Mary Agnes Manor ALP

Inspection Reports

Citations

Citations from August 1, 2021 through July 31, 2025

A total of 86 violations resulted from 33 inspections of this facility from August 1, 2021 through July 31, 2025, including 11 inspections resulting in no violations.

Note: Violations under dispute through the Inspection Review Process (IRP) are not displayed below.

Inspections
33
Total violations
86
No-violation inspections
11
Date range
Citations from August 1, 2021 through July 31, 2025
Report Issued: June 11, 2025
Relicensure, Complaint Survey Violations: 22 Plan/Notice of Correction Under Review
Regulation Cited Regulation Section
485.5 (g)  Operating certificates (CFR Code 485.5 (g) )
487.7 (f) (8)  Resident services (CFR Code 487.7 (f) (8) )
487.8 (e) (1)  Food service (CFR Code 487.8 (e) (1) )
487.8 (e) (12-13)  Food service (CFR Code 487.8 (e) (12-13) )
487.9 (a) (1)  Personnel (CFR Code 487.9 (a) (1) )
487.9 (a) (6)  Personnel (CFR Code 487.9 (a) (6) )
487.11 (f) (8)  Environmental standards (CFR Code 487.11 (f) (8) )
487.11 (f) (12)  Environmental standards (CFR Code 487.11 (f) (12) )
487.11 (f) (17)  Environmental standards (CFR Code 487.11 (f) (17) )
487.11 (f) (19)  Environmental standards (CFR Code 487.11 (f) (19) )
487.11 (i) (1)  Environmental standards (CFR Code 487.11 (i) (1) )
487.11 (k) (1-3)  Environmental standards (CFR Code 487.11 (k) (1-3) )
487.11 (k) (13)  Environmental standards (CFR Code 487.11 (k) (13) )
487.11 (k) (14)  Environmental standards (CFR Code 487.11 (k) (14) )
487.11 (k) (15)  Environmental standards (CFR Code 487.11 (k) (15) )
487.11 (k) (16)  Environmental standards (CFR Code 487.11 (k) (16) )
487.12 (a-b)  Disaster and emergency planning (CFR Code 487.12 (a-b) )
1001.7 (k) (5)  Admission and retention standards. (CFR Code 1001.7 (k) (5) )
1001.10 (i) (1)  Resident services. (CFR Code 1001.10 (i) (1) )
1001.10 (i) (5-8)  Resident services. (CFR Code 1001.10 (i) (5-8) )
1001.10 (l)(1)  Medication management. (CFR Code 1001.10 (l)(1) )
1001.10 (l) (4-7)  Medication management (CFR Code 1001.10 (l) (4-7) )
Report Issued: May 22, 2025
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: May 23, 2025
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: March 25, 2025
Complaint Survey Violations: 2 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
485.5 (g)  Operating certificates (CFR Code 485.5 (g) )
1001.10 (i) (5-8)  Resident services. (CFR Code 1001.10 (i) (5-8) )
Report Issued: February 14, 2025
Complaint Survey Violations: 2 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.7 (f) (11) (iii)  Resident services (CFR Code 487.7 (f) (11) (iii) )
1001.10 (l)(1)  Medication management. (CFR Code 1001.10 (l)(1) )
Report Issued: January 8, 2025
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: December 31, 2024
Complaint Survey Violations: 4 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.3 (g) (1-2)  General provisions (CFR Code 487.3 (g) (1-2) )
487.7 (f) (8)  Resident services (CFR Code 487.7 (f) (8) )
1001.10 (l)(1)  Medication management. (CFR Code 1001.10 (l)(1) )
1001.10 (l) (4-7)  Medication management (CFR Code 1001.10 (l) (4-7) )
Report Issued: November 14, 2024
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: August 27, 2024
Complaint Survey Violations: 1 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.7 (d) (1) (i)  Resident services (CFR Code 487.7 (d) (1) (i) )
Report Issued: September 25, 2024
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: September 9, 2024
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: July 26, 2024
Complaint Survey Violations: 3 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.4 (a)  Admission standards (CFR Code 487.4 (a) )
487.4(f)-(g)  Admission standards (CFR Code 487.4(f)-(g) )
487.7 (d) (11)  Resident services (CFR Code 487.7 (d) (11) )
Report Issued: June 13, 2024
Complaint Survey Violations: 2 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.7 (d) (11)  Resident services (CFR Code 487.7 (d) (11) )
487.11 (a)  Environmental standards (CFR Code 487.11 (a) )
Report Issued: March 25, 2024
Complaint Survey Violations: 1 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
1001.10 (l)(1)  Medication management. (CFR Code 1001.10 (l)(1) )
Report Issued: November 15, 2023
Complaint Survey Violations: 1 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
1001.10 (l)(1)  Medication management. (CFR Code 1001.10 (l)(1) )
Report Issued: February 29, 2024
Complaint Survey Violations: 4 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
494.4 (k)  Admission and retention standards (CFR Code 494.4 (k) )
1001.10 (i) (5-8)  Resident services. (CFR Code 1001.10 (i) (5-8) )
1001.10 (l)(1)  Medication management. (CFR Code 1001.10 (l)(1) )
1001.10 (l) (2)  Medication management. (CFR Code 1001.10 (l) (2) )
