Queen Of Peace Residence

In the surveyor’s words

From the most serious findings on record at Queen Of Peace Residence, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Nov 22, 2021

  Based on record review and staff interview during the Recertification survey, the facility did not ensure infection prevention control practices were maintained to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the facility was missing a Legionella sampling plan based on the facility's risk assessment. Finding is: Record review revealed the Facility Risk Assessment lacked a Legionella sampling plan that identified specific locations where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. […]

• No harm, potential for more than minimal, patternF730Nov 24, 2025

  Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure a performance review of every nurse's aide was conducted at least once every 12 months and that regular in-service education was provided based on the outcome of these reviews. This was evident for all Certified Nursing Assistants reviewed for nurse aides' training requirements.The findings are:The facility did not provide a policy and procedure regarding certified nursing aides yearly performance reviewsOn 09/26/2025, Certified Nursing Assistants records were reviewed, and there was no documented evidence a performance review was conducted for any of the Certified Nursing Assistants.On 09/26/2025 at 4:42 PM, the Director of Nursing was interviewed and stated the facility… […]

• No harm, potential for more than minimal, patternF947Nov 24, 2025

  Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that training requirements were met. This was evident for all certified nurse's aides. Specifically, there was no documented evidence certified nurse aides received no less than 12 hours per year of in-service training.The findings are:The facility did not provide a policy and procedure on nurse's aide training.On 09/26/2025 certified nurse's aides records were reviewed. There were no inservice records or lesson plans provided that certified nurse's aides received 12 hours in-service education in the past year. […]

• No harm, potential for more than minimal, isolatedF685Nov 24, 2025

  Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure residents were provided the proper treatment and assistive devices to maintain vision abilities. This was evident for 1 (Resident #16) of 1 resident reviewed for Communication-Sensory, out of a sample of 16 residents. Specifically, there was no documented evidence a follow up Ophthalmology consult was done for Resident #16 who had high intraocular pressure. […]

• No harm, potential for more than minimal, isolatedF582Jun 20, 2023

  Based on interviews and record review conducted during the recertification survey from 6/13/23 to 6/20/23, the facility did not ensure a resident or their designated representative was provided with a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) at the termination of Medicare Part A benefits. This was evident for 2 (Residents # 12 and # 21) of 2 residents reviewed for Beneficiary Notification of a total sample of 13 residents. Specifically, 1) Resident #12 and their designated representative were not provided with a SNFABN once Resident #12 was terminated from skilled rehabilitation services and remained in the facility, and 2) Resident #21 and their designated representative were not provided with a SNFABN once Resident #21 was terminated from skilled… […]