Inspection Reports for Mary Agnes Manor

NY, 14201

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Inspection Report Summary

The most recent inspection on June 11, 2025, identified multiple deficiencies across areas such as operating certificates, resident services, food service, personnel, environmental standards, disaster planning, and medication management. Earlier inspections showed a pattern of recurring issues mainly related to resident services and medication management, with occasional findings in operating certificates and admission standards. Complaint investigations during this period were unsubstantiated or did not result in violations. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history shows ongoing challenges with regulatory compliance, with deficiencies persisting over time rather than clear improvement.

Deficiencies (last 2 years)

Deficiencies (over 2 years) 16 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

214% worse than New York average
New York average: 5.1 deficiencies/year

Deficiencies per year

20 15 10 5 0
2024
2025

Inspection Report

Relicensure
Capacity: 60 Deficiencies: 20 Date: Jun 11, 2025

Visit Reason
22 violations noted including operating certificates, resident services, food service, personnel, environmental standards, disaster planning, and medication management. Plan/Notice of Correction Under Review.

Findings
22 violations noted including operating certificates, resident services, food service, personnel, environmental standards, disaster planning, and medication management. Plan/Notice of Correction Under Review.

Deficiencies (20)
485.5 (g) — Operating certificates
487.7 (f) (8) — Resident services
487.8 (e) (1) — Food service
487.8 (e) (12-13) — Food service
487.9 (a) (1) — Personnel
487.9 (a) (6) — Personnel
487.11 (f) (8) — Environmental standards
487.11 (f) (12) — Environmental standards
487.11 (f) (17) — Environmental standards
487.11 (f) (19) — Environmental standards
487.11 (i) (1) — Environmental standards
487.11 (k) (1-3) — Environmental standards
487.11 (k) (13) — Environmental standards
487.11 (k) (14) — Environmental standards
487.11 (k) (15) — Environmental standards
487.11 (k) (16) — Environmental standards
487.12 (a-b) — Disaster and emergency planning
1001.7 (k) (5) — Admission and retention standards
1001.10 (i) (5-8) — Resident services
1001.10 (l) (4-7) — Medication management

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 0 Date: May 23, 2025

Visit Reason
No violations found. Plan/Notice of Correction Not Required.

Findings
No violations found. Plan/Notice of Correction Not Required.

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 0 Date: May 22, 2025

Visit Reason
No violations found. Plan/Notice of Correction Not Required.

Findings
No violations found. Plan/Notice of Correction Not Required.

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 2 Date: Mar 25, 2025

Visit Reason
Two violations including operating certificates and resident services. Plan/Notice of Correction Approved.

Findings
Two violations including operating certificates and resident services. Plan/Notice of Correction Approved.

Deficiencies (2)
485.5 (g) — Operating certificates
1001.10 (i) (5-8) — Resident services

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 2 Date: Feb 14, 2025

Visit Reason
Two violations related to resident services and medication management. Plan/Notice of Correction Approved.

Findings
Two violations related to resident services and medication management. Plan/Notice of Correction Approved.

Deficiencies (2)
487.7 (f) (11) (iii) — Resident services
1001.10 (l)(1) — Medication management

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 0 Date: Jan 8, 2025

Visit Reason
No violations found. Plan/Notice of Correction Not Required.

Findings
No violations found. Plan/Notice of Correction Not Required.

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 4 Date: Dec 31, 2024

Visit Reason
Four violations including general provisions, resident services, and medication management. Plan/Notice of Correction Approved.

Findings
Four violations including general provisions, resident services, and medication management. Plan/Notice of Correction Approved.

Deficiencies (4)
487.3 (g) (1-2) — General provisions
487.7 (f) (8) — Resident services
1001.10 (l)(1) — Medication management
1001.10 (l) (4-7) — Medication management

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 1 Date: Aug 27, 2024

Visit Reason
One violation related to resident services supervision. Plan/Notice of Correction Approved.

Findings
One violation related to resident services supervision. Plan/Notice of Correction Approved.

Deficiencies (1)
487.7 (d) (1) (i) — Resident services

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 3 Date: Jul 26, 2024

Visit Reason
Three violations including admission standards and resident services. Plan/Notice of Correction Approved.

Findings
Three violations including admission standards and resident services. Plan/Notice of Correction Approved.

Deficiencies (3)
487.4 (a) — Admission standards
487.4(f)-(g) — Admission standards
487.7 (d) (11) — Resident services

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