Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heron's Key during CMS and state inspections, most recent first.
Inaccurate Dental Assessment and Care Planning: A resident with AFib, HF, CKD, and weakness was observed with missing teeth and stated that their teeth had fallen out and that no dentist comes to the facility. However, the quarterly MDS showed no dental issues and the care plan had no dental focus area. The RN/MDS and DON both stated the resident's dental status should have been accurately reflected.
Incomplete Monitoring of Skin Injuries, Bowel Status, and Orthostatic Blood Pressure: The facility failed to properly monitor a resident with repeated bruising and another resident with dementia who had an incomplete orthostatic BP order and no documented BM for four consecutive days. The record showed unclear bruise descriptions and weekly skin checks that did not reflect new issues, while the resident with bowel concerns had an order for milk of magnesia after 3 days without a BM but did not receive it.
Failure to Provide Routine Dental Care: A resident with CKD, AFib, and HF reported a lost tooth, multiple missing teeth, and a filling that fell out, but no dental consults were documented and the care plan did not address dental needs. The RN/MDS stated the resident needed a referral for dental services, and the DON said the records did not meet expectations.
The facility did not periodically inform residents of their rights after admission, impacting all sampled residents. Interviews showed residents were unaware of their rights or the Resident Council. The Administrator noted no resident council attendance in recent months, and the Life Enrichment Assistant confirmed no periodic communication of rights. Resident Council Minutes showed no alternative communication of rights.
The facility failed to maintain sanitary conditions in the kitchen and resident refrigerator, risking food contamination. Observations showed improper storage of cleaning supplies near food, inadequate hair covering by staff, and lack of hand hygiene. The resident refrigerator contained unlabeled and expired food items, including staff food, indicating poor monitoring.
The facility did not provide written notification of the reason for hospital transfer to a resident or their responsible party, as required. The resident, who had hypertension and heart failure, was hospitalized and readmitted without documented notice of transfer. The administrator confirmed the lack of written notices for such transfers.
A facility failed to provide a written bed hold notice to a resident during a hospital transfer, as required by regulations. The resident, with diagnoses including hypertension and heart failure, was hospitalized and later readmitted without documentation of a bed hold notice. The facility's administrator admitted that bed holds were not being offered, despite the requirement.
Two residents in a facility were not allowed to share a room despite their expressed wishes, due to a policy of single occupancy rooms. One resident, with hypertension and heart failure, and another with depression and dementia, both expressed a desire to live together, but were informed they could not. Staff confirmed the policy and were unaware of any requests to live together, despite the residents' clear expressions of their wishes.
A facility failed to update a resident's advanced directives (AD) after a significant change in condition, including being placed on hospice care. The resident, with multiple diagnoses such as cancer and dementia, had an AD last updated in March 2020, despite being capable of making decisions. An audit to ensure current ADs was conducted, but the resident's records were not reviewed, leading to the deficiency.
A facility failed to develop a comprehensive care plan for a resident with PTSD, Parkinson's, dementia, and end-of-life care needs. Despite the resident's inability to communicate and dependence on staff, their EHR lacked a PTSD care plan. Interviews confirmed the absence of a PTSD care plan, which was acknowledged as unacceptable by the Social Service Coordinator and the DON.
A facility failed to implement the bowel program for a resident with impaired communication and multiple diagnoses, including dementia. The resident did not have a bowel movement for several days, and the facility's protocol, which included administering Milk of Magnesia, Dulcolax, and Fleet enema, was not followed in a timely manner. The DON acknowledged the protocol should have been implemented within the specified timeframe.
A facility failed to ensure safety for a resident using a recliner chair, lacking necessary assessments and orders. Additionally, common area stoves, marked as out of order, were still functional and accessible to residents, posing a safety risk.
A facility failed to document non-pharmacological interventions before administering as-needed pain medication to a resident with left hip pain, muscle weakness, and Guillain-Barre Syndrome. The resident received Tramadol and acetaminophen multiple times without prior non-pharmacological interventions being documented. The DON stated that staff were expected to provide and document such interventions.
A resident with Parkinson's and dementia was found with wheelchair armrests covered in frayed tape, making them unsanitary and uncleanable. Staff E applied the tape after the resident pulled out the original covers, and the DON confirmed that wheelchairs should have cleanable surfaces.
