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 25 of 26 citations
No harm, with potential for more than minimal harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
The home gave a date the problem would be corrected (March 4, 2024).
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 (March 4, 2024).
No harm, with potential for more than minimal harm
Install properly constructed and protected linen or trash chutes.
The home gave a date the problem would be corrected (March 4, 2024).
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 (March 4, 2024).
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 (April 8, 2024).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
The home gave a date the problem would be corrected (March 21, 2024).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
The home gave a date the problem would be corrected (March 21, 2024).
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 (March 21, 2024).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (April 8, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (March 21, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (January 27, 2025).
No harm, with potential for more than minimal harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
The home gave a date the problem would be corrected (March 21, 2024).
No harm, with potential for more than minimal harm
Assess the resident when there is a significant change in condition
The home gave a date the problem would be corrected (March 21, 2024).
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 (March 21, 2024).
No harm, with potential for more than minimal harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
The home gave a date the problem would be corrected (March 21, 2024).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (March 21, 2024).
No harm, with potential for more than minimal harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
The home gave a date the problem would be corrected (April 8, 2024).
No harm, with potential for more than minimal harm
Develop and maintain an Emergency Preparedness Program (EP).
The home gave a date the problem would be corrected (March 4, 2024).
No harm, with potential for more than minimal harm
Have exits that are accessible at all times.
The home gave a date the problem would be corrected (March 4, 2024).
No harm, with potential for more than minimal harm
Have an enclosure around a vertical opening shaft.
The home gave a date the problem would be corrected (March 4, 2024).
No harm, with potential for more than minimal harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
The home gave a date the problem would be corrected (March 4, 2024).
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 (March 4, 2024).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
The home gave a date the problem would be corrected (March 4, 2024).
No harm, with potential for more than minimal harm
Have properly installed electrical wiring and gas equipment.
The home gave a date the problem would be corrected (March 4, 2024).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
The home gave a date the problem would be corrected (March 4, 2024).
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.