Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Queen Anne Healthcare during CMS and state inspections, most recent first.
A resident with a sacral pressure ulcer that had undergone failed flap surgery was inaccurately coded on the MDS as having a stage 4 pressure ulcer instead of a surgical wound, as required by the RAI manual. Both the MDS nurse and DON confirmed the incorrect coding during interviews, and the error was identified through review of medical records and assessment documentation.
Two residents were found self-administering medications without proper assessments or physician orders. One resident had Vitamin A & D and Turmeric supplements at their bedside, while another had Terbinafine cream, which they used more frequently than prescribed. The facility's policy requires an interdisciplinary team assessment and physician orders for self-administration, which were not completed for these residents.
The facility inaccurately assessed two residents' MDS, leading to incorrect documentation. One resident's discharge was incorrectly coded as to an acute hospital instead of the community, while another resident's insulin administration was over-reported. The errors were identified during joint record reviews with the MDS Coordinator and confirmed by the DON.
A facility failed to notify the PASARR Coordinator after a resident with serious mental illness and other conditions experienced a significant change in status by enrolling in hospice. Despite the requirement for a new Level I PASARR and referral for Level II evaluation, the facility did not complete these steps, risking unmet care needs for the resident.
The facility failed to ensure proper physician's orders for oxygen therapy for two residents, leading to a deficiency in respiratory care. One resident with sarcoidosis and chronic respiratory failure was receiving continuous oxygen without documented orders, while another resident with COPD was observed receiving continuous oxygen despite orders for as-needed use. Staff interviews and record reviews confirmed the lack of appropriate documentation and adherence to physician's orders.
A resident received an incorrect dosage of Ferrous Sulfate due to a failure to verify and clarify a physician's order. An LPN administered 325 mg instead of the prescribed 324 mg delayed release, without confirming the medication's label. The error was documented, and the provider was notified.
The facility failed to follow infection control protocols, including Enhanced Barrier Precautions for a resident requiring oral hygiene, proper hand hygiene between glove changes for a resident with a pressure wound, and correct transport of clean linens for a resident receiving wound care. Staff did not adhere to PPE requirements, neglected hand hygiene between glove changes, and improperly carried clean linens against their body.
A resident at the facility did not receive the influenza vaccine despite consent being given by their representative. The facility's policy required the vaccine to be offered and administered between October and March. The Infection Preventionist and Director of Nursing acknowledged the oversight, as there was no documentation or order for the vaccine, placing the resident at risk.
A resident did not receive the COVID-19 vaccine despite consent being obtained, as the facility failed to order and document the administration of the vaccine. The Infection Preventionist acknowledged missing the order, and the DON expected the vaccine to be available within days of consent.
The facility failed to ensure proper labeling, dating, and monitoring of food stored in residents' personal refrigerators and a common resident refrigeration unit. Expired and unlabeled food items were found, and internal thermometers were missing. Staff admitted to not following the facility's policy, placing residents at risk for foodborne illness.
Inaccurate MDS Coding of Surgical Wound
Penalty
Summary
The facility failed to accurately assess a resident's surgical wound during the Minimum Data Set (MDS) process. According to the RAI 3.0 User's Manual, a pressure ulcer that has been surgically closed with a flap or graft should be coded as a surgical wound, even if the flap fails, until it is healed. Record review showed that the resident had a sacral pressure ulcer that underwent a failed flap surgery, as well as an unstageable pressure ulcer on the left ischium. Despite this, the significant change and discharge MDS assessments coded the sacral wound as a stage 4 pressure ulcer rather than as a surgical wound, contrary to the RAI manual's guidance. Interviews with the MDS nurse and the Director of Nursing confirmed that the sacral wound was not coded correctly on the MDS. The MDS nurse acknowledged following the RAI manual but admitted to inaccurately coding the wound as a pressure ulcer instead of a surgical wound. The Director of Nursing also confirmed the incorrect coding and stated an expectation for accurate MDS assessments. This failure to accurately assess and code the resident's wound was identified through both record review and staff interviews.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for self-administration of medications, and did not obtain necessary physician orders for two residents. This deficiency was identified during observations, interviews, and record reviews. The facility's policy requires an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration is safe and appropriate, and mandates that unauthorized medications found at the bedside be returned to the nurse in charge. Resident 30, who was cognitively intact, was observed with Vitamin A & D and Turmeric supplements at their bedside, which they self-administered without a physician's order. The resident's Medication Administration Record (MAR) did not include these supplements, although there was an order for Vitamin D3. No self-medication program was completed for Resident 30, and staff were unaware of the resident's self-administration practices. Resident 48 was observed with Terbinafine cream at their bedside, which they used more frequently than prescribed. Although there was an order for the cream, no self-medication program was completed. Staff interviews revealed that medications should not be kept at the bedside without a physician's order and a completed self-medication program. The Director of Nursing expected staff to ensure a safe environment by securing medications and completing necessary assessments and orders for self-administration.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess two residents, leading to incorrect documentation in their Minimum Data Set (MDS) assessments. Resident 89 was discharged from the facility to the community against medical advice, but their discharge MDS inaccurately indicated a discharge to an acute hospital. This discrepancy was identified during a joint record review with the MDS Coordinator, who acknowledged the error and confirmed that the discharge should have been coded as to the community. Resident 190's MDS was also inaccurately coded. The resident's Medication Administration Record showed that insulin was administered on five specific days during the look-back period. However, the admission MDS inaccurately recorded six insulin injections. Upon review, it was found that insulin was held and not given on one of the days, leading to the incorrect coding. The Director of Nursing confirmed the expectation for accurate MDS completion and acknowledged the inaccuracies in both residents' assessments.
