Resident 110.

Laundry

During an interview on 03/27/2026 at 10:10 AM, Resident 5 stated when they had missing clothing the facility let them go into the laundry room and look for them.

Observation and interview on 03/27/2026 at 12:05 PM showed boxes of supplies being stored in the soiled linen sorting room with an open box of gauze bandages.

There was one soiled linen barrel present.

Staff V, Laundry, stated the soiled laundry room was currently being used for central supply and they sorted the soiled linens in the laundry room.

Review of the temperature logs on 03/27/2026 for the month of March 2026 showed the last entry was on 03/24/2026.

Staff V stated it should be monitored/logged every shift.

During an interview on 03/27/2026 at 12:07 PM, Staff X, Central Supply, stated residents had come into the laundry room and looked through the non-labeled clothes for missing items.

During an interview on 03/27/2026 at 12:07 PM, Staff B, Director of Nursing Services, stated soiled linens should be sorted in a separate area from the washing and the temperatures should be monitored daily.

During an interview on 03/27/2026 at 1:37 PM, Staff E, RN/IP, stated it was their expectation that soiled linens be sorted separately from the clean linens and the temperature monitoring be completed daily.

Staff E stated residents should not have been going through the laundry themselves.

During an interview on 03/30/2026 at 11:12 AM, Staff A, Administrator, stated soiled linens being sorted in the washing area, temperature monitoring not being completed, and residents going through the laundry themselves did not meet expectations.

Staff A stated it was their expectation that the infection preventionist reviewed all infectious disease labs results to ensure appropriate antibiotics and precautions were in place.

Reference WAC 388-97-1320(2)(a)(3)

505326 03/30/2026

Heartwood Extended Healthcare 1649 East 72nd Tacoma, WA 98404