A list of the most recent deficiencies for St Mary's D'youville Pavilion. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-12 | 2023-08-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-19 | 2022-11-03 | 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 | 2022-06-01 | 2022-07-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-01 | 2022-07-16 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-03-08 | 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 | 2022-03-08 | 2022-05-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-08 | 2022-05-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-08 | 2022-05-12 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-03-08 | 2022-05-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-08 | 2022-04-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-08 | 2022-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-08 | 2022-04-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-08 | 2022-04-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-08 | 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 |
| Use approved construction type or materials. | Fire Safety | 2019-10-07 | 2019-11-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-07 | 2019-11-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-07 | 2019-11-12 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-10-07 | 2019-11-12 | 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 | 2018-11-30 | 2019-02-08 | 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 | 2018-11-30 | 2019-02-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-30 | 2019-02-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-30 | 2019-02-08 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-11-30 | 2019-02-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-11-28 | 2019-01-31 | 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 | 2018-11-28 | 2019-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-28 | 2019-01-31 | N |
