Marian Manor: Elevator Door Strikes Resident - MA
The fall occurred on June 28, 2025, when Resident #1 walked into the front elevator. According to the Director of Therapeutic Activities, who spoke with federal inspectors by phone on August 21, the elevator door hit the resident and caused them to fall inside the elevator. She learned about the incident from the Administrator and Activity Assistant #1 when she returned from vacation.
The Director of Facility Operations told inspectors during interviews on August 19 and August 26 that he was never informed by administration or anyone that a fall had occurred in the front elevator. He said he was unaware of any resident incidents involving the elevator.
His ignorance of the fall is striking given the elevator's documented problems. Repair records show the front elevator was shut down on June 4, 2025, because it was not level with the basement floor. The doors were found out of adjustment and required realignment and readjustment of the entire operation, including clutch retraction.
Twenty days later, on June 24, contractors had to install a new contactor and retrofit a new accelerating contactor to replace the old unit. The elevator required extensive testing both times before being returned to service.
The Director of Facility Operations acknowledged these repairs to inspectors. He said the first repair was because the elevator was not level with the floor when it stopped. The second was due to the elevator door not closing and remaining in the open position.
He also said a relay was installed so the elevator door would open if it sensed something was in the way.
The Director of Nursing received a call from the Nursing Supervisor about the fall, she told inspectors on August 19. The supervisor said Resident #1 had lost balance while walking into the front elevator and fell. When the Director of Nursing asked if there was anything wrong with the elevator, she was told there was nothing wrong with it.
But the resident's family member told a different story. The Director of Nursing said Resident #1's family member told her that the resident said the elevator door struck them and caused the fall.
The Director of Nursing said she was not informed by any staff member that the elevator door hit Resident #1 and that it was inconclusive whether the elevator door actually struck the resident.
Multiple staff members acknowledged that the elevator should have been locked during resident transport. The Director of Therapeutic Activities said the elevator should be locked if there is a lengthy time needed to transport residents in and out. She said she was not aware of any written facility policy about locking the elevator during resident transport, but staff knew they needed to lock it.
The Director of Facility Operations said the elevator should be locked when residents are being transported on and off so the elevator remains open and the door does not close.
The Director of Nursing said it was her expectation that the elevator be locked so it remains open and the door does not close when residents are being transported. She said she did not know if the elevator was locked at the time of the incident.
The Administrator told inspectors on August 19 that she was informed Resident #1 fell in the front elevator and witness statements were obtained. She said she was told the resident walked into the elevator, lost balance and fell inside. The Administrator said she did not know how the resident fell because she was not present.
Like the others, the Administrator said it was her expectation that the elevator be locked so it remains open and the door does not close when residents are being transported. She said she did not know if the elevator door was locked during the June 28 incident.
The facility's failure to inform the Director of Facility Operations about the elevator-related fall represents a breakdown in communication about safety incidents involving equipment under his direct responsibility. Federal inspectors found the facility failed to ensure residents could be safely transported, resulting in actual harm to few residents.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MARIAN MANOR OF TAUNTON in TAUNTON, MA was cited for violations during a health inspection on August 19, 2025.
The fall occurred on June 28, 2025, when Resident #1 walked into the front elevator.
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.