Inspection Reports for
St. Mary’s D‘Youville Pavilion

There were no regulatory deficiencies identified as a result of the revisit survey conducted on 6/22/26.

The facility was found not in compliance with multiple federal requirements including resident dignity and rights, abuse investigation, comprehensive care planning, quality of care, trauma-informed care, and immunization documentation.

The facility was found not in substantial compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition, with multiple deficiencies observed in fire separations, emergency lighting, exit signage, smoke barriers, means of egress, discharge from exits, cooking facilities, and corridor doors.

The facility failed to ensure Resident #1 was free from an avoidable accident and environmental hazards, resulting in immediate jeopardy. Additionally, the facility did not notify the State agency of the resident's elopement within 24 hours as required.

St. Mary's D'Youville Pavilion was determined to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.

The facility was found not in substantial compliance with several fire safety and emergency preparedness regulations, including means of egress obstructions, door locking mechanisms, emergency lighting, exit signage, fire alarm and sprinkler system maintenance, smoke barrier penetrations, fire door inspections, electrical receptacle testing, and essential electric system maintenance.

Complaint #ME00048207

St. Mary's D'Youville Pavilion was found to be in compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.

St. Mary's D'Youville Pavilion was found to be in compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.

St. Mary's D'Youville Pavilion was found to be in substantial compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities.

The facility failed to provide adequate housekeeping and maintenance services and failed to ensure foods were dated and labeled in a freezer and refrigerator. The Quality Assurance Committee failed to ensure the Plan of Correction from the prior survey was effective.

The facility was found not in compliance with housekeeping and maintenance services necessary to maintain the building in good repair and sanitary condition on the 3rd floor, and failed to ensure foods were dated and/or labeled in the kitchen freezer and refrigerator. The Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction from the prior survey, as deficiencies were still observed during the follow-up visit.

No regulatory deficiencies were identified as a result of the 3/11/24 investigation.

Investigation included complaints #ME00043822, #ME00044863, #ME00045616, #ME00045719, #ME00046031, #ME00046071, and facility reported incident #ME00045852.

This document contains the facility's plan of correction addressing deficiencies cited in the survey completed on 01/26/2024, including issues related to advance directives, safe and homelike environment, comprehensive assessments, care plans, quality of care, drug regimen review, psychotropic medication use, and infection prevention.

St. Mary's d'Youville Pavilion was found to be in substantial compliance with 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities. No deficiencies were cited.

Complaint #ME00045285

St. Mary's d'Youville Pavilion was found to be in compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities.

St. Mary's D'Youville Pavilion was determined to be in substantial compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities. No deficiencies were cited.

No regulatory deficiencies were identified as a result of the investigation conducted on 8/1/23 and 8/2/23.

This is the facility's plan of correction for the survey dated 05/13/2026 addressing the failure to ensure a resident was free from avoidable accident hazards and supervision issues under rule F 689.

Multiple deficiencies were cited related to emergency preparedness, fire safety, sprinkler system maintenance, and utilities. The facility failed to maintain an updated emergency preparedness plan, proper exit discharge, fire door closures, fire alarm system functionality, sprinkler system maintenance, fire drills, and gas system maintenance.

The facility failed to ensure staff spoke to residents in a dignified manner for 2 of 3 residents reviewed for abuse. The facility investigated and took corrective actions including termination of the CNA involved.

The facility was cited for multiple deficiencies including inadequate maintenance and housekeeping, failure to develop baseline care plans, improper oxygen therapy, lack of smoking safety assessments, unsanitary respiratory care equipment, insufficient dialysis care and monitoring, lack of trauma-informed care plans for residents with PTSD, unlocked medication carts, and incomplete Quality Assurance and Performance Improvement meeting attendance.

The facility was cited for multiple deficiencies including failure to maintain sanitary conditions and building repair, failure to develop and implement appropriate care plans, failure to follow physician orders, failure to ensure proper infection control practices for MRSA, and failure to maintain food safety standards including proper labeling and temperature monitoring. The facility's Quality Assurance Committee failed to ensure effective correction of these deficiencies as many issues were recited during the re-visit.

Based on observations, interviews, and record review, the facility did not provide adequate personal hygiene care to residents, including food debris on Resident #1's face and soiled fingernails on Residents #2 and #3.

Two deficiencies were cited: failure to ensure PASARR Level II evaluation for a resident whose stay extended beyond 30 days, and multiple food safety and sanitation violations in the kitchen including dirty ceiling vents, lights, tiles, unlabelled and undated food items, and lack of chemical sanitizer monitoring.