Federal inspection record · CMS data as of October 1, 2026
Our Lady Of Peace Nursing Care Residence
5285 Lewiston Road, Lewiston, NY · (716) 298-2900
- Certified beds
- 250
- Residents per day
- 171
- Ownership
- Non-Profit
- Chain
- Ascension Living
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 12, 2003
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in New York.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change (already 5)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among New York homes
Our Lady Of Peace Nursing Care Residence carries 10 inspection points. That is fewer than 92% of New York's 589 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in New York: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–12 pts
- 4★ 12–27 pts
- 3★ 27–46 pts
- 2★ 46–82 pts
- 1★ over 82 pts
Bars show every rated home in New York by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
9 health citations on record since 2020. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Quality of Life and Care3D
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Freedom from Abuse, Neglect, and Exploitation2D
- B
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- D
Respond appropriately to all alleged violations.
Pharmacy Service2D
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
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.
Administration1C
- C
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.
Inspection history
2024-10-15
3 health deficiencies · 17 fire-safety deficiencies
Top issue: Administration (1 deficiency)
2022-11-23
3 health deficiencies · 8 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2020-01-10
3 health deficiencies · 3 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 27 min of nursing staff time a day, 24 min of it from a registered nurse.
This home
3 h 27 min
New York average
3 h 41 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 51% of nursing staff and 44% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.9 pts better | 0.8 | 1.7 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.5 pts better | 0.8 | 1.3 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine8.2 pts better | 100.0% | 91.8% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.8 pts better | 100.0% | 95.2% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.2 pts worse | 3.3% | 3.1% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms19.4 pts better | 0.7% | 20.1% | 13.5% |
| Percentage of long-stay residents who lose too much weight2.8 pts better | 2.9% | 5.7% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.1 pts better | 13.1% | 13.2% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.4 pts better | 13.3% | 13.7% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.2 pts better | 0.0% | 0.2% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.9 pts worse | 12.0% | 11.1% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased1.6 pts better | 12.1% | 13.7% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.4 pts better | 0.1% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.9 pts better | 0.3% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.1 pts better | 9.5% | 18.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.7 pts better | 3.8% | 6.5% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine14.5 pts better | 92.1% | 77.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit4.5 pts better | 4.9% | 9.4% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.5 pts better | 0.6% | 1.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.4 pts better | 85.3% | 78.9% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission15.3 pts better | 5.3% | 20.6% | 23.4% |
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Who owns and runs it
16 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Ascension Health Senior Care | 5% Or Greater Direct Ownership Interest · Organization | 100% | 11 facilities |
| Ascension Health Senior Care | Adp Of The SNF · Organization | 0% | 11 facilities |
| Bothwell, Denise | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Bothwell, Denise | Adp Of The SNF · Individual | 0% | 1 facilities |
| Health Dimensions Consulting Inc | Adp Of The SNF · Organization | 0% | 20 facilities |
| Medical Solutions LLC | Adp Of The SNF · Organization | 0% | 16 facilities |
| Minimum Data Set Consultant LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Musgrave, Lisa | Corporate Officer · Individual | 0% | 11 facilities |
| Musgrave, Lisa | Adp Of The SNF · Individual | 0% | 11 facilities |
| Sauvageau, Philip | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Sauvageau, Philip | Adp Of The SNF · Individual | 0% | 2 facilities |
| Shadbolt, Erin | Corporate Director · Individual | 0% | 11 facilities |
| Shadbolt, Erin | Adp Of The SNF · Individual | 0% | 11 facilities |
| Shiftmed, LLC | Adp Of The SNF · Organization | 0% | 3 facilities |
| Smoot, Kenneth | Corporate Director · Individual | 0% | 10 facilities |
| Smoot, Kenneth | Adp Of The SNF · Individual | 0% | 10 facilities |
·
Fire safety
28 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke11E
- E
Have an enclosure around a vertical opening shaft.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Inspect, test, and maintain automatic sprinkler systems.
Egress4E
- E
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.
- E
Install emergency lighting that can last at least 1 1/2 hours.
- D
Meet other general requirements.
- E
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Miscellaneous4E
- E
Have simulated fire drills held at unexpected times.
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E
Have restrictions on the use of portable space heaters.
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Emergency Preparedness4C
- C
Develop a communication plan.
- C
Provide primary/alternate means for communication.
- C
Implement emergency and standby power systems.
- C
Provide family notifications of emergency plan.
Gas, Vacuum, and Electrical Systems3E
- E
Meet requirements for the installation and maintenance of electrical systems.
- E
Have proper medical gas storage and administration areas.
- E
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Services1E
- E
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Electrical1E
- E
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
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