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 12 of 12 citations

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

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 12, 2022).

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

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

    Widespread (many residents). CMS level F.

    Fire safety citation K-0374, Smoke Deficiencies. Inspection of March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 12, 2022).

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

    PASARR screening for Mental disorders or Intellectual Disabilities

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

    Health citation F-0645, Resident Assessment and Care Planning Deficiencies. Inspection of March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2022).

  4. 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.

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

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 20, 2022).

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

    Install a two-hour-resistant firewall separation.

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

    Fire safety citation K-0133, Construction Deficiencies. Inspection of March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 12, 2022).

  6. 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 March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 12, 2022).

  7. 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 March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 25, 2022).

  8. 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 March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 25, 2022).

  9. 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 March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 25, 2022).

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

    Have a battery powered remote alarm panel in a location accessible by operating personnel.

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

    Fire safety citation K-0916, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 12, 2022).

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

    Have proper medical gas storage and administration areas.

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

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 25, 2022).

  12. No harm, with potential for minimal harm

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

    Widespread (many residents). CMS level C.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 9, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 25, 2022).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.