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Deficiency Records for St Mary's D'youville Pavilion
View the most recent health deficiencies and inspection results for St Mary's D'youville Pavilion. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for St Mary's D'youville Pavilion. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-15 | 2026-05-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-04-15 | 2026-05-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-11-21 | 2025-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-28 | 2025-05-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-28 | 2025-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-03-28 | 2025-05-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-03-28 | 2025-05-01 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2025-03-28 | 2025-05-01 | N |
| 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. | Health | 2025-03-28 | 2025-05-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-03-28 | 2025-05-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-03-28 | 2025-05-01 | N |
| 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. | Health | 2025-03-28 | 2025-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-03-28 | 2025-05-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2025-03-28 | 2025-04-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-03-28 | 2025-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-01-02 | 2025-01-27 | Y |
| 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. | Health | 2024-01-26 | 2024-04-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-26 | 2024-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-04-08 | N |
| 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. | Health | 2024-01-26 | 2024-03-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-01-26 | 2024-03-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-26 | 2024-03-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-26 | 2024-03-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-26 | 2024-03-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-26 | 2024-03-21 | N |
| 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. | Health | 2024-01-26 | 2024-03-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | 2024-03-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-26 | 2024-03-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-26 | 2024-03-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-12 | 2023-08-18 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-09 | 2022-05-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-09 | 2022-05-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-09 | 2022-05-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-09 | 2022-05-12 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-03-09 | 2022-05-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-09 | 2022-04-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-09 | 2022-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-09 | 2022-04-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-09 | 2022-04-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-09 | 2022-04-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-09 | 2022-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-09 | 2022-04-20 | N |