Facility profile · CCN 205053
St Mary's D'youville Pavilion
26 federal citations on record .
Record summary
Federal record · Q1 202626
Total citations
24
Last 3 years
0
Actual harm+
0
Federal penalties
$0
Total fines
3
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
26 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Nov 21, 2025 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Complaint |
| Mar 28, 2025 | F868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | D | Standard |
| Mar 28, 2025 | F761 | 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. | D | Standard |
| Mar 28, 2025 | F699 | Provide care or services that was trauma informed and/or culturally competent. | E | Standard |
| Mar 28, 2025 | F698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E | Standard |
| Mar 28, 2025 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Standard |
| Mar 28, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Mar 28, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Mar 28, 2025 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Mar 28, 2025 | F584 | 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. | E | Standard |
| Jan 2, 2025 | F880 | Provide and implement an infection prevention and control program. | D | Complaint |
| Jan 26, 2024 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Jan 26, 2024 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | D | Standard |
| Jan 26, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Jan 26, 2024 | F758 | 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. | D | Standard |
| Jan 26, 2024 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Jan 26, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard |
| Jan 26, 2024 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Standard |
| Jan 26, 2024 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E | Standard |
| Jan 26, 2024 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Jan 26, 2024 | F637 | Assess the resident when there is a significant change in condition | D | Standard |
| Jan 26, 2024 | F584 | 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. | E | Standard |
| Jan 26, 2024 | F578 | 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. | D | Standard |
| Jul 12, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Mar 9, 2022 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Standard |
| Mar 9, 2022 | F645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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