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OUR LADY OF PEACE NURSING CARE RESIDENCE Inspection Report, Violations & Safety Grade (LEWISTON, New York)

5285 LEWISTON ROAD, LEWISTON, New York 14092

Phone: 7162982900

CMS Overall:5/5

Overview & Bed Count

Certified Beds
250
Avg Residents/Day
171.4
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Niagara
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall5/5
Health5/5
Staffing3/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityNew York AvgDifference
RN Hours per Resident per Day0.400.73-0.33
Total Nurse Hours per Resident per Day3.443.69-0.24
CMS Staffing Rating3/52.9/5-
Nursing Staff Turnover50.9%40.3%-

Health Citation History

9 health citations on record

DateCategoryDescriptionSeverity
2024-10-15Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2024-10-15Administration DeficienciesEnsure 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.C – Minimal Harm Potential
2024-10-15Freedom from Abuse, Neglect, and Exploitation DeficienciesDevelop and implement policies and procedures to prevent abuse, neglect, and theft.B – Minimal Harm Potential
2022-11-23Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.G – Actual Harm
2022-11-23Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2022-11-23Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2020-01-10Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2020-01-10Pharmacy Service DeficienciesEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.D – Moderate Harm Potential
2020-01-10Pharmacy Service DeficienciesImplement 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.D – Moderate Harm Potential

Fire Safety Citation History

28 fire safety citations on record

DateCategoryDescriptionSeverity
2024-10-15Egress DeficienciesAdd 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 – Moderate Harm Potential
2024-10-15Egress DeficienciesInstall emergency lighting that can last at least 1 1/2 hours.E – Moderate Harm Potential
2024-10-15Smoke DeficienciesHave an enclosure around a vertical opening shaft.E – Moderate Harm Potential
2024-10-15Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2024-10-15Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.E – Moderate Harm Potential
2024-10-15Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2024-10-15Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.E – Moderate Harm Potential
2024-10-15Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2024-10-15Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2024-10-15Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.E – Moderate Harm Potential
2024-10-15Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.E – Moderate Harm Potential
2024-10-15Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.E – Moderate Harm Potential
2024-10-15Miscellaneous DeficienciesHave restrictions on the use of portable space heaters.E – Moderate Harm Potential
2024-10-15Electrical DeficienciesEnsure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.E – Moderate Harm Potential
2024-10-15Gas, Vacuum, and Electrical Systems DeficienciesMeet requirements for the installation and maintenance of electrical systems.E – Moderate Harm Potential
2024-10-15Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.E – Moderate Harm Potential
2024-10-15Egress DeficienciesMeet other general requirements.D – Moderate Harm Potential
2022-11-23Egress DeficienciesHave stairways and smokeproof enclosures used as exits that meet safety requirements.E – Moderate Harm Potential
2022-11-23Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2022-11-23Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2022-11-23Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.E – Moderate Harm Potential
2022-11-23Gas, Vacuum, and Electrical Systems DeficienciesEnsure gas and vacuum systems are inspected and tested as part of a maintenance program.E – Moderate Harm Potential
2022-11-23Emergency Preparedness DeficienciesDevelop a communication plan.C – Minimal Harm Potential
2022-11-23Emergency Preparedness DeficienciesProvide primary/alternate means for communication.C – Minimal Harm Potential
2022-11-23Emergency Preparedness DeficienciesImplement emergency and standby power systems.C – Minimal Harm Potential
2020-01-10Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2020-01-10Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2020-01-10Emergency Preparedness DeficienciesProvide family notifications of emergency plan.C – Minimal Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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