Cycle 1
Health 2026-02-13 · Fire 2026-02-13
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Gig Harbor, WA
Heron's Key
5-star overall rating with 5-star inspections with $15,015 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4340 Borgen Blvd Nw, Gig Harbor, WA
(253) 313-0800
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
21
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-01-31
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.32
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.04
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.66
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
1.30
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.54
CMS adjusted RN staffing hours
Adjusted total hours
5.90
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 47% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.44% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 8.11% · Lower 95% interval 6.28% |
| Discharge to community | 56.04% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 54.29% · Lower 95% interval 41.95% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 15 · Denominator 20 |
| Discharge mobility score | 65% |
50.94%
14.1 pts better
|
Numerator 13 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 24.59% |
8.2%
16.4 pts better
|
Numerator 30 · Denominator 122 |
| Staff flu vaccination coverage | 44.27% |
42%
2.3 pts better
|
Numerator 58 · Denominator 131 |
| Discharge function score | 80% |
56.45%
23.5 pts better
|
Numerator 16 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.0%
4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
16.3%
12.9 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.8%
2.9 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
12.1%
3.8 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
15.9%
1.2 pts worse
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.9% |
20.0%
0.9 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
15.8%
7.2 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.2%
1.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.7%
1.5 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
23.5%
5.8 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.7%
4.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.7%
12.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.4%
1.5 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-15 · Fire 2024-11-15
12 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2024-01-08 · Fire 2024-01-08
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-02-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2026-03-10
F · Potential for more than minimal harm
2026-02-13
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2026-03-10
F · Potential for more than minimal harm
2026-02-13
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2026-03-10
F · Potential for more than minimal harm
2026-02-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2026-03-10
F · Potential for more than minimal harm
2026-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-03-10
F · Potential for more than minimal harm
2026-02-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-03-10
E · Potential for more than minimal harm
2026-02-13
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2026-03-10
F · Potential for more than minimal harm
2024-11-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-11-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-11-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-01-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-12
F · Potential for more than minimal harm
2024-01-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-02-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Not marked corrected
D · Potential for more than minimal harm
2026-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2026-02-13
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Not marked corrected
F · Potential for more than minimal harm
2024-11-15
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-11-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-11-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-11-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-15
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-27
D · Potential for more than minimal harm
2024-11-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-27
C · Minimal harm
2024-11-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-01-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-01
G · Actual harm
2023-08-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-28
Penalties and ownership
What sits behind the stars
$15,015
2023-08-31
Fine
Fine · fine $15,015
Fine
Ownership
Herons Key
5% Or Greater Direct Ownership Interest · Organization
Antonucci, James
Corporate Officer · Individual
Antonucci, James
W-2 Managing Employee · Individual
Ashley, Johnathan
W-2 Managing Employee · Individual
Chambard, Allan
Corporate Officer · Individual
Emerald Communities
Operational/Managerial Control · Organization
Kilcup, Leroy
Corporate Director · Individual
King, Gary
Corporate Director · Individual
Schneider, Daphne
Corporate Director · Individual
Vanhorn, Danna
Corporate Director · Individual
Wallin, Kay
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Gig Harbor Health And Rehabilitation
Gig Harbor, WA
2-star overall rating with 1-star inspections with $115,343 in total fines with 35 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Cottesmore Of Life Care
Gig Harbor, WA
3-star overall rating with 2-star inspections with $18,233 in total fines with 20 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Eliseo
Tacoma, WA
3-star overall rating with 2-star inspections with 20 recent health deficiencies with 33 fire-safety deficiencies in the latest cycle
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