Cycle 1
Health 2024-10-15 · Fire 2024-10-15
3 health deficiencies
Top issue: Administration (1 deficiency)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Lewiston, NY
Our Lady Of Peace Nursing Care Residence
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
5285 Lewiston Road, Lewiston, NY
(716) 298-2900
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
250
Certified beds
Average residents
149
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
2003-06-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
12%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,486
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.49
Composite VBP score used to determine payment impact.
Payment multiplier
1.0034
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.97
Performance 18.66% · Measure score 5.97 · Achievement 5.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.83
Performance 6.09% · Measure score 5.83 · Achievement 5.83 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.95
Baseline 45.65% · Performance 43.44% · Measure score 4.95 · Achievement 4.95 · Improvement 0.56
Adjusted total nurse staffing
3.04
Baseline 3.93 hours · Performance 3.94 hours · Measure score 3.04 · Achievement 3.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.5% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 5.88% · Lower 95% interval 5.92% |
| Discharge to community | 55.29% |
50.57%
4.7 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 53.73% · Lower 95% interval 46.49% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 30 · Denominator 45 |
| Discharge mobility score | 80% |
50.94%
29.1 pts better
|
Numerator 36 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.09% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 2.17% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 6.38% |
8.2%
1.8 pts worse
|
Numerator 12 · Denominator 188 |
| Staff flu vaccination coverage | 73.91% |
42%
31.9 pts better
|
Numerator 170 · Denominator 230 |
| Discharge function score | 71.11% |
56.45%
14.7 pts better
|
Numerator 32 · Denominator 45 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 5 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.3
0.8 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
91.2%
7 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 95.3% · Q3 99.2% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.0%
0.8 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.1% · Q3 4.0% · Q4 4.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
18.5%
18.1 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
6.1%
1.8 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.8% · Q3 2.4% · Q4 3.9% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
13.5%
0.7 pts worse
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 13.5% · Q3 14.6% · Q4 15.5% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
14.8%
2.8 pts better
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 11.3% · Q3 12.7% · Q4 14.8% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.5% |
15.1%
2.6 pts better
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 7.1% · Q3 11.5% · Q4 13.8% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.5%
2.7 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 11.7% · Q3 10.3% · Q4 15.3% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.4%
1.2 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.2% |
20.8%
12.6 pts better
|
19.8%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 4.5% · Q3 8.7% · Q4 10.7% · 4Q avg 8.2% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.9%
1.9 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.5% · Q3 5.0% · Q4 7.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.1% |
76.7%
4.4 pts better
|
81.7%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.7% · Q2 81.2% · Q3 82.9% · Q4 90.4% · 4Q avg 81.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 1.9% |
9.7%
7.8 pts better
|
12.0%
10.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 1.9% · Observed 1.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.1% |
78.8%
5.3 pts better
|
79.7%
4.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 2.0% |
20.6%
18.6 pts better
|
23.9%
21.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.0% · Observed 1.9% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-23 · Fire 2022-11-23
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2020-01-10 · Fire 2020-01-10
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-10-15
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-12-13
E · Potential for more than minimal harm
2022-11-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-11-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-11-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-11-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-11-23
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2023-01-20
C · Minimal harm
2022-11-23
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-01-20
C · Minimal harm
2022-11-23
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-01-20
C · Minimal harm
2022-11-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-01-20
E · Potential for more than minimal harm
2020-01-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-02-25
E · Potential for more than minimal harm
2020-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-25
C · Minimal harm
2020-01-10
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2020-02-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-13
C · Minimal harm
2024-10-15
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-12-13
B · Minimal harm
2024-10-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-13
D · Potential for more than minimal harm
2023-07-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-07-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-22
G · Actual harm
2022-11-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-11-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-11-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-20
D · Potential for more than minimal harm
2020-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-02-25
D · Potential for more than minimal harm
2020-01-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2020-02-25
D · Potential for more than minimal harm
2020-01-10
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2020-02-25
Penalties and ownership
What sits behind the stars
Ownership
Ascension Health Senior Care
5% Or Greater Direct Ownership Interest · Organization
Bothwell, Denise
Operational/Managerial Control · Individual
Musgrave, Lisa
Corporate Officer · Individual
Sauvageau, Philip
Operational/Managerial Control · Individual
Shadbolt, Erin
Corporate Director · Individual
Smoot, Kenneth
Corporate Director · Individual
Nearby options
Other facilities in reach
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Niagara Falls, NY
1-star overall rating with 2-star inspections with 7 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Schoellkopf Health Center
Niagara Falls, NY
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Elderwood At Wheatfield
Niagara Falls, NY
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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