MARIAN MANOR

Nursing Home Inspector

130 DORCHESTER AVENUE
BOSTON, MA 02127
Suffolk County
Phone: 617-268-3333
Provider Number: 225415
Last Inspection: 01/20/2017

About the Nursing Home

Number of Beds: 344
Number of Residents: 176
Beds Available: 168
Percent Occupancy: 51%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

22

Facility
11

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

22

2017
28

2016
18

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

1/20/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 3/6/2017
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 3/6/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 3/6/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 3/6/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 3/6/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 3/6/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 3/6/2017
 

3/1/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 4/15/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 4/15/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 4/15/2016
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 4/15/2016
 
Failed To: Keep all essential equipment working safely. Isolated : Minimal 3 4/15/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 4/15/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 4/15/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 4/15/2016
 

11/20/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 12/21/2014
 
Failed To: Make sure that doctors visit residents regularly, as required. Isolated : Minimal 3 12/21/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 12/21/2014
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Pattern : Minimal 4 12/21/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 12/21/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

12/30/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 2/22/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 2/22/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 2/22/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 176 98.14 96.79
Registered Nurses 1.45 1.14 0.89
Licensed Practical / Vocational Nurses 0.40 0.83 0.84
Certified Nursing Assistants 3.06 2.59 2.30
Total Staff Hours 4.90 4.56 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 2 6 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 97 92 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 95 95
of long-stay residents experiencing one or more falls with major injury 3 2 3
of long-stay residents who have depressive symptoms 4 2 2
of long-stay residents who lose too much weight 6 4 5
of long-stay residents who received an antianxiety or hypnotic medication 16 18 20
of long-stay residents who received an antipsychotic medication 16 15 18
of long-stay residents who self-report moderate to severe pain 10 4 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 17 16 18
of long-stay residents whose need for help with daily activities has increased 19 13 14
of long-stay residents with a catheter inserted and left in their bladder 2 2 1
of long-stay residents with a urinary tract infection 3 3 3
of low risk long-stay residents who lose control of their bowels or bladder 52 54 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 87 75 79
of short-stay residents who had an outpatient emergency department visit 11 12 11
of short-stay residents who made improvements in function 46 53 60
of short-stay residents who newly received an antipsychotic medication 1 0 1
of short-stay residents who self-report moderate to severe pain 9 12 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 84 79 82
of short-stay residents who were rehospitalized after a nursing home admission 20 25 22
of short-stay residents who were successfully discharged to the community 62 56 56
of short-stay residents with pressure ulcers that are new or worsened 0 1 0