Marian Manor of Taunton: Elevator Door Fall Violation - MA
The elevator had already been repaired twice that month.
Records reviewed by inspectors showed a repair visit on June 4, 2025, after the elevator was found not level with the basement floor when it stopped. Technicians realigned the doors, readjusted the clutch retraction, and tested the unit before returning it to service. A second repair followed on June 24, when a new accelerating contactor was installed, wires were lengthened and rewired, and the elevator was tested again.
Four days after that second repair, on June 28, Resident 1 fell inside the elevator.
The Director of Nursing told inspectors she received a call from a nursing supervisor that Resident 1 had lost his or her balance walking into the front elevator and fallen. She said she asked the supervisor whether anything was wrong with the elevator and was told there was not. She then notified the Director of Facility Operations about the fall.
But the family told a different story. The Director of Nursing said Resident 1's family member told her that the resident said the elevator door struck him or her and caused the fall. She said no staff member had told her the door made contact with the resident. She called it inconclusive.
The Director of Facility Operations said he was never told a fall had occurred in the front elevator at all. He learned about the two June repairs, he said, but had no knowledge of any resident incident involving the elevator. He told inspectors that the elevator had been repaired once because it wasn't level with the floor and a second time because the door wasn't closing and was remaining in the open position. He also explained that a relay had been installed so the door would open if it sensed something in its path.
He said the elevator should be locked when residents are being transported on and off it, so the door stays open and doesn't close on anyone.
The administrator said she was informed that Resident 1 had walked into the elevator, lost his or her balance, and fallen. She said she didn't know how the resident fell and was not present. She said witness statements were obtained.
When inspectors asked whether the elevator had been locked during the June 28 incident, the administrator said she didn't know. The Director of Nursing said the same. It was her expectation, the director said, that the elevator be locked during resident transport. Whether anyone had followed that expectation on the day of the fall, she could not say.
The inspection was conducted on August 19, 2025, in response to a complaint. CMS cited the facility for failing to maintain the environment in a safe condition, a deficiency tagged at the level of actual harm.
What the resident told his or her family, and what the nursing supervisor told the Director of Nursing, remain two different accounts. One says the door hit a person. The other says nothing was wrong with the elevator. The facility's own records show the elevator had been shut down, repaired, and returned to service twice in the three weeks before the fall. The person who would have known whether the safety lock was engaged that day, the Director of Facility Operations, was never told the fall happened at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marian Manor of Taunton from 2025-08-19 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Marian Manor Of Taunton in TAUNTON, MA was cited for violations during a health inspection on August 19, 2025.
The elevator had already been repaired twice that month.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.