Failure to Notify PASARR Coordinator After Significant Change in Resident's Status
Penalty
Summary
The facility failed to notify the State Pre-Admission Screening and Resident Review (PASARR) Coordinator after a significant change in status occurred for a resident who was reviewed for PASARR. The resident, who had diagnoses including depression, paranoid personality disorder, and unspecified psychosis, was admitted to the facility and had a Level I PASARR updated, indicating the need for a Level II PASARR evaluation. However, after the resident was certified with a terminal illness and enrolled in hospice services, which constituted a significant change in status, the facility did not complete a new Level I PASARR or notify the PASARR coordinator for a Level II evaluation. Interviews with the Social Services Director and the Administrator revealed that the facility's process required a new Level I PASARR and a referral for Level II evaluation upon a significant change in status, such as hospice enrollment. Despite this, the facility did not follow through with the necessary notifications and evaluations, as evidenced by the lack of documentation in the resident's Electronic Health Record. This oversight placed the resident at risk for unmet care needs and a diminished quality of life.
Deficiency in Oxygen Therapy Orders for Two Residents
Penalty
Summary
The facility failed to ensure that physician's orders for oxygen were in place and followed according to professional standards of practice for two residents, leading to a deficiency in respiratory care. Resident 85, who was admitted with sarcoidosis of the lungs and chronic respiratory failure with hypoxia, was observed receiving oxygen at a rate of two and a half liters per minute via nasal cannula. However, there were no physician's orders for continuous oxygen upon admission, despite the hospital discharge summary indicating a need for continuous oxygen at two to three liters per minute. Staff interviews revealed that there was an expectation for oxygen orders to be in place, but they were not documented until later. Resident 12, admitted with chronic obstructive pulmonary disease and chronic respiratory failure, was observed receiving continuous oxygen at two and a half liters per minute, although the physician's order was for oxygen at two liters per minute as needed for shortness of breath or cyanosis. Staff interviews confirmed that Resident 12 had been using oxygen continuously, yet the orders did not reflect this practice. The facility's records did not document any instances of Resident 12's oxygen saturation dropping below 90 percent, which was the condition for administering oxygen as per the existing order. The deficiency in respiratory care was identified through observations, interviews, and record reviews, highlighting a lack of proper documentation and adherence to physician's orders for oxygen therapy. The facility's failure to have appropriate oxygen orders in place for both residents placed them at risk for unmet care needs and potential respiratory complications.
Medication Administration Error Due to Unverified Physician Order
Penalty
Summary
The facility failed to ensure a physician's order was followed and/or clarified for a resident regarding medication administration. Specifically, the resident had a physician's order for Ferrous Sulfate oral tablet delayed release 324 mg to be given once a day every other day. However, during an observation, a Licensed Practical Nurse (LPN) administered Ferrous Sulfate 325 mg instead of the prescribed 324 mg delayed release. The LPN admitted to administering the iron supplement they had in supply without confirming if it was delayed release, as it was not labeled on the bottle. The LPN acknowledged that they should have confirmed the order, read it, and clarified it with the provider if it did not match the medication available. Further review and interviews revealed that the LPN documented the error in a nursing progress note and notified the provider. The Resident Care Manager confirmed that the LPN should have checked the resident's name, medication, dose, and route prior to administration and should have clarified the order with the provider. The Director of Nursing reiterated the expectation for nursing staff to verify the correct medication order, patient, dose, route, and strength, and stated that the LPN should have clarified the order with the provider.