Report Issued: February 29, 2024
Complaint Survey Violations: 2 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
485.5 (f)  Operating certificates (CFR Code 485.5 (f) )
1001.10 (i) (5-8)  Resident services. (CFR Code 1001.10 (i) (5-8) )
Report Issued: August 10, 2023
Complaint Survey Violations: 5 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.4 (c) (5)  Admission standards (CFR Code 487.4 (c) (5) )
487.7 (d) (6) (i)  Resident services (CFR Code 487.7 (d) (6) (i) )
487.7 (f) (5)  Resident services (CFR Code 487.7 (f) (5) )
487.7 (f) (11) (iii)  Resident services (CFR Code 487.7 (f) (11) (iii) )
1001.7 (k) (5)  Admission and retention standards. (CFR Code 1001.7 (k) (5) )
Report Issued: September 28, 2023
Complaint Survey Violations: 3 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.7 (d) (6) (i)  Resident services (CFR Code 487.7 (d) (6) (i) )
487.9 (a) (3)  Personnel (CFR Code 487.9 (a) (3) )
1001.7 (k) (1)  Admission and retention standards. (CFR Code 1001.7 (k) (1) )
Report Issued: September 7, 2023
Complaint Survey Violations: 1 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.7 (d) (1) (i)  Resident services (CFR Code 487.7 (d) (1) (i) )
Report Issued: August 18, 2023
Complaint Survey Violations: 3 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.7 (d) (10) (i-iii)  Resident services (CFR Code 487.7 (d) (10) (i-iii) )
487.7 (d) (11)  Resident services (CFR Code 487.7 (d) (11) )
1001.10 (i) (5-8)  Resident services. (CFR Code 1001.10 (i) (5-8) )
Report Issued: July 7, 2023
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: July 7, 2023
Relicensure, Complaint Survey Violations: 21 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
485.5 (f)  Operating certificates (CFR Code 485.5 (f) )
487.7 (d) (1) (iv)  Resident services (CFR Code 487.7 (d) (1) (iv) )
487.7 (d) (6) (ii)  Resident services (CFR Code 487.7 (d) (6) (ii) )
487.7 (d) (11)  Resident services (CFR Code 487.7 (d) (11) )
487.7 (d) (12-13)  Resident services (CFR Code 487.7 (d) (12-13) )
487.7 (f) (11) (i-v)  Resident services (CFR Code 487.7 (f) (11) (i-v) )
487.7 (f) (11) (iii)  Resident services (CFR Code 487.7 (f) (11) (iii) )
487.7 (f) (12) (iii)  Resident services (CFR Code 487.7 (f) (12) (iii) )
487.8 (c)  Food service (CFR Code 487.8 (c) )
487.11 (f) (8)  Environmental standards (CFR Code 487.11 (f) (8) )
487.11 (f) (19)  Environmental standards (CFR Code 487.11 (f) (19) )
487.11 (i) (7)  Environmental standards (CFR Code 487.11 (i) (7) )
487.12 (a-b)  Disaster and emergency planning (CFR Code 487.12 (a-b) )
1001.7 (g)(1-3)  Admission and retention standards. (CFR Code 1001.7 (g)(1-3) )
1001.7 (h) (1)  Admission and retention standards. (CFR Code 1001.7 (h) (1) )
1001.7 (k) (1)  Admission and retention standards. (CFR Code 1001.7 (k) (1) )
1001.10 (i) (5-8)  Resident services. (CFR Code 1001.10 (i) (5-8) )
1001.10 (l)(1)  Medication management. (CFR Code 1001.10 (l)(1) )
1001.10 (l) (3)  Medication management. (CFR Code 1001.10 (l) (3) )
1001.10 (l) (4-7)  Medication management (CFR Code 1001.10 (l) (4-7) )
1001.11 (c) (2) (i-iv)  Personnel. (CFR Code 1001.11 (c) (2) (i-iv) )
Report Issued: February 23, 2023
Complaint Survey Violations: 2 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.11 (k) (8)  Environmental standards (CFR Code 487.11 (k) (8) )
1001.11 (c) (2) (i-iv)  Personnel. (CFR Code 1001.11 (c) (2) (i-iv) )
Report Issued: May 16, 2022
Other Survey Violations: 1 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
485.5 (f)  Operating certificates (CFR Code 485.5 (f) )
Report Issued: November 4, 2022
Other Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: October 25, 2022
Complaint Survey Violations: 3 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.7 (f) (11) (i-v)  Resident services (CFR Code 487.7 (f) (11) (i-v) )
487.7 (f) (11) (iii)  Resident services (CFR Code 487.7 (f) (11) (iii) )
1001.10 (l)(1)  Medication management. (CFR Code 1001.10 (l)(1) )
Report Issued: July 11, 2022
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: June 8, 2022
Complaint Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: September 29, 2022
Other Survey Violations: 1 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
485.11 (b)  Records and reports (CFR Code 485.11 (b) )
Report Issued: February 9, 2022
Other Survey Violations: 1 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
487.10 (e) (2)  Records and reports (CFR Code 487.10 (e) (2) )
Report Issued: July 1, 2021
Other Survey Violations: 0 Plan/Notice of Correction Not Required
No violations.
Report Issued: October 6, 2021
Other Survey Violations: 1 Plan/Notice of Correction Approved
Regulation Cited Regulation Section
485.11 (b)  Records and reports (CFR Code 485.11 (b) )

Enforcement Actions

Date of Issuance of Stipulation & Order Details
May 1, 2024 Stipulation & Order #: ACF-24-012