All citations for St Mary's D'Youville Pavilion
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
March 28, 2025
Showing 1 to 24 of 24 citations
Immediate jeopardy to resident health or safety
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (May 25, 2026).
No harm, with potential for more than minimal harm
Install emergency lighting that can last at least 1 1/2 hours.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Provide care or services that was trauma informed and/or culturally competent.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Have properly located and lighted "Exit" signs.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Respond appropriately to all alleged violations.
The home has a plan to correct it (August 9, 2026).
No harm, with potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
The home gave a date the problem would be corrected (May 25, 2026).
No harm, with potential for more than minimal harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Past non-compliance: already corrected by the time of the inspection (September 24, 2025).
No harm, with potential for more than minimal harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
The home gave a date the problem would be corrected (March 26, 2025).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (April 3, 2025).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Install an approved automatic sprinkler system.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
The home gave a date the problem would be corrected (May 1, 2025).
No harm, with potential for more than minimal harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
The home gave a date the problem would be corrected (May 1, 2025).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.