Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Accura Healthcare Of Pierce during CMS and state inspections, most recent first.
A resident’s PASRR was completed incorrectly and did not identify known MI diagnoses, including schizophrenia and major depressive disorder. The hospital PASRR stated there was no suspected or known MH diagnosis, ID, or related condition, even though the resident’s records and care plan documented schizophrenia, schizoaffective disorder, aggressive behaviors, and psychotropic medication use; the DON confirmed a level 2 PASRR was not completed because the level 1 screen was inaccurate.
A resident with stroke, hemiplegia, diabetes, and bowel incontinence had repeated periods without documented bowel movements, including stretches of 4 to 6 days. Although the care plan and facility bowel protocol required daily monitoring, bowel sound assessments, and stepwise interventions such as prune juice, MOM, and Bisacodyl, staff did not consistently document or carry out the required actions, and PRN constipation meds were not consistently offered or given. The DON and an LPN confirmed the resident had ongoing constipation and that staff were expected to follow the bowel movement list and document assessments.
The facility failed to employ a qualified Dietary Manager, potentially affecting food service for all residents. The current Dining Services Manager did not meet state qualifications, and the Registered Dietician was not full-time. This deficiency could impact the quality of food service for the facility's 33 residents.
The facility failed to accurately code the MDS for two residents, leading to discrepancies in their assessments. One resident had a PASRR Level II indicating an intellectual disability, while the other had a serious mental illness, but these were not reflected in their MDS. The DON confirmed the incorrect coding during interviews.
A facility failed to complete a new PASRR for a resident with a serious mental illness after the initial 180-day approval expired. The DON confirmed the facility was unaware of the expiration and had not conducted a subsequent assessment, with no evidence of a new PASRR found in the resident's records.
A resident experienced significant weight loss, dropping from 232 lbs to 212 lbs in three weeks, due to the facility's failure to provide a recommended nutritional supplement. Despite the RD's recommendation for Ensure, the supplement was unavailable, and the facility only offered Mighty Shake, which was not provided. The MAR lacked details on the supplement's dosage, leading to a lapse in nutritional intervention.
A facility failed to develop and implement trauma-informed care interventions for a resident with PTSD, despite the resident identifying specific triggers such as loud noises and being approached from behind. The care plan lacked details on these triggers and interventions, and interviews confirmed the absence of a trauma-informed care policy.
A facility failed to manage psychotropic medication for a resident with Parkinson's and dementia. The resident's care plan lacked target behaviors and non-pharmacological interventions, and a recommended Gradual Dose Reduction (GDR) for Seroquel was not attempted or justified. Staff interviews revealed uncertainty about the medication's necessity.
The facility failed to notify two residents about the resolution of their grievances regarding missing personal items. Despite having a grievance process in place, pertinent findings were not documented, and residents were not informed of the outcomes. Interviews confirmed the lack of communication, and staff acknowledged the absence of a specific policy for handling missing items.
Incorrect PASRR Screening for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure Resident 7’s PASRR was completed accurately. Review of the resident’s MDS showed the resident was admitted and was not considered by the state PASRR to have MI, ID, or RC, even though the resident had diagnoses of major depressive disorder and schizophrenia. The resident’s diagnosis report also listed Adjustment Disorder with mixed anxiety and depression and Schizoaffective Disorder, bipolar type. The resident’s hospital-completed PASRR stated the resident had no suspected or known mental health diagnosis, intellectual disability, or related condition. However, the resident’s current care plan identified schizophrenia with physically aggressive behaviors and use of psychotropic medications. During interview, the DON confirmed the admission PASRR did not identify the resident’s schizophrenia and major depressive disorder, and that the PASRR had been completed incorrectly.
