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 28 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
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
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
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
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).
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.