Nursing HomeMedicaid Medicare 5-star

Our Lady of Peace Nursing Care Residence

Strong Medicare quality ratings. Still worth an in-person visit before deciding.

5285 Lewiston Road, Lewiston, NY 14092|250 beds|Licensed & active

5/5

Medicare

Inspection

Quality

Staffing

(716) 298-2900 Directions

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Public Medicare Flags to Review

These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.

Staff turnover reported at 53%

No Medicare penalties on record · 3 findings in latest survey

Source: Medicare data

What this means for your family

Our Lady of Peace Nursing Care Residence has a strong overall Medicare rating. Review the component ratings and current source records before deciding.

Staffing

Staffing Hours

per resident/day · Medicare public data

RN Hours

0.44hrs

59%

Registered nurses for medical care

Total Nursing

3.39hrs

83%

All nurses + aides combined

Staff Turnover

53%

Lower is better (< 30% = good)

RN Turnover

50%

Lower is better (< 30% = good)

Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.

Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating

5/ 5

Better Than Avg

measures

Mixed Results

measures

Long-Stay Residents

Residents with depression symptoms

↓ Lower is better

This Facility0.7%

Better than Avg

Here

0.7%

12.8%

19.5%

Niagara

6.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

Residents whose bladder or bowel control got worse

↓ Lower is better

This Facility10.2%

Better than Avg

Here

10.2%

19.0%

19.5%

Niagara

21.8%

Residents vaccinated for pneumonia

↑ Higher is better

This Facility99.8%

Better than Avg

Here

99.8%

93.5%

91.5%

Niagara

96.5%

Residents vaccinated for the flu

↑ Higher is better

This Facility100.0%

Better than Avg

Here

100.0%

95.5%

95.3%

Niagara

93.4%

Residents on anti-anxiety or sleep medication

↓ Lower is better

This Facility14.1%

Mixed vs Avgs

Here

14.1%

19.5%

13.2%

Niagara

13.2%

Residents with pressure sores (bedsores)

↓ Lower is better

This Facility4.6%

Better than Avg

Here

4.6%

6.5%

Niagara

8.7%

Short-Stay Residents (Rehab / Post-Acute)

Short-stay residents vaccinated for pneumonia

↑ Higher is better

This Facility88.6%

Better than Avg

Here

88.6%

82.0%

77.4%

Niagara

79.5%

Short-stay residents vaccinated for the flu

↑ Higher is better

This Facility84.1%

Better than Avg

Here

84.1%

79.8%

78.8%

Niagara

81.2%

Short-stay residents newly given antipsychotics

↓ Lower is better

This Facility0.6%

Better than Avg

Here

0.6%

1.6%

1.2%

Niagara

2.3%

Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

Detailed Medicare record · up to 3-year lookback

37findings in history

Latest survey: 3 · well below NY avg (7.6)

The facility shows concerning patterns with abuse prevention cited three times across surveys, including complaints from families who reported concerns about resident protection and care planning. Fire safety and emergency preparedness deficiencies recur consistently, with sprinkler systems, fire doors, and emergency communications repeatedly flagged across multiple inspections from 2020 to 2024, suggesting ongoing compliance struggles despite reported corrections.

Oct 15, 2024Routine20 findings

0222Potential for harm · PatternCorrected

Egress Deficiencies

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.

0291Potential for harm · PatternCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0311Potential for harm · PatternCorrected

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0345Potential for harm · PatternCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0355Potential for harm · PatternCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0374Potential for harm · PatternCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0521Potential for harm · PatternCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

0712Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0761Potential for harm · PatternCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0781Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

0901Potential for harm · PatternCorrected

Electrical Deficiencies

Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

0911Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

0923Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0200Potential for harm · IsolatedCorrected

Egress Deficiencies

Meet other general requirements.

0836Minimal · WidespreadCorrected

Administration Deficiencies

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.

0607Minimal · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Nov 23, 2022Routine11 findings

0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0225Potential for harm · PatternCorrected

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0761Potential for harm · PatternCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0908Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0029Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop a communication plan.

0032Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Provide primary/alternate means for communication.

0041Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Jan 10, 2020Routine6 findings

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0035Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Provide family notifications of emergency plan.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Our Lady of Peace Nursing Care Residence

Organization Type

nonprofit

Chain Affiliation

Chain Name

Ascension Living

Chain Size

12 facilities nationwide

Chain avg rating: 2.6/5 · Rank 1 of 19 (Highest rating)

Ownership & Management

Owners

Ascension Health Senior Care

Owner · Organization

100%

Key personnel

Shadbolt, ErinOfficer / DirectorSmoot, KennethOfficer / DirectorMusgrave, LisaOfficer / DirectorBothwell, DeniseManagerSauvageau, PhilipManager

Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

(716) 298-2900

5285 Lewiston Road

Lewiston, NY 14092

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References & Resources

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Official Medicare quality ratings, inspections & staffing data

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Medicare data downloads

Original nursing home datasets

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