Infection Control Deficiencies in PPE, Hand Hygiene, and Linen Transport
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for Resident 72, who required substantial assistance for oral hygiene and was on EBP due to infection control needs. During an observation, a Speech Therapist entered Resident 72's room wearing only gloves and provided oral care without a gown or mask, despite the EBP signage indicating the need for full PPE during personal hygiene activities. Interviews with the Infection Preventionist and Director of Nursing confirmed that oral care is considered personal hygiene, and staff should wear a gown, gloves, and mask. For Resident 12, who had a pressure wound and required daily dressing changes, the facility failed to ensure proper hand hygiene and glove use. During observations, a Licensed Practical Nurse (LPN) did not perform hand hygiene between glove changes while assisting with Resident 12's wound care and changing briefs. The LPN acknowledged the oversight, and both the Infection Preventionist and Director of Nursing stated that hand hygiene should be performed between glove changes, as per facility policy. Additionally, the facility did not follow proper procedures for transporting clean linens for Resident 6, who had wounds and was receiving wound care treatments. A Certified Nursing Assistant was observed carrying clean linens against their chest, contrary to the facility's policy that requires linens to be carried away from the body. Interviews with nursing staff confirmed that clean linens should not touch the body, and the expectation is to carry them away from the uniform to prevent contamination.
Failure to Administer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to ensure that the influenza vaccine was provided to a resident, identified as Resident 10, who was reviewed for immunizations. The facility's policy required that the influenza vaccine be offered to residents and employees between October 1st and March 31st each year, unless medically contraindicated or already immunized. Resident 10 was admitted to the facility, and their representative consented to receive the influenza vaccine. However, there was no documentation in the electronic health record indicating that Resident 10 received the influenza vaccination. During an interview and joint record review, the Infection Preventionist, Staff D, acknowledged that the influenza vaccine was offered to residents upon admission. Despite the consent being signed, there was no order placed for the vaccine, and it was not administered to Resident 10. Staff D admitted to missing this case, and the Assistant Director of Nursing, Staff C, stated that the vaccine should have been given within a week of consent. The Director of Nursing, Staff B, confirmed that the vaccine should be ordered immediately after consent and expected to be administered within three to four days. This oversight placed Resident 10 at risk of acquiring and transmitting influenza.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a COVID-19 vaccine was provided to a resident, identified as Resident 10, who was reviewed for immunizations. The resident's representative had consented to the COVID-19 vaccination, but there was no documentation in the resident's electronic health record indicating that the vaccine was administered. This oversight placed the resident at risk for contracting COVID-19 and related complications. During interviews and record reviews, it was revealed that the facility's process involved offering the COVID-19 vaccine to residents upon admission. Staff D, the Infection Preventionist, acknowledged that they missed ordering the vaccine for Resident 10 after receiving consent. Staff C, the Assistant Director of Nursing, confirmed that the consent form was received, and the vaccine should have been administered within a week. Staff B, the Director of Nursing, stated that the vaccine is typically ordered immediately after consent is obtained and should be available within 3-4 days. However, in this case, the vaccine was not ordered or documented as administered.
Failure to Ensure Proper Food Storage and Monitoring
Penalty
Summary
The facility failed to ensure proper labeling, dating, and monitoring of food stored in residents' personal refrigerators and a common resident refrigeration unit. Specifically, Resident 1's personal refrigerator contained expired deli meats that were not discarded after their use-by dates, and the refrigerator lacked an internal thermometer. Staff responsible for monitoring these items admitted to missing the inspection and discarding of expired food. Similarly, Resident 2's personal refrigerator contained unlabeled chicken salad sandwiches and also lacked an internal thermometer. The dietary staff failed to label the food items with the resident's name and use-by date, and the refrigerator's temperature was not recorded for an entire month. Additionally, the first-floor resident refrigeration unit contained unlabeled and expired food items, and it did not have an internal thermometer or a temperature log. Staff acknowledged that the food items should have been labeled with the resident's name and the date received, and expired items should have been discarded. The facility's policy required that all refrigeration units have internal thermometers and that food items be labeled and monitored for expiration, but these procedures were not followed. Interviews with various staff members, including the Director of Nursing and the Administrator, confirmed that the facility's policy on personal food storage was not adhered to. The staff admitted that they were responsible for checking the food items and monitoring the temperatures in residents' personal refrigerators and the common refrigeration unit but failed to do so. This lack of compliance with the facility's policy placed residents at risk for foodborne illness and diminished their quality of life.
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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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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Columbia Lutheran Home | 1.3 mi | — | 1 | 0 |
| Mirabella | 2 mi | — | 2 | 0 |
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| The Terraces At Skyline | 2.8 mi | — | 0 | 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 August 2026) and official state health department websites.