A list of the most recent deficiencies for Queen Anne Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | 2023-11-27 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-24 | 2023-11-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-20 | 2023-11-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-20 | 2023-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-20 | 2023-11-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-20 | 2023-11-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-20 | 2023-11-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-20 | 2023-11-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-20 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-20 | 2023-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-20 | 2023-11-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-20 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-19 | 2023-11-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-29 | 2022-09-14 | Y |
| 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. | Health | 2019-05-17 | 2019-06-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-05-17 | 2019-06-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-17 | 2019-06-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-17 | 2019-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-17 | 2019-06-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-17 | 2019-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-17 | 2019-06-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-17 | 2019-06-25 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-17 | 2019-06-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-17 | 2019-06-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-17 | 2019-06-25 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-05-17 | 2019-06-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-17 | 2019-06-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-05-09 | 2019-06-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-05-09 | 2019-06-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-09 | 2019-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-09 | 2019-06-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-09 | 2019-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-09 | 2019-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-09 | 2019-06-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-05-09 | 2019-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-09 | 2019-06-07 | N |
