Our Lady of Peace Nursing Care Residence — nursing home in Lewiston, NY

Facility type: Nursing home · SNF / NF
CMS provider type: Medicare and Medicaid
Certified beds: 250 CMS-certified beds (not state-licensed beds)
Licensed beds: 250 state-licensed beds · New York State Department of Health
State license: 3121303N active · licensee Our Lady of Peace,Inc
Average residents per day: 171.4 CMS, MDS-derived
CMS Certification Number: 335843
Certification status: Active CMS certification Verified
First approved (Medicare/Medicaid): Jun 12, 2003
Ownership type: Non profit - Corporation
Operator (legal business name): Our Lady of Peace Inc
CMS chain: Ascension Living 12 facilities
Phone: (716) 298-2900
Resident & family council: Resident
Sprinklers in all required areas: Yes
Official profile: Medicare Care Compare ↗

Inspection record · CMS window

Verified

Inspections

6

latest Oct 15, 2024

Citations

37

9 health · 28 fire

Harm or worse

1

no immediate jeopardy

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J·	K·	L·
Actual harm	G1	H·	I·
Potential harm	D7	E23	F·
Minimal	A·	B1	C5

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

CMS Five-Star ratings

Federal · CMS

Overall

Health inspections

Staffing

Quality measures

Penalties · about the last 3 years

Fines

0

$0

Payment denials

0

Latest

—

Federal certification

Federal · CMS

Authority: Centers for Medicare & Medicaid Services (CMS), surveyed by the state survey agency
CCN: 335843
Program: Medicare and Medicaid
Medicare (SNF): Certified
Medicaid (NF): Certified
Certified beds: 250
First approved: Jun 12, 2003
Located in a hospital: No
Status: Active CMS certification as of CMS release Nov 1, 2026
Evidence: Verified

State license

Authority: New York State Department of Health (NYSDOH)
License number: 3121303N
State facility ID: 6528
License type: Residential Health Care Facility - SNF
License status: active
Licensed beds: 250
Bed certifications: RHCF: 250
Link to CMS record: Linked by exact street address + ZIP Inferred
Licensee: Our Lady of Peace,Inc · Not for Profit Corporation
Initially licensed: Jun 11, 2003
As of: Oct 23, 2026
Evidence: Inferred source ↗

Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

Date	Domain	Survey types	Citations	Most severe	Open
Oct 15, 2024	Fire safety	Fire Safety Standard	17	Potential harm	—	Open →
Oct 15, 2024	Health	Health Standard	3	Potential harm	—	Open →
Nov 23, 2022	Fire safety	Fire Safety Standard	8	Potential harm	—	Open →
Nov 23, 2022	Health	Health Standard	3	Actual harm	—	Open →
Jan 10, 2020	Fire safety	Fire Safety Standard	3	Potential harm	—	Open →
Jan 10, 2020	Health	Health Standard	3	Potential harm	—	Open →

Enforcement

Penalties

Civil money penalties and denials of payment for new admissions, as published by CMS (about the last three years). Amounts may change on appeal.

No fines or payment denials in the CMS Penalties file for this CCN.

Scope × severity

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J·	K·	L·
Actual harm	G1	H·	I·
Potential harm	D7	E23	F·
Minimal	A·	B1	C5

By concept

Date	Tag	Deficiency	Scope / severity	Correction
Oct 15, 2024	K-0200	Meet other general requirements. Egress Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Dec 13, 2024
Oct 15, 2024	K-0222	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. Egress Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0291	Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0311	Have an enclosure around a vertical opening shaft. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0345	Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0355	Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0712	Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0781	Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0901	Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. Electrical Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0911	Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	K-0923	Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Dec 13, 2024
Oct 15, 2024	F-0677	Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Dec 13, 2024
Oct 15, 2024	F-0607	Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	B · Minimal Pattern	Corrected Dec 13, 2024
Oct 15, 2024	F-0836	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. Administration Deficiencies · Administration & records	C · Minimal Widespread	Corrected Dec 13, 2024
Nov 23, 2022	F-0600	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	G · Actual harm Isolated	Corrected Jan 20, 2023
Nov 23, 2022	K-0225	Have stairways and smokeproof enclosures used as exits that meet safety requirements. Egress Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jan 20, 2023
Nov 23, 2022	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jan 20, 2023
Nov 23, 2022	K-0363	Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jan 20, 2023
Nov 23, 2022	K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jan 20, 2023
Nov 23, 2022	K-0908	Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jan 20, 2023
Nov 23, 2022	F-0610	Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jan 20, 2023
Nov 23, 2022	F-0689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jan 20, 2023
Nov 23, 2022	E-0029	Develop a communication plan. Emergency Preparedness Deficiencies · Emergency preparedness	C · Minimal Widespread	Corrected Jan 20, 2023
Nov 23, 2022	E-0032	Provide primary/alternate means for communication. Emergency Preparedness Deficiencies · Emergency preparedness	C · Minimal Widespread	Corrected Jan 20, 2023
Nov 23, 2022	E-0041	Implement emergency and standby power systems. Emergency Preparedness Deficiencies · Emergency preparedness	C · Minimal Widespread	Corrected Jan 20, 2023
Jan 10, 2020	K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Feb 25, 2020
Jan 10, 2020	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Feb 25, 2020
Jan 10, 2020	F-0689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Feb 25, 2020
Jan 10, 2020	F-0756	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Feb 25, 2020
Jan 10, 2020	F-0758	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. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Feb 25, 2020
Jan 10, 2020	E-0035	Provide family notifications of emergency plan. Emergency Preparedness Deficiencies · Emergency preparedness	C · Minimal Widespread	Corrected Feb 25, 2020

“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.

