Inspection Reports for
Queen of Peace Residence
110-30 221st St, Queens Village, NY, 11429
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 24, 2025
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with health, safety, and regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to post the most recent health survey results, lack of follow-up on ophthalmology consults for a resident, absence of annual performance reviews for nurse aides, and failure to provide required in-service training for certified nurse aides.
Deficiencies (4)
F 0577: The facility did not ensure the most recent health survey results were posted in a place readily accessible to residents, visitors, or legal representatives. The facility lacked a policy related to posting survey results.
F 0685: The facility did not provide proper treatment and assistive devices to maintain vision abilities for Resident #16, including failure to follow up on an ophthalmology consult for high intraocular pressure.
F 0730: The facility did not conduct performance reviews of every nurse aide at least once every 12 months and did not provide regular in-service education based on these reviews.
F 0947: The facility did not ensure certified nurse aides received the required minimum 12 hours per year of in-service training, lacking policy and documentation for such training.
Report Facts
Residents affected: 12
Residents reviewed: 16
Residents affected: 1
Certified Nursing Assistants reviewed: No documented performance reviews found
In-service training hours required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Named in relation to failure to follow up on ophthalmology consult for Resident #16 | |
| Director of Nursing | Interviewed regarding nurse aide training and ophthalmology consult follow-up | |
| Administrator | Interviewed regarding posting of survey results and nurse aide training | |
| Recreation Director | Interviewed regarding posting of survey results | |
| Social Worker | Interviewed regarding posting of survey results |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
One standard health citation related to reporting to national health safety network; no life safety citations.
Findings
One standard health citation related to reporting to national health safety network; no life safety citations.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
One standard health citation related to reporting to national health safety network; no life safety citations.
Findings
One standard health citation related to reporting to national health safety network; no life safety citations.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 20, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with Medicare and Medicaid regulations and to evaluate the facility's adherence to care planning, medication management, and resident notification requirements.
Findings
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage to residents or their representatives upon termination of Medicare Part A benefits. Additionally, the facility did not develop or implement a comprehensive care plan for a resident's Foley catheter use. Psychotropic medications were prescribed without documented use of non-pharmacological interventions for behavioral symptoms in two residents.
Deficiencies (3)
F 0582: The facility did not ensure residents or their representatives were provided Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage at Medicare Part A termination for 2 residents.
F 0656: The facility failed to develop and implement a comprehensive care plan addressing Foley catheter use for a resident.
F 0758: Psychotropic medications were prescribed without documented use of non-pharmacological interventions for behavioral symptoms in 2 residents.
Report Facts
Residents reviewed for Beneficiary Notification: 13
Residents with deficiency: 2
Residents reviewed for Urinary Catheter: 2
Residents with deficiency: 1
Residents reviewed for Unnecessary Medication: 5
Residents with deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding failure to provide SNF Advanced Beneficiary Notices of Non-coverage and care plan management. | |
| Administrator | Interviewed about responsibility for providing forms to residents and familiarity with required forms. | |
| Director of Nursing | Interviewed regarding care plan updates and oversight. | |
| Certified Nursing Assistant #2 | Interviewed about resident behavior related to psychotropic medication use. | |
| Registered Nurse #2 | Interviewed about resident behavior and medication effects. | |
| Assistant Director of Nursing | Interviewed about resident medication management and physician interactions. | |
| Attending Physician/Medical Director | Interviewed about psychotropic medication use and clinical judgment. | |
| Psychiatrist | Interviewed about psychotropic medication prescribing rationale and resident behavior. | |
| Certified Nursing Assistant #3 | Interviewed about resident sundowning and behavioral symptoms. | |
| Pharmacy Consultant | Interviewed about medication regimen review and recommendations for gradual dose reduction. | |
| Certified Nursing Assistant #1 | Interviewed about resident behavior and hallucinations. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jun 20, 2023
Visit Reason
Multiple standard health citations related to care planning, psychotropic medication use, and Medicaid/Medicare notices; multiple life safety citations including electrical equipment, emergency lighting, and door maintenance; all corrected.
Findings
Multiple standard health citations related to care planning, psychotropic medication use, and Medicaid/Medicare notices; multiple life safety citations including electrical equipment, emergency lighting, and door maintenance; all corrected.
Deficiencies (7)
Develop/implement comprehensive care plan
Free from unnec psychotropic meds/prn use
Medicaid/medicare coverage/liability notice
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Emergency lighting
Maintenance, inspection & testing - doors
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 24, 2022
Visit Reason
One standard health citation related to reporting to national health safety network; no life safety citations.
Findings
One standard health citation related to reporting to national health safety network; no life safety citations.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 22, 2021
Visit Reason
The visit was a Recertification survey to assess the facility's compliance with infection prevention and control requirements.
Findings
The facility failed to maintain an adequate infection prevention and control program by lacking a Legionella sampling plan based on the facility's risk assessment. Documentation of such a plan was not available during the survey but was provided one day after exit.
Deficiencies (1)
F 0880: The facility's risk assessment lacked a Legionella sampling plan identifying specific locations for testing waterborne pathogens. Staff interviews confirmed unawareness of the requirement and absence of documentation during the survey.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding Legionella water sampling practices and documentation. | |
| Director of Nursing | Interviewed regarding responsibility for maintaining the water management plan and awareness of sampling plan requirements. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Date: Nov 22, 2021
Visit Reason
Standard health citation for infection prevention and control; multiple life safety citations including electrical systems, hazardous areas enclosure, and means of egress; all corrected.
Findings
Standard health citation for infection prevention and control; multiple life safety citations including electrical systems, hazardous areas enclosure, and means of egress; all corrected.
Deficiencies (4)
Infection prevention & control
Electrical systems - essential electric syste
Hazardous areas - enclosure
Means of egress - general
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