Heron's Key: Resident Assessment Failures - WA
That gap, between what a resident's body showed and what the paperwork said, is at the center of a February inspection that found Heron's Key failed to properly monitor injuries and follow a doctor's treatment order for a second resident who could not speak for themselves.
The resident with bruises, identified in the report as Resident 8, had been admitted with atrial fibrillation, heart failure, and chronic kidney disease. Progress notes going back to January 2026 documented bruises appearing in different locations: a large bruise on the top of the right hand on January 17, a 3-by-3-centimeter bruise near the left elbow on January 31, bruising on both the right hand and left upper arm on February 1, and new bruising to the inner right forearm by February 5. The bruises kept moving. The weekly skin forms kept saying nothing was new.
The progress notes themselves were incomplete. Inspectors found that while nurses had written some alerts about bruising, the documentation lacked consistent measurements, descriptions of color, and precise locations. A Licensed Practical Nurse told inspectors on February 12 that the expected process for new bruises was to notify providers, get monitoring orders, open an investigation, and place the resident on alert status. The records showed that process was not consistently followed.
The Director of Nursing Services, identified as Staff B, acknowledged it directly. "The records for Resident 8 did not meet expectations," she told inspectors on February 13.
The second resident, Resident 11, lived with dementia and could not communicate their needs. They had been diagnosed with hypertension, diabetes, and delusions. A doctor had written an order for monthly orthostatic blood pressure monitoring, a test that measures blood pressure while lying, sitting, and standing to catch dangerous drops in pressure. The February order was not completed.
But the more immediate failure involved a four-day stretch without a documented bowel movement. On February 5, 6, 7, and 8, no bowel movement was recorded for Resident 11. A provider's order was already in place: give milk of magnesia if the resident goes three days without a bowel movement. The medication administration record showed the milk of magnesia was never given.
The Director of Nursing told inspectors the expectation was for licensed nurses to follow provider orders and the bowel protocol. Then she said the same thing she had said about the first resident. The records did not meet expectations.
Inspectors rated the violations at minimal harm or potential for actual harm, affecting a small number of residents. But the pattern they described points to something more than individual lapses. Resident 8's bruises were appearing regularly enough to generate multiple progress notes across three weeks. Nobody had connected them, tracked them systematically, or ensured the weekly skin evaluations reflected what was actually happening to the resident's body. Resident 11 had a standing order designed specifically to prevent constipation from going untreated, and the order sat unused while four days passed.
Resident 8 told inspectors they did not know how the bruises were happening. Neither, based on the records, did the facility.
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 resident with bruises, identified in the report as Resident 8, had been admitted with atrial fibrillation, heart failure, and chronic kidney disease.
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.