Heron's Key: Emergency Dental Care Violations - WA
That was February 10. Two days later, a review of the electronic health record showed the bruises had company: a large bruise on the top of the right hand documented January 17, a 3-centimeter bruise near the left elbow on January 31, bruising on the right hand and left upper arm on February 1, and new bruising to the inner right forearm on February 5. The notes described locations and colors inconsistently. Size was sometimes missing. Actual location, sometimes unclear.
The weekly skin evaluation forms for January and February recorded no new issues.
Both documents covered the same resident. They described different realities.
The resident, identified in the inspection report as Resident 8, had been admitted with atrial fibrillation, heart failure, and chronic kidney disease. They were able to communicate their needs and did so, pointing to their own arm and telling an inspector the bruising kept happening without explanation.
Staff D, a licensed practical nurse, told inspectors that the expected process for new bruises was to notify providers, get monitoring orders, start an investigation, and place the resident on alert status. Alert status had been initiated. The investigation, the documentation, the measurements — those were another matter.
The Director of Nursing Services, identified as Staff B, said on February 13 that nurses were expected to conduct weekly skin evaluations with measurements and descriptions of any bruises. Then she said the records for Resident 8 did not meet expectations.
The second resident, Resident 11, could not communicate their needs. Their diagnoses included dementia, hypertension, diabetes, and delusions. The inspection report does not describe anyone pointing to anything on their behalf.
Resident 11 had a provider's order for orthostatic blood pressure monitoring — a test that measures blood pressure while lying, sitting, and standing to catch sudden drops that can cause falls — due February 1, 2026. It had not been completed.
They also had a standing order for milk of magnesia if they went three days without a bowel movement.
Records showed Resident 11 went four consecutive days without a documented bowel movement: February 5, 6, 7, and 8.
The medication administration record showed no milk of magnesia given during that stretch.
Staff B, the Director of Nursing Services, said the expectation was for licensed nurses to follow provider orders and the bowel protocol. Then she said the records for Resident 11 did not meet expectations.
The inspection, conducted February 13, 2026, identified the failures as placing residents at risk of injuries, untreated constipation, discomfort, and diminished quality of life. The level of harm was classified as minimal harm or potential for actual harm. Two of nine sampled residents were affected.
The violations were not dramatic in the way that abuse cases or medication errors are dramatic. Nobody was assaulted. No emergency hospitalization was documented. What the record shows instead is a quieter kind of failure: a resident with recurring unexplained bruises whose weekly evaluations said nothing was wrong, and a resident who couldn't speak for themselves going four days past the threshold their own doctor had set for intervention, with no one acting on it.
Resident 8 pointed to their arm and told an inspector they didn't know how the bruises kept happening. The weekly skin forms, signed off week after week, said there was nothing to report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heron's Key from 2026-02-13 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: August 4, 2026 · Our methodology
HERON'S KEY in GIG HARBOR, WA was cited for violations during a health inspection on February 13, 2026.
The notes described locations and colors inconsistently.
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.