Five-Star ratings

Federal · CMS

Overallstate 3.1

Health inspectionsstate 2.7

Staffingstate 2.9

Quality measuresstate 3.9

Long-stay QM

Short-stay QM

CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.

Nurse staffing · hours per resident per day

Total nurse staffing3.44

State avg 3.69US avg 3.90

Registered nurse (RN)0.40

State avg 0.73US avg 0.69

Licensed practical nurse1.11

State avg 0.76US avg 0.86

Nurse aide1.93

State avg 2.20US avg 2.35

Weekend total nurse3.10

State avg 3.20US avg 3.43

Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.04 (case-mix index 1.19).

Staff turnover

Total nursing staff turnover50.9%

State avg 40.3%US avg 45.3%

Registered nurse turnover44.4%

State avg 39.6%US avg 42.5%

Administrators who left0

State avg 1US avg 1

Health survey score

Cycle 1 standard survey: Oct 15, 2024
Cycle 1 health score: 4
Total weighted score: 10

Operating entity

Our Lady of Peace Inc

CMS legal business name of the certified provider. Operates this facility only.

VerifiedLinked by exact legal name

CMS chain

Ascension Living

12 facilities in 8 states. CMS chain ID 48.

VerifiedAssigned by CMS

Chain average overall rating (CMS): 2.9

Ownership disclosures

Disclosures

16

Organizations

5

Individuals

10

Direct & indirect ownership

Owners of record

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Ascension Health Senior Care	Organization	Direct owner	5% OR GREATER DIRECT OWNERSHIP INTEREST	100%	Jul 1, 2015

CMS Ownership file

All disclosed roles

Operator, owners, managers, officers and lenders are distinct roles and are never flattened into one entity. Organizations link across facilities by exact normalized legal name; individuals are listed per facility only.

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Ascension Health Senior Care	Organization	Direct owner	5% OR GREATER DIRECT OWNERSHIP INTEREST	100%	Jul 1, 2015
Denise Bothwell	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Sep 5, 2023
Philip Sauvageau	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Apr 1, 2012
Erin Shadbolt	Individual	Corporate officer / director	CORPORATE DIRECTOR	not provided	Jan 1, 2024
Kenneth Smoot	Individual	Corporate officer / director	CORPORATE DIRECTOR	not provided	Jan 1, 2024
Lisa Musgrave	Individual	Corporate officer / director	CORPORATE OFFICER	not provided	Jan 1, 2024
Ascension Health Senior Care	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Jul 1, 2015
Health Dimensions Consulting Inc	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Mar 13, 2024
Medical Solutions LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Jun 14, 2017
Minimum Data Set Consultant LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Jun 7, 2021
Shiftmed, LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Jun 7, 2021
Denise Bothwell	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Sep 5, 2023
Lisa Musgrave	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jan 1, 2024
Philip Sauvageau	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Apr 1, 2012
Erin Shadbolt	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jan 1, 2024
Kenneth Smoot	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jan 1, 2024

No building or property record is linked to this facility yet. Parcel, assessor and building-permit joins will be added only where a valid site match exists.

Coordinates as published by CMS.

Address: 5285 Lewiston Road, Lewiston, NY 14092
ZIP: 14092
County: Niagara County FIPS 36063
State: New York
Urban / rural (CMS): Urban

Within ~25 km

Nearby nursing homes

Facility	Distance	Beds	Last inspection	Citations (window)	Fines
Niagara Rehabilitation and Nursing Center 822 Cedar Avenue, Niagara Falls, NY 14301 CCN 335742	6.6 km	160	Apr 8, 2026	491 open	—
Schoellkopf Health Center 621 Tenth Street, Niagara Falls, NY 14302 CCN 335376	6.9 km	120	Aug 22, 2025	31	—
Elderwood at Wheatfield 2600 Niagara Falls Boulevard, Niagara Falls, NY 14304 CCN 335790	12.8 km	123	Aug 14, 2024	33	—
Elderwood at Grand Island 2850 Grand Island Blvd, Grand Island, NY 14072 CCN 335391	13.7 km	90	Dec 2, 2025	28	—
North Gate Health Care Facility 7264 Nash Road, North Tonawanda, NY 14120 CCN 335649	16.8 km	200	May 13, 2026	28	—
Degraff Memorial Hospital-Skilled Nursing Facility 445 Tremont Street, North Tonawanda, NY 14120 CCN 335669	20.2 km	80	Jun 2, 2026	20	—

Source	Record	Facts	Evidence	Source release	Retrieved
CMS Provider Information US-CMS	335843	name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain	Verified	Oct 1, 2026	Nov 7, 2026
CMS Provider Information US-CMS	335843	ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only.	Verified	Oct 1, 2026	Nov 7, 2026
New York DOH Health Facility Information NY	6528	state_license, licensed_beds, licensee Linked to the CMS record by exact normalized street address and ZIP (the state roster does not publish the CCN).	Inferred	Oct 23, 2026	Nov 7, 2026
New York DOH Bed Certifications NY	6528	capacity, bed_certifications	Verified	Nov 1, 2026	Nov 7, 2026

Record-level source links for CCN 335843

First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction