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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 29 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
This facility has areas of concern that warrant careful consideration. The latest standard survey recorded 12 findings, above the ME average of 11.3. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
St. Mary's D'Youville Pavilion receives highly polarized feedback, with some families praising individual staff members while others report severe neglect and safety concerns. Critical issues consistently cited include poor hygiene, inadequate staffing, and a lack of responsiveness to medical needs, particularly regarding pressure ulcers and patient toileting. Families considering this facility should be aware of the significant disparity between the positive experiences of some and the alarming reports of neglect from others.
Quality Themes
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Concerns
Rating Trends
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Distribution · 31 analyzed
Personalized based on this facility's data
Key Review Excerpts
“When he first arrived here, it was great. Then, they started leaving him in a wheelchair for 12 hours a day (he could not move) and he developed a stage 4 pressure ulcer. Stage 4 ulcers are neglect!”
“Nurses left our mom on toilet and disappeared leaving her alone with broken arm and knee. She was unable to walk by herself. She fell off the toilet.”
“Many of the nurses and staff are wonderful, and took great care of our loved ones. Hospice care was simply incredible.”
Total nursing hours are below the EveryPlace reference benchmark, though RN coverage meets its reference level. Ask how aides are staffed for daily tasks such as bathing and mobility.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
5
measures
7
measures
5
measures
Residents needing more daily help over time
Residents whose walking got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose bladder or bowel control got worse
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility has persistent fire safety concerns across multiple surveys, with recurring deficiencies in smoke detection systems, emergency power, and fire barriers appearing from 2022 through 2025. Care planning and medication management issues also recur, and families have filed complaints resulting in citations for infection control, daily care assistance, and resident dignity. While the facility reports correcting all deficiencies, the pattern of repeated safety violations suggests ongoing operational challenges.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
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.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
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.
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Egress Deficiencies
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.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Install an approved automatic sprinkler system.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
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.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Egress Deficiencies
Have exits that are accessible at all times.
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Install an approved automatic sprinkler system.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Federal Penalties
Fine
Apr 15, 2026
$22,205
Payment Denial
Apr 15, 2026
4-day denial
St Mary's D'youville Pavilion
nonprofit
Covenant Health
8 facilities nationwide
Chain avg rating: 3.4/5 · Rank 6 of 11
Owners
St. Marys Health System
Owner · Organization
Covenant Health
Owner (parent company) · Organization
Key personnel
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