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Complaint Investigation

Marian Manor Of Taunton

August 19, 2025 · Taunton, MA · 33 Summer Street
Citations 1
CMS Rating 3/5
Beds 116
Provider ID 225477
Healthcare Facility
Marian Manor Of Taunton
Taunton, MA  ·  View full profile →
Inspection Summary

MARIAN MANOR OF TAUNTON in TAUNTON, MA — inspection on August 19, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Actual Harm

During a telephone interview on 08/21/25, the Director of Therapeutic Activities said that she was on vacation when Resident #1 fell.

The Director of Therapeutic Activities said that when she returned to work, the Administrator and Activity Assistant #1 told her that when Resident #1 walked into the front elevator, the elevator door hit him/her and caused him/her to fall into the elevator.

The Director of Therapeutic Activities said that the elevator should be locked if there is a lengthy time that it needs to remain open to transport residents in and out of the elevator.

The Director of Therapeutic Activities said that she was not aware of any written facility policy or procedure regarding locking the elevator during resident transport, but that staff knew they needed to lock the elevator.Review of an Elevator Invoice and Repair Document, dated 6/04/25, indicated that the front elevator was not level with basement floor and was shutdown.

The Document indicated that the doors were found out of adjustment, doors were realigned and readjusted entire operation including clutch retraction, elevator was tested extensively and returned to service.Review of an Elevator Invoice and Repair Document, dated 6/24/25, indicated furnish and install new contactor.

The Document indicated retro-fit new accelerating contactor in place of old unit, lengthened wires and rewired, elevator was tested extensively and returned to service.During an in-person interview on 08/19/25 at 2:00 P.M. and a subsequent telephone interview on 8/26/25 at 9:48 A.M., the Director of Facility Operations said that he was never informed by Administration or anyone that a fall had occurred in the front elevator.

The Director of Facility Operations said he was unaware of any resident incidents involving the front elevator.

The Director of Facility Operations said that the front elevator was repaired a few times in June 2025, once because the elevator was not level with the floor when it stopped and the second was due to the elevator door not closing and remaining in the open position.The Director of Facility Operations also said a relay was installed so that the elevator door would open if it sensed something was in the way.

The Director of Facility Operations said that the elevator should be locked when residents are being transported on and off the elevator so that the elevator remains open and the elevator door does not close.During an interview on 08/19/25 at 3:20 P.M., the Director of Nursing (DON) said that she received a call from the Nursing Supervisor that Resident #1 had lost his/her balance while walking into the front elevator and fell.

The DON said that she asked the Nursing Supervisor if there was anything wrong with the front elevator and said she was told by the Nursing Supervisor that there was nothing wrong with the front elevator.

The DON said that she notified the Director of Facility Operations of the fall involving the front elevator.The DON said that Resident #1's Family Member told her that Resident #1 told him/her that the elevator door struck him/her and caused him/her to fall.

The DON said that she was not informed by any staff member that the elevator door hit Resident #1 and caused him/her to fall and said that it was inconclusive if the elevator door hit Resident #1.

The DON said she did not know if the elevator was locked at the time of the incident.

The DON said that it was her expectation that the elevator be locked so that the elevator remains open and the elevator door does not close when residents are being transported on and off the elevator.During an interview on 08/19/25 at 3:55 P.M., the Administrator said that she was informed that Resident #1 fell in the front elevator and witness statements were obtained.

The Administrator said that she was informed that Resident #1 walked into the elevator, lost his/her balance and fell in the elevator.

The Administrator said that she did not know how Resident #1 fell, that she was not present during the fall.

The Administrator said that it was her expectation that the elevator be locked so that the elevator remains open and the elevator door does not close when residents are being transported on and off the elevator.

The Administrator said she did not know if the elevator door was locked during the 6/28/25 incident.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TAUNTON, MA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MARIAN MANOR OF TAUNTON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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