Failure to Monitor and Treat Constipation
Penalty
Summary
The facility failed to provide monitoring and treatment for changes in bowel elimination for a resident with diagnoses of stroke, hypertension, peripheral vascular disease, diabetes, hemiplegia, anxiety, and depression. The resident was cognitively intact, always involuntary of bowel, and required substantial to maximal assistance with toileting. The care plan identified the resident as at risk for constipation due to decreased mobility, poor oral intake, and refusal at times to take medications to promote bowel movements, and it directed staff to monitor bowel movement patterns daily, monitor for signs and symptoms of constipation complications, and administer medications as ordered. The resident’s bowel movement record showed multiple periods without documented bowel movements, including a 5-day period in March and several periods in April lasting 4 to 6 days. The facility’s Bowel Movement Needs List required staff to identify residents without bowel movements for 2, 3, 4, or 5 days and to implement specific interventions, including offering prune juice on day 2, Milk of Magnesia on day 3, Bisacodyl suppository on day 4, and Fleets enema on day 5, with bowel sounds assessed every shift. The record showed these interventions were not consistently carried out or documented, including missed offers of prune juice, Milk of Magnesia, and Bisacodyl during the periods without bowel movements. The MAR showed orders for daily Miralax and PRN constipation medications, including Bisacodyl tablets, Dulcolax suppositories, and Milk of Magnesia, but the PRN medications were not offered and/or administered throughout March, and some April administrations were documented as ineffective. There was no evidence that staff completed bowel sound assessments during the periods of constipation, and there was no evidence that the PCP was notified when the resident had gone 6 days without a bowel movement. During interviews, the DON confirmed the resident had ongoing constipation and that staff should have documented assessments when the resident went 4 to 6 days without a bowel movement, and an LPN confirmed staff were to follow the Bowel Movement Needs List interventions.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified Dietary Manager (DM), which had the potential to affect the food service provided to all residents. The facility's job description for the Director of Dining Services, revised on 07/18/2024, required the individual to meet state requirements for a Dietary Manager. However, a review of an undated staff list revealed that the current Dining Services Manager did not possess the necessary qualifications. During an interview, the facility Administrator confirmed that the current DM lacked the required training for the position and also noted that the Registered Dietician was not employed full-time at the facility. This deficiency had the potential to impact the quality of food service for the facility's 33 residents.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, which is a federally mandated comprehensive assessment used to develop resident care plans. Resident 22 had a PASRR Level II completed, indicating an intellectual disability or related condition, and was approved for unlimited days of nursing facility care. However, the MDS did not reflect this Level II screening or the resident's serious mental illness and intellectual disability. The resident's care plan included diagnoses of bipolar disorder, major depressive disorder, schizoaffective disorder, impaired cognitive function, and Down Syndrome, all of which were not accurately coded in the MDS. The Director of Nursing (DON) confirmed the incorrect coding during an interview. Similarly, Resident 29 had a PASRR Level II completed, indicating a serious mental illness, and was approved for 180 days of nursing facility care. The MDS for this resident also failed to reflect the Level II screening or the serious mental illness. The resident's care plan noted the use of antidepressant and psychotropic medications, which were not accurately coded in the MDS. The DON confirmed the incorrect coding during an interview. These inaccuracies in the MDS coding for both residents indicate a failure to ensure accurate assessments, as required by federal regulations.
Failure to Update PASRR Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASRR) for a resident with a serious mental illness after the initial PASRR approval period expired. The resident was initially approved for nursing facility services for 180 days, but the facility did not conduct an updated screening after this period ended. This oversight was identified during a review of the resident's medical records, which showed no evidence of a new PASRR assessment being completed. Interviews with the Director of Nursing (DON) revealed that the facility was unaware of the expiration of the resident's PASRR approval and had not conducted a subsequent assessment. The DON confirmed that the Minimum Data Set (MDS) assessments were being completed by an outside source and acknowledged the lack of awareness regarding the resident's PASRR status. The facility was unable to locate any documentation indicating that a new PASRR assessment had been conducted after the initial approval period expired.