The facility did not post actual nurse staffing hours for 11 months, as observed in November 2024. The Daily Staffing sheet lacked updates on actual hours worked, and some staffing forms were missing. Interviews with the Staffing Coordinator and Administrator confirmed the sheets were not updated, failing to meet expectations.
Inaccurate Dental Assessment and Care Planning
Penalty
Summary
The facility failed to accurately assess the dental status of Resident 8, who was admitted with diagnoses including atrial fibrillation, heart failure, chronic kidney disease, and weakness and was able to communicate needs. During observation and interview, Resident 8 stated, "My teeth have fallen out" and "No dentist comes here," and was observed with missing teeth. However, the quarterly MDS dated 11/16/2025 was marked with no dental issues, and the care plan dated 11/24/2025 did not include a dental focus area. Staff E, RN/MDS, stated the MDS should have been marked accurately and the care plan should reflect the status of teeth, and Staff B, DON, stated the expectation was for the MDS to correctly reflect residents' dental status and that Resident 8's MDS needed to be corrected.
Incomplete Monitoring of Skin Injuries, Bowel Status, and Orthostatic Blood Pressure
Penalty
Summary
The facility failed to provide quality care related to monitoring of resident skin injuries, bowel management, and orthostatic blood pressure for 2 of 9 sampled residents. Resident 8 was admitted with diagnoses including atrial fibrillation, heart failure, chronic kidney disease, and weakness, and was able to communicate needs. Observation and interview showed two reddish bruises on the left forearm, and the resident stated they did not know how the bruises were happening. The record showed multiple progress notes about bruises on different areas of the hands and arms, including a large bruise on the top of the right hand, a bruise near the left elbow measuring 3x3 cm and almost fading, bruising to the right hand and left upper arm, and new bruising to the inner right forearm. The weekly skin evaluation forms for January and February 2026 showed no new issues, and the documentation did not clearly identify the size, color, or exact location of the bruises. Resident 11 was admitted with diagnoses including delusions, hypertension, diabetes, and dementia and could not communicate needs. The record showed a provider order for monthly orthostatic blood pressure for 02/01/2026 that was not completed. The bowel monitoring documentation showed no bowel movements recorded for four consecutive days in February 2026, and the resident had an order for milk of magnesia if there was no bowel movement in three days. The February 2026 medication administration record showed no milk of magnesia was given. The DNS stated the expectation was for licensed nurses to follow provider orders and the bowel protocol, and stated the records for Resident 11 did not meet expectations.
Failure to Provide Routine Dental Care
Penalty
Summary
Routine dental care was not provided for Resident 3, who was admitted with chronic kidney disease, atrial fibrillation, and heart failure and was able to communicate needs. The resident stated they lost a tooth and needed to see a dentist, but their dentist did not see patients in wheelchairs. Review of the EHR showed no dental consultations, and the care plan dated 07/07/2025 did not address dental needs. The resident later stated they had five missing teeth and a gold filling that fell out. Staff E, RN/MDS, stated the facility did not automatically assign dentists, Resident 3 needed to be referred for dental services, and the care plan should accurately address dental needs. Staff B, DON, stated the facility would be working on the resident’s dental needs and the records did not meet expectations.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to periodically inform residents of their rights after admission, affecting all eight sampled residents. Interviews revealed that residents were not aware of their rights or the existence of a Resident Council. Staff A, the Administrator, acknowledged the absence of a Resident Council President and noted that no residents had attended council meetings in recent months. Resident Council Minutes for August, September, and October 2024 confirmed no attendance and no alternative communication of resident rights. Staff P, the Life Enrichment Assistant, admitted to not providing periodic information on resident rights. Staff A stated that residents should have been informed of their rights at admission and throughout their stay, but this was not done due to the lack of resident council participation.
