Inspection Reports for
Our Lady of Peace Nursing Care Residence
5285 Lewiston Road, Lewiston, NY, 14092
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 3
Date: Oct 15, 2024
Visit Reason
The inspection was a standard routine survey conducted to assess compliance with federal, state, and local regulations for the nursing care facility.
Findings
The facility was found deficient in implementing proper employee screening policies to prevent abuse and neglect, providing adequate care for residents unable to perform activities of daily living, and maintaining required carbon monoxide detection and testing per fire code regulations.
Deficiencies (3)
F 0607: The facility did not implement written policies and procedures for screening employees to prevent abuse, neglect, and exploitation. Two employees were not verified through the New York State Nurse Aide Registry prior to employment.
F 0677: The facility did not ensure residents unable to perform activities of daily living received necessary grooming and hygiene care. Resident #66 was not assisted with removing unwanted facial hair, and Resident #100 did not receive timely and complete incontinent care with proper glove changes and hand hygiene.
F 0836: The facility did not comply with the 2020 Fire Code of New York State requiring carbon monoxide detection in all rooms with fuel-burning appliances and ongoing maintenance. Alarms were installed but testing documentation was incomplete and user guide information was insufficient.
Report Facts
Employees reviewed: 13
Residents reviewed for ADL care: 4
Resident affected by grooming deficiency: 2
Resident floors affected by CO detection deficiency: 3
Resident floors plus basement affected by CO detection deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #5 | Agency Licensed Practical Nurse | Named in finding for lack of Nurse Aide Registry verification prior to employment |
| Employee #7 | Nutritional Services Aide | Named in finding for lack of Nurse Aide Registry verification prior to employment |
| Certified Nurse Aide #6 | Observed providing care and interviewed regarding grooming deficiency for Resident #66 | |
| Certified Nurse Aide #1 | Observed and interviewed regarding incontinent care deficiencies for Resident #100 | |
| Certified Nurse Aide #2 | Interviewed regarding incontinent care deficiencies for Resident #100 | |
| Registered Nurse #2 | Unit Manager | Interviewed regarding expectations for grooming care |
| Director of Nursing | Interviewed regarding grooming and incontinent care expectations and staff education | |
| Assistant Director of Nursing | Interviewed regarding incontinent care practices and staff expectations | |
| Licensed Practical Nurse #3 | Interviewed regarding documentation of toileting and care protocols | |
| Maintenance Supervisor | Interviewed regarding carbon monoxide alarm testing and maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 25, 2023
Visit Reason
The inspection was conducted as an abbreviated complaint investigation related to allegations of abuse, neglect, and failure to implement a comprehensive care plan for Resident #1.
Complaint Details
Complaint investigation (Complaint #NY00318540) focused on abuse, neglect, and failure to follow care plans for Resident #1. The complaint was substantiated with findings of incomplete investigation and care plan noncompliance.
Findings
The facility failed to thoroughly investigate an injury of unknown origin for Resident #1, including not reviewing video surveillance timely and not interviewing all relevant staff. Additionally, the facility did not implement Resident #1's comprehensive care plan in the areas of transfers, eating, and incontinent care as required.
Deficiencies (2)
F 0610: The facility did not ensure all alleged violations of abuse, neglect, or mistreatment including injuries of unknown origin were thoroughly investigated for Resident #1. Video surveillance from 6/18/23 to 6/19/23 was not reviewed prior to investigation completion, and not all staff working the east unit were interviewed.
F 0656: The facility failed to implement a comprehensive person-centered care plan for Resident #1, specifically in transfers and eating on 6/18/23 and incontinent care on 6/19/23, contrary to the resident's documented needs and care plan interventions.
Report Facts
Date of injury: Jun 18, 2023
Date of hospital evaluation: Jun 19, 2023
Number of staff interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Named in investigation for Resident #1 transfer and video surveillance observation |
| Director of Nursing | DON | Conducted investigation and provided interviews regarding Resident #1 |
| Director of Quality | DOQ | Conducted interviews and investigation follow-up for Resident #1 |
| Licensed Practical Nurse #1 | LPN | Documented Resident #1 condition on 6/19/23 |
| Registered Nurse #1 | RN | Documented Resident #1 condition and involved in investigation |
| Certified Nurse Aide #6 | CNA | Provided care to Resident #1 on 6/18/23 and interviewed |
| Certified Nurse Aide #8 | CNA | Provided incontinent care and repositioning to Resident #1 on 6/18-19/23 |
| Licensed Practical Nurse #4 | LPN | Provided care and interviews related to Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 23, 2022
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #NY00280511) regarding allegations of abuse and neglect at the facility.
