Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- New YorkAbove 77% of peers593 rated homes · average 3.0★
- Niagara CountyTop 1%10 rated homes · average 3.1★
- United StatesAbove 80% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point4★+1.2 vs NY avg
- StaffingCan add or remove a star4★+1.3 vs NY avg
- Quality measuresCan add or remove a star5★+1.1 vs NY avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles4★Above 68% of peersNY avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 75% of peersNY avg2.7★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 61% of peersNY avg3.9★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.57hrsAbove 54% of peersNY avg3.65Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.45hrsAbove only 28% of peersNY avg0.70Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better38%Above 55% of peersNY avg41%RN turnover12%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 30% of peersNY avg$22,640Fines · denials0 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthJan 2020 – Oct 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Oct 15, 2024Cycle 1worst D · no actual harm
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationB · patternCorrected Dec 13, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 13, 2024
- F836Ensure 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.AdministrationC · widespreadCorrected Dec 13, 2024
Jul 25, 2023Cycle 3worst D · no actual harm
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 22, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Sep 22, 2023
Nov 23, 2022Cycle 2worst G · actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 20, 2023
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Jan 20, 2023
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 20, 2023
Jan 10, 2020Cycle 3worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Feb 25, 2020
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Feb 25, 2020
- F758Implement 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 ServiceD · isolatedCorrected Feb 25, 2020
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.57hrs
- Registered nursesRN hours only0.45hrs
- Licensed practical nursesLPN hours1.00hrs
- Nurse aidesCNA hours2.12hrs
- Weekend nursingAll staff on Saturdays and Sundays3.31hrs
- New York average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better38%Above 55% of peersNY avg 41%
- RN turnoverRegistered nurses only12%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy250 certified beds · ~149 residents a day59%Above only 3% of peersNY avg 90%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $22,640NY avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Ascension Living20 facilities in the chain2.6★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Ascension Health Senior Care
- Denise Bothwell
- Philip Sauvageau
- Erin Shadbolt
- Kenneth Smoot
- Lisa Musgrave
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 335843 · 5285 LEWISTON ROAD, LEWISTON, NY, 14092.
- Percentiles compare this facility with every rated nursing home in New York and Niagara County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
