St Mary's D'Youville Pavilion

In the surveyor’s words

From the most serious findings on record at St Mary's D'Youville Pavilion, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 15, 2026

  Based on record review, review of the facility internal investigation, interviews, and video surveillance, the facility failed to ensure a resident was free from an avoidable accident and environmental hazards. Specifically, Resident #1 [R1] exited their assigned unit onto an exterior courtyard/patio area without staff knowledge. The resident remained outdoors, inadequately dressed for the weather, for approximately 30 minutes before being discovered face down on the snow-covered ground. This failure created an immediate jeopardy situation.Findings: The Department of Licensing and Certification [State Agency] received an anonymous complaint which stated R1 was found outside on the ground in wet/snowy conditions in the early morning hours of March 21, 2026. […]

• No harm, potential for more than minimal, patternF584Mar 28, 2025

  Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 3 units (3rd floor unit and 4th floor unit) and the laundry rooms for 1 of 1 environmental tour (3/28/25). Findings: On 3/28/25 from 8:20 a.m. to 8:45 a.m., an Environmental Tour was conducted with the Administrator, the Quality Assurance and Performance Improvement Program (QAPI) Manager and the 3rd Floor Unit Manager in which the following findings were observed: Laundry rooms >Clean Linen Area: There were 4 wall mounted fans that were dusty/dirty. There were 2 wall mounted air conditioning units that were dusty/dirty. […]

• No harm, potential for more than minimal, patternF695Mar 28, 2025

  Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care on 3 of 4 days of survey (3/25/25, 3/26/25 and 3/27/25) for 9 of 13 residents reviewed for respiratory care. (#40, #52, #153, #370, #366, #42, #24, #468 and #472) Findings: 1. On 3/25/25 from 9:24 a.m. to 10:23 a.m., and again on 3/26/25 at 7:25 a.m., the following was observed: > Resident #40 had an unlabeled/dated nebulizer pipe stored on the bedside dresser. In a brief interview, the resident stated he/she hasn't had to use the nebulizer in a week. > Resident #52 room had an unlabeled/dated oxygen nasal cannula tubing with the nasal prongs lying on the floor. […]

• No harm, potential for more than minimal, patternF698Mar 28, 2025

  Based on observations, interviews and record reviews, the facility failed to ensure that a resident who requires Hemodialysis receives such services, consistent with the professional standards of practice and failed to ensure the care plan contained the needed information, including emergency interventions necessary to properly care for 2 of 2 residents reviewed for Hemodialysis. (#105 and #32) Findings: 1. On 3/26/25 at 8:32 a.m., the surveyor observed Resident #105 with a bandage to the upper arm. At this time, during an interview, Resident #105 stated he/she has an AVF (Arteriovenous Fistula) and has been going to dialysis for a couple of years. […]

• No harm, potential for more than minimal, patternF699Mar 28, 2025

  Based on record reviews and interviews, the facility failed to assess resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 2 of 3 sampled residents reviewed with a current diagnosis of PTSD (Resident #39 and #110). Findings: 1. A review of Resident #39's Annual Minimum Data Set (MDS) 3.0, dated 2/18/25, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate Resident #39 has an active diagnosis for PTSD. The surveyor was unable to find information in the clinical record that indicates what Resident #39's PTSD was caused by, what trigger(s) might cause re-traumatization, and measures to avoid trigger(s) that might cause re-traumatization. […]