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Deficiency Records for St Mary's D'youville Pavilion
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.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-01-24 | 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 | 2024-01-24 | 2024-03-04 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | Fire Safety | 2024-01-24 | 2024-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-24 | 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 |
| 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 |
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