Sanitation and Food Safety Deficiencies in Kitchen and Resident Refrigerator
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and resident refrigerator, which posed a risk of food contamination and foodborne illness. Observations revealed several issues: a peroxide cleaning spray was improperly stored near food items, a cook with an uncovered beard was preparing food, and a dietary aide wore a hairnet that did not fully cover their hair. Additionally, a personal cell phone was found in a food preparation area, and a dietary aide failed to perform hand hygiene after interacting with residents and returning to the kitchen. Interviews with staff confirmed these practices did not meet the facility's expectations for food safety and hygiene. The resident refrigerator was also found to be improperly monitored, containing several unlabeled and expired food items, including a jar of blackberry preserve past its use-by date and a squeeze-style guacamole with a use-by date that had already passed. Staff food items were also improperly stored in the resident refrigerator. Interviews with staff indicated that the contents of the resident refrigerator were supposed to be monitored and discarded by nursing or dietary staff, but this was not done, leading to unsanitary conditions.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to residents or their responsible parties, as required by regulations. This deficiency was identified during a review of the electronic health record (EHR) for a resident who was admitted to the facility with diagnoses including hypertension and heart failure. The resident was hospitalized and then readmitted to the facility, but there was no documentation of a notice of transfer. During an interview, the facility's administrator confirmed that they did not provide written notices for hospital transfers.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident at the time of transfer to the hospital, as required by regulations. This deficiency was identified during a review of the electronic health record (EHR) of a resident who was admitted to the facility with diagnoses including hypertension and heart failure. The resident was hospitalized and later readmitted to the facility, but there was no documentation of a bed hold notice being provided. During an interview, the facility's administrator acknowledged that they were not offering bed holds to residents, although they should have been.
Failure to Honor Resident Room Sharing Rights
Penalty
Summary
The facility failed to honor the rights of married residents to share a room, as evidenced by the cases of two residents who were not allowed to room together despite their expressed wishes. Resident 1, who was admitted with diagnoses including hypertension and heart failure, expressed a preference to share a room with their spouse, Resident 212. However, the facility did not accommodate this request, citing a policy of single occupancy rooms. The care plan for Resident 1 indicated a risk of decreased socialization due to cognitive decline, and it was noted that Resident 1 enjoyed spending time and eating meals with their spouse. Despite this, the facility only moved Resident 1's recliner to their spouse's room to facilitate more time together, rather than allowing them to share a room. Similarly, Resident 4, who was admitted with diagnoses including depression, dementia, and heart failure, was also unable to share a room with their spouse, Resident 1. During interviews, both residents expressed their desire to live together, but were informed that the facility's rooms were private and only allowed one resident per room. Staff members, including the Social Services Coordinator and the Administrator, confirmed the single occupancy policy and stated that they were unaware of any requests from the residents to live together, despite the residents' clear expressions of their wishes. This oversight placed the residents at risk for psychosocial stress and a diminished quality of life.
Failure to Update Advanced Directives for Resident on Hospice Care
Penalty
Summary
The facility failed to ensure that a resident had current advanced directives (AD) or to determine if the resident wished to develop them. This deficiency was identified for one of the four sampled residents, referred to as Resident 9, during a review for AD. The facility's policy required the interdisciplinary team to review ADs annually, upon the resident's request, when the resident's condition warranted a review, and when there was a significant change in the resident's condition. However, the facility did not adhere to this policy for Resident 9, who had a significant change in condition, including being placed on hospice care, without an updated AD. Resident 9 was admitted with multiple diagnoses, including cancer, anemia, dementia, anxiety, and depression. The resident was capable of making their needs known and had a change in condition documented in the Minimum Data Set (MDS) to reflect hospice care. Despite this, the resident's electronic health record (EHR) showed an AD last dated March 2020, with no updates to reflect the change in condition. Interviews with facility staff revealed that an audit was conducted to ensure all residents had current ADs, but Resident 9's records were not audited, resulting in the outdated AD.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with post-traumatic stress disorder (PTSD), Parkinson's, dementia, and end-of-life care needs. The resident, who was unable to communicate their needs and was dependent on staff for daily activities, was admitted to the facility with these diagnoses. Despite the resident's condition and specific PTSD triggers, the electronic health record (EHR) lacked a care plan addressing PTSD, including focus areas, goals, or interventions. Observations and interviews revealed that the resident was very weak and had resolved behaviors, but their PTSD was not addressed in the care plan. The Social Service Coordinator, responsible for trauma assessments and care plan development, confirmed the absence of a PTSD care plan for the resident and acknowledged this was unacceptable. The Director of Nursing Services also stated that PTSD should be addressed in residents' care plans, indicating a failure to meet the expected standard of care for this resident.