Complaint Details
Complaint #NY00280511 involved allegations that Unit Attendant #1 entered Resident #27's room multiple times despite being restricted, spoke about harming themselves and others, causing the resident fear and anxiety. The complaint investigation found actual psychosocial harm and inadequate investigation of all abuse allegations.
Findings
The facility failed to protect residents from mental abuse and neglect by a restricted employee, did not thoroughly investigate all alleged violations of abuse, and failed to ensure adequate supervision and use of safety devices during resident transfers.
Deficiencies (3)
F 600: The facility failed to protect Resident #27 from mental abuse and neglect by Unit Attendant #1 who was restricted from interacting with the resident but entered their room multiple times and caused psychosocial harm.
F 610: The facility did not thoroughly investigate all alleged violations of abuse for Resident #27, lacking interviews with other residents potentially victimized.
F 689: The facility failed to ensure Resident #104 was transferred and ambulated with a gait belt as required for safety, posing an accident hazard.
Report Facts
Number of times UA #1 entered Resident #27's room: 8
Dates of video recorded entries: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Attendant #1 | Unit Attendant | Restricted from Resident #27 but entered their room multiple times causing mental abuse. |
| Director of Nursing | Director of Nursing | Provided information about UA #1's restriction and acknowledged psychological harm to Resident #27. |
| Licensed Practical Nurse #1 | Unit Manager | Reported Resident #27's fear of UA #1 and awareness of UA #1's restriction. |
| Social Worker | Social Worker | Responsible for interviewing residents during abuse investigation. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed transferring Resident #104 without gait belt, violating safety policy. |
| Licensed Practical Nurse Unit Manager #2 | Licensed Practical Nurse Unit Manager | Stated gait belts are required for resident safety during transfers. |
| Therapy Department Director | Therapy Department Director | Confirmed gait belt use policy for residents requiring assistance. |
Inspection Report
Routine
Deficiencies: 3
Date: Jan 10, 2020
Visit Reason
The inspection was a standard survey conducted to assess compliance with regulatory requirements related to resident care, medication management, and safety.
Findings
The facility was found deficient in ensuring adequate supervision to prevent accidents for a resident with aspiration precautions and in ensuring pharmacist identification and reporting of irregularities in drug regimen reviews. Additionally, deficiencies were found in the use of unnecessary psychotropic medications without adequate non-pharmacological interventions or documented indications.
Deficiencies (3)
F 0689: The facility failed to ensure adequate supervision and assistive devices to prevent accidents for a resident with aspiration precautions, who was observed coughing multiple times during a meal without staff intervention.
F 0756: The facility failed to ensure the pharmacist identified and reported irregularities in drug regimen reviews, specifically the lack of identification of duplicate antipsychotic therapy for a resident.
F 0758: The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications, lacking documented diagnoses to support duplicative antipsychotic therapy and lacking non-pharmacological interventions prior to medication use.
Report Facts
Residents reviewed for accidents: 9
Residents reviewed for drug regimen reviews: 7
Duplicate antipsychotic therapy duration: 2
Medication Administration Record review period: 105
Seroquel dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Mentioned in relation to supervision deficiency and medication irregularities. |
| Consultant Pharmacist | Consultant Pharmacist | Mentioned in relation to drug regimen review and psychotropic medication use. |
| Medical Director | Medical Director | Mentioned regarding medication orders and clinical rationale. |
| Speech Language Pathologist | Speech Language Pathologist | Provided expert opinion on aspiration precautions and supervision. |
| Registered Nurse RN #1 | Unit Manager | Provided information on supervision during meals. |
| Licensed Practical Nurse LPN #1 | Licensed Practical Nurse | Provided information on resident behaviors related to skin picking. |
| Certified Nurse Aide CNA #3 | Certified Nurse Aide | Provided information on resident behaviors and non-pharmacological interventions. |
| Registered Nurse RN #2 | Registered Nurse | Provided information on resident behaviors and medication effects. |
| Licensed Practical Nurse LPN #2 | Licensed Practical Nurse | Provided information on resident behaviors and anxiety indicators. |
| Social Worker | Social Worker | Provided information on resident distress and non-pharmacological interventions. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Inspection Report
Visit Reason
Inspection history and enforcement summary for Our Lady of Peace Nursing Care Residence
Findings
No citations or deficiencies reported from inspections between 2021 and 2025; enforcement actions include stipulations and fines related to Quality of Care from prior years.
Deficiencies (1)
Quality of Care — enforcement stipulations with fines
Report Facts
Total inspections: 0
Viewing
Loading inspection reports...
