Heron's Key: Care Treatment Deficiencies - WA
That was not a new problem. Records showed the same resident, identified in inspection documents only as Resident 8, had been accumulating bruises for weeks. A large bruise appeared on the top of their right hand on January 17. Two weeks later, a bruise near the left elbow measured three centimeters across. The following day, notes recorded bruising on the right hand and left upper arm. By February 5, there was new bruising on the inner right forearm.
The weekly skin evaluation forms, filled out across January and February, recorded no new issues.
Resident 8 had been admitted with atrial fibrillation, heart failure, and chronic kidney disease. They were able to communicate their needs, and they communicated them: they told inspectors they did not know why the bruises kept coming back.
A Licensed Practical Nurse told inspectors on February 12 that the standard process for new bruises was to notify providers, get orders to monitor, start an investigation, and put the resident on alert status. The facility's Director of Nursing Services, identified as Staff B, told inspectors the following morning that nurses were expected to conduct weekly skin evaluations with measurements and descriptions of any bruises. Staff B said the records for Resident 8 did not meet expectations.
The weekly forms that said no new issues covered the same weeks the progress notes were logging bruise after bruise.
The second resident, Resident 11, could not communicate their needs. They had dementia, along with hypertension, diabetes, and a history of delusions. A provider had ordered monthly orthostatic blood pressure monitoring, a test that measures whether blood pressure drops sharply when a person moves from lying to sitting to standing. The February order was never completed.
Orthostatic blood pressure drops can cause dizziness and falls, and the test exists precisely to catch that risk before something happens.
The bowel monitoring record told a similar story. Resident 11 went without a documented bowel movement for four consecutive days, February 5 through February 8. A doctor had already written an order: give milk of magnesia if the resident goes three days without a bowel movement. The medication administration record for February showed no milk of magnesia given.
Staff B told inspectors the expectation was for licensed nurses to follow provider orders and the bowel protocol. Staff B said the records for Resident 11 did not meet expectations either.
The inspection, conducted February 13, 2026, identified the violations as causing minimal harm or potential for actual harm. Inspectors cited risks of injury from unmonitored bruising, untreated constipation, discomfort, and diminished quality of life.
What the records showed was a gap between what the facility said it expected and what actually happened, documented in its own notes. The progress entries for Resident 8 tracked bruise after bruise across six weeks. The skin evaluation forms, meant to capture exactly that information in a consistent format, said nothing was wrong. For Resident 11, a doctor wrote down what to do if constipation set in. Nobody did it.
Resident 8 sat in a chair in their room and pointed at their arm, and the weekly forms 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.
Records showed the same resident, identified in inspection documents only as Resident 8, had been accumulating bruises for weeks.
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.