01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-10-15 | 3 | 2024-10-15 | 17 |
| Cycle 2 | 2022-11-23 | 3 | 2022-11-23 | 8 |
| Cycle 3 | 2020-01-10 | 3 | 2020-01-10 | 3 |
CMS CCN 3358432026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Our Lady Of Peace Nursing Care Residence
5285 Lewiston Road · Lewiston, NY 14092 · Niagara County
Certified beds250CMS provider file
Recent citation rows37current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-10-15 · HEALTHF0607Severity B · pattern; potential for minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · HEALTHF0836Severity C · widespread; potential for minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0200Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0222Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0291Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0311Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0521Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0712Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0761Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0781Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0901Severity E · pattern; potential for more than minimal harm
Electrical Deficiencies
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0911Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Correction field: Deficient, Provider has date of correction · 2024-12-132024-10-15 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2024-12-132022-11-23 · FIREE0029Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Develop a communication plan.
Correction field: Deficient, Provider has date of correction · 2023-01-202022-11-23 · FIREE0032Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Provide primary/alternate means for communication.
Correction field: Deficient, Provider has date of correction · 2023-01-202022-11-23 · FIREE0041Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2023-01-202022-11-23 · HEALTHF0600Severity G · isolated actual harm
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.
Correction field: Deficient, Provider has date of correction · 2023-01-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- ASCENSION HEALTH SENIOR CAREOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 07/01/2015
- SHADBOLT, ERINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- SMOOT, KENNETHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- MUSGRAVE, LISAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
- BOTHWELL, DENISEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/05/2023
- SAUVAGEAU, PHILIPIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2012
- ASCENSION HEALTH SENIOR CAREOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/01/2015
- HEALTH DIMENSIONS CONSULTING INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/13/2024
- MEDICAL SOLUTIONS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/14/2017
- MINIMUM DATA SET CONSULTANT LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/07/2021
- SHIFTMED, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/07/2021
- BOTHWELL, DENISEIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/05/2023
- MUSGRAVE, LISAIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2024
- SAUVAGEAU, PHILIPIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/01/2012
- SHADBOLT, ERINIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2024
- SMOOT, KENNETHIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.39per resident day
RN hours0.44per resident day
Weekend nurse hours3.04per resident day
Staff turnover53.3%CMS reported field
06 / LOCAL RECORDS
Open the New York ledger →Other published facilities nearby
No second facility in the same city met the directory rule.