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.

Back to St Mary's D'Youville Pavilion

Last standard health inspection on record

March 28, 2025

Showing 1 to 13 of 13 citations

  1. No harm, with potential for more than minimal harm

    Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0342, Smoke Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  2. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  3. No harm, with potential for more than minimal harm

    Install properly constructed and protected linen or trash chutes.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0541, Services Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  4. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  5. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Isolated (one or a few residents). CMS level D.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  6. No harm, with potential for more than minimal harm

    Have exits that are accessible at all times.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0271, Egress Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  7. No harm, with potential for more than minimal harm

    Have an enclosure around a vertical opening shaft.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0311, Smoke Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  8. 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.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  9. No harm, with potential for more than minimal harm

    Install an approved automatic sprinkler system.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0351, Smoke Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  10. No harm, with potential for more than minimal harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  11. No harm, with potential for more than minimal harm

    Have properly installed electrical wiring and gas equipment.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0511, Services Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  12. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 4, 2024).

  13. No harm, with potential for more than minimal harm

    Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0902, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of January 26, 2024. Found during a standard inspection.

    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.