Failure to Implement Nutritional Interventions for Weight Loss
Penalty
Summary
The facility failed to implement nutritional interventions for a resident, identified as Resident 21, who experienced significant weight loss. The facility's policy on unintended weight loss required staff to identify risk factors, monitor weight and food intake, and implement individualized interventions. However, despite a recommendation from the Registered Dietician (RD) for the resident to receive Ensure, a nutritional supplement, once a day, the facility did not provide the supplement due to its unavailability. The resident's weight decreased from 232 pounds to 212 pounds, a 9% loss in three weeks, yet the recommended nutritional intervention was not implemented. The RD confirmed that the resident's Medication Administration Record (MAR) did not specify the amount of Ensure to be given, and the supplement was not provided from January 28 to February 6. The RD was unaware that the facility only offered Mighty Shake as a nutritional supplement and did not provide Ensure. This oversight resulted in the resident not receiving the necessary nutritional support despite the significant weight loss, highlighting a failure in the facility's implementation of its nutritional policy.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement individualized interventions to prevent or minimize the effects of potential trauma triggers for a resident diagnosed with anxiety, depression, and post-traumatic stress disorder (PTSD). The resident, who was cognitively intact, had identified specific preferences and triggers during a Trauma Informed Care assessment, such as not being approached from behind without warning, disliking loud slamming noises, bright flashing lights, and violent men's voices. Despite these identified triggers, there was no evidence that the facility staff developed interventions to alleviate or lessen the resident's PTSD triggers. The resident's care plan, although acknowledging the diagnosis of PTSD, did not include any specific triggers or interventions to mitigate them. Interviews with the resident revealed that the facility had not addressed these triggers, and no interventions were in place. Additionally, interviews with the Social Service Director, the Administrator, and the Director of Nursing confirmed that the facility lacked a policy related to trauma-informed care and had not developed or implemented any interventions to minimize or mitigate potential trauma triggers for the resident.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to properly manage the use of psychotropic medication for a resident, leading to a deficiency. The facility's policy required that residents receiving psychotropic medications be evaluated, monitored, and managed by an Interdisciplinary Team (IDT). However, the facility did not identify and monitor specific target behaviors for the resident, nor did it document non-pharmacological interventions to address potential behaviors. Additionally, there was no attempt at a Gradual Dose Reduction (GDR) or documented contraindication for the GDR related to the use of the psychotropic medication Seroquel. The resident in question had diagnoses of Parkinson's disease and non-Alzheimer's dementia, with severe cognitive impairment, and was taking Seroquel. Despite a recommendation from the Consultant Pharmacist for a GDR, the physician ordered the continuation of the medication without providing a clinical rationale for not attempting the GDR. The resident's care plan lacked evidence of specific target behaviors and non-pharmacological interventions. Interviews with facility staff revealed uncertainty about the necessity of the antipsychotic medication for the resident, further highlighting the deficiency in medication management.
Failure to Notify Residents of Grievance Resolutions
Penalty
Summary
The facility failed to notify residents of the resolution for grievances related to missing personal items for two residents out of a sample of 21. The grievance process, as outlined in the facility's policy revised in January 2023, requires the Grievance Official to oversee the process, track grievances, lead investigations, and issue written decisions to residents. However, the review of grievance forms revealed that pertinent findings were not documented, and residents were not properly informed of the resolution of their grievances. For instance, Resident 11 reported a missing pink turtleneck shirt, and Resident 16 reported missing clothing items, but there was no documentation of pertinent findings or proper notification to the residents about the resolution. Interviews with the residents confirmed that they had not been notified about the resolution of their grievances. Additionally, interviews with staff members, including the Activity Assistant, Registered Nurse, Activities Director, and Social Services Director, revealed that the facility lacked a specific policy for handling missing personal items. The staff followed a process of filling out grievance forms and checking rooms and laundry, but residents were only informed of the outcome if they inquired. This lack of communication and documentation led to the deficiency in honoring residents' rights to voice grievances and receive timely resolutions.
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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 Pierce
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Of Bel Air | 11.7 mi | ★★★★★ | 0 | 0 |
| St. Joseph's Rehabilitation And Care Center | 12.1 mi | ★★★★★ | 17 | 0 |
| Colonial Manor Of Randolph | 14.6 mi | ★★★★★ | 13 | 0 |
| Community Pride Care Center | 14.9 mi | ★★★★★ | 7 | 0 |
| Plainview Manor | 17.7 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.