Inspection Reports for
Queen of Peace Residence
110-30 221st St, Queens Village, NY, 11429
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Inspection Report — Nov 24, 2025
Annual Inspection CMS
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.
Citations (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 — Nov 19, 2025
State
Date: Nov 19, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2025 with citation and complaint history.
Complaint Details
The state logged 14 complaints about this facility; 2 led to on-site inspections. No citations resulted from those complaints.
Findings
Across 5 inspections, 33 citations were issued including 13 standard health and 20 Life Safety Code citations. The facility had 14 complaints with 2 on-site inspections and no formal enforcement actions.
Citations (24)
Criminal History Record Check Process: Standard Health Citation related to quality of care with minor potential harm.
Infection Control: Standard Health Citation related to quality of care with no harm potential.
Nurse Aide Perform Review-12 Hr/yr In-service: Standard Health Citation related to quality of care with minor potential harm.
Required In-service Training For Nurse Aides: Standard Health Citation related to quality of care with minor potential harm.
Requirements Before Submitting A Request For: Standard Health Citation related to quality of care with no harm potential.
Right To Survey Results/advocate Agency Info: Standard Health Citation related to quality of care with potential for minimal harm.
Treatment/devices To Maintain Hearing/vision: Standard Health Citation related to quality of care with minor potential harm.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Electrical Systems - Receptacles: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Exit Signage: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Hazardous Areas - Enclosure: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Physical Environment: Life Safety Code Citation related to NFPA requirements with no harm potential.
Sprinkler System - Installation: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Reporting - National Health Safety Network: Standard Health Citation related to quality of care with minor potential harm (not yet corrected).
Develop/implement Comprehensive Care Plan: Standard Health Citation related to quality of care with minor potential harm.
Free From Unnec Psychotropic Meds/prn Use: Standard Health Citation related to quality of care with minor potential harm.
Medicaid/medicare Coverage/liability Notice: Standard Health Citation related to quality of care with minor potential harm.
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Emergency Lighting: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Maintenance, Inspection & Testing - Doors: Life Safety Code Citation related to NFPA requirements with minor potential harm.
Reporting - National Health Safety Network: Standard Health Citation related to quality of care with minor potential harm (not yet corrected).
Report Facts
Inspections on page: 5
Total citations: 33
Standard Health citations: 13
Life Safety Code citations: 20
Total complaints: 14
On-site complaint inspections: 2
Complaints with citations: 0
Citations issued from complaints per 100 beds: 0
Complaints per 100 occupied beds: 37.8
Facility-Reported Incidents: 93
Inspection Report — Jun 20, 2023
Annual Inspection CMS
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.
Citations (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 — Nov 22, 2021
Annual Inspection CMS
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.
Citations (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. |
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