Failure to Implement Bowel Program for Resident
Penalty
Summary
The facility failed to consistently implement the bowel program for Resident 15, who was reviewed for unnecessary medications. Resident 15, admitted with diagnoses including hypertension, diabetes, and dementia, had impaired communication abilities. The facility's Bowel Care Protocol required specific interventions for constipation, including administering Milk of Magnesia, Dulcolax suppository, and Fleet enema, with further action to notify a physician if no results were achieved. However, the electronic health record showed that Resident 15 had no bowel movement from November 6 to November 9, 2024, and was only administered a Dulcolax suppository on November 9, 2024. This delay in implementing the bowel protocol was acknowledged by the Director of Nursing Services, who stated that the protocol should have been followed within the specified timeframe.
Safety Deficiencies in Recliner Use and Common Area Appliances
Penalty
Summary
The facility failed to maintain a safe environment for Resident 14, who was observed slumped in a recliner chair in their room. The resident's electronic health record (EHR) lacked a safety assessment or informed consent regarding the use of the recliner chair, and there was no provider's order for its use. During an interview, the Director of Nursing Services admitted that there was no process in place to assess the safety of recliners for residents, although the expectation was that residents with recliners should have a provider's order, an initial and quarterly assessment, and information on risks and benefits. Additionally, the facility did not ensure that common area appliances were safe from resident use. Observations revealed that stoves in the east and west common areas, which were supposed to be out of order, were still functional and accessible to residents. Despite signs indicating the stoves were defective and out of service, both stoves could be turned on. The Maintenance Supervisor was unaware that the ovens continued to function and acknowledged that they should have been disabled but were not.
Failure to Document Non-Pharmacological Interventions Before Pain Medication
Penalty
Summary
The facility failed to initiate non-pharmacological interventions before administering as-needed pain medication to Resident 14, who was one of five residents reviewed for unnecessary medications. Resident 14 was admitted with diagnoses including left hip pain, muscle weakness, and Guillain-Barre Syndrome, and was capable of communicating needs. The electronic health record indicated orders for Tramadol 25 mg and acetaminophen 325 mg as needed for pain. In October 2024, Tramadol was administered eighteen times and acetaminophen twice without documentation of non-pharmacological interventions. In November 2024, Tramadol was given six times, again without such documentation. During an interview, the Director of Nursing Services stated that the expectation was for staff to provide and document non-pharmacological interventions for all residents receiving as-needed pain medications.
Unsanitary Wheelchair Armrests for Resident
Penalty
Summary
The facility failed to provide a sanitary piece of equipment for Resident 6, who was reviewed for a safe and sanitary environment. Resident 6, admitted with diagnoses including Parkinson's, dementia, and end-of-life care, was observed in the dining room with wheelchair armrests covered in multiple layers of black plastic and fabric tape, which were frayed and not cleanable. Staff E from Central Supply admitted to applying the tape after Resident 6 had pulled out the armrest covers, acknowledging that the armrests were not a cleanable surface. The Director of Nursing Services, Staff B, confirmed that the expectation was for wheelchairs to be in good condition with cleanable surfaces.
Failure to Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to post actual nurse staffing hours for a period of 11 months, from January 10, 2024, through November 14, 2024. This deficiency was identified during an observation on November 13, 2024, which revealed that the Daily Staffing sheet posted at the front of the facility included a column for staff hours and a column labeled Changes, but did not reflect any updates or actual hours worked by staff. A review of the nurse staff posting binder showed missing daily staffing forms for specific dates in April 2024 and no recorded changes in staffing for the entire period reviewed. Interviews conducted on November 14, 2024, with Staff F, the Staffing Coordinator, and Staff A, the Administrator, confirmed that the daily staffing sheets were posted but not updated with the actual hours worked by staff. Staff A acknowledged that the lack of actual hours worked on the nurse staff postings did not meet the facility's expectations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gig Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gig Harbor Health And Rehabilitation | 4.2 mi | ★★★★★ | 44 | 0 |
| Cottesmore Of Life Care | 5.4 mi | ★★★★★ | 18 | 0 |
| Eliseo | 7.5 mi | ★★★★★ | 5 | 0 |
| Avamere Transitional Care Of Puget Sound | 7.9 mi | ★★★★★ | 56 | 0 |
| Park Rose Care Center | 9.3 mi | ★★★★★ | 0 | 0 |
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