St Mary's D'youville Pavilion
102 Campus Ave, Lewiston, ME 04240
St Mary's D'youville Pavilion is a nursing home in Lewiston, Maine. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (207) 777-4200
- Last standard health inspection
- March 28, 2025 (1 year ago)
- Certified beds
- 210
- Residents per day, on average
- 160.8
- Ownership type
- Non profit - Corporation
- Legal business name
- St Marys Regional Medical Center
- Chain
- Covenant Health
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Maine average (28 vs 31).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
1 citation
Health inspection on June 25, 2026
CMS lists this as a complaint inspection.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on August 9, 2026.
CMS update of June 24, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 1 of 5.
Payment stopped
May 21, 2026 (5 months ago)
CMS stopped payment for new admissions from May 21, 2026, for 4 days.
2 citations
Health inspection on April 15, 2026
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
1 of 78 Maine homes (1%) got a citation at the immediate jeopardy level in 2026.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 25, 2026.
CMS has cited this home for F0689 2 times since 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on May 25, 2026.
Fine
April 15, 2026 (6 months ago)
CMS fine of $22,205 on April 15, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
1 citation
Health inspection on November 21, 2025
CMS lists this as a complaint inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on September 24, 2025.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of June 25, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Health citation
CMS removed citation F0758 from the health inspection on January 26, 2024.
9 citations
Health inspection on March 28, 2025
CMS lists this as a standard inspection.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for F0584 2 times since 2024.
Citation F0695. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 1, 2025.
Citation F0698. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on May 1, 2025.
Citation F0699. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on May 1, 2025.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for F0655 2 times since 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for F0684 2 times since 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 1, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 1, 2025.
Citation F0868. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on May 1, 2025.
11 citations
Fire safety inspection on March 28, 2025
CMS lists this as a standard inspection.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on May 1, 2025.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for K0353 2 times since 2024.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on May 1, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for K0918 3 times since 2022.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on May 1, 2025.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on March 26, 2025.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 3, 2025.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on May 1, 2025.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for K0351 3 times since 2022.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on May 1, 2025.
CMS has cited this home for K0372 2 times since 2022.
Citation K0914. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on May 1, 2025.
1 citation
Health inspection on January 2, 2025
CMS lists this as a complaint inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 27, 2025.
CMS has cited this home for F0880 2 times since 2024.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of June 26, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 2 of 5.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
12 citations
Health inspection on January 26, 2024
CMS lists this as a standard inspection.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 8, 2024.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on March 21, 2024.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on March 21, 2024.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 21, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 8, 2024.
CMS has cited this home for F0812 2 times since 2022.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 21, 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 21, 2024.
Citation F0637. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident when there is a significant change in condition
CMS lists it as corrected on March 21, 2024.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on March 21, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on March 21, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 21, 2024.
Citation F0867. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on April 8, 2024.
13 citations
Fire safety inspection on January 26, 2024
CMS lists this as a standard inspection.
Citation K0342. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
CMS lists it as corrected on March 4, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 4, 2024.
Citation K0541. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on March 4, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 4, 2024.
Citation E0004. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on March 4, 2024.
Citation K0271. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on March 4, 2024.
Citation K0311. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on March 4, 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on March 4, 2024.
CMS has cited this home for K0321 2 times since 2022.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on March 4, 2024.
Citation K0374. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on March 4, 2024.
CMS has cited this home for K0374 2 times since 2022.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on March 4, 2024.
CMS has cited this home for K0511 2 times since 2022.
Citation K0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on March 4, 2024.
CMS has cited this home for K0712 2 times since 2022.
Citation K0902. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
CMS lists it as corrected on March 4, 2024.
2 citations
Health inspection on March 9, 2022
CMS lists this as a standard inspection.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on April 20, 2022.
Citation F0812. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 20, 2022.
10 citations
Fire safety inspection on March 9, 2022
CMS lists this as a standard inspection.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on May 12, 2022.
Citation K0374. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on May 12, 2022.
Citation K0133. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install a two-hour-resistant firewall separation.
CMS lists it as corrected on May 12, 2022.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on May 12, 2022.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on April 25, 2022.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on April 25, 2022.
Citation K0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 25, 2022.
Citation K0916. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on May 12, 2022.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on April 25, 2022.
Citation K0918. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 25, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- ST. MARYS HEALTH SYSTEM5% or greater direct ownership interest · 100% · since 09/16/1983
- COVENANT HEALTH5% or greater indirect ownership interest · 100% · since 01/29/1992
- GRUBBS, STEPHENOperational/managerial control · not applicable · since 09/23/2019
- WOOD, JOSEPHOperational/managerial control · not applicable · since 01/01/2025
Questions
When was St Mary's D'youville Pavilion last inspected?
CMS lists March 28, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does St Mary's D'youville Pavilion have?
CMS lists 28 health citations since March 9, 2022. CMS also calls these deficiencies.
Has St Mary's D'youville Pavilion been fined?
CMS lists 1 fine in the past three years, $22,205 in total.
What is the CMS star rating of St Mary's D'youville Pavilion?
Its CMS overall star rating is 1 of 5.
Is St Mary's D'youville Pavilion a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.