Marian Manor of Taunton

Inspectors wroteBased on observations, interviews, and records reviewed for one Resident (#5), of 17 sampled residents, the facility failed to ensure care was provided in accordance with professional standards of practice. Specifically, the facility failed, for Resident #5, to follow the prescriber's orders for how liquids were provided to the Resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe environment free of potential accident hazards for one Resident (#30), out of a total sample of 17 residents. Specifically, for Resident #30, the facility failed to implement interventions to prevent falls by ensuring his/her bed was in the lowest possible position and he/she had access to their call bell.

Inspectors wroteBased on observation and interview, the facility failed to ensure one Resident (30), out of a total sample of 17 residents, had a bed that was in safe operating condition. Specifically, Resident #30's bed was unable to be positioned in the lowest possible position.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing promptly notified his/her Health Care Agent (HCA), when nursing transcribed a physician's order to decrease the dosage of his/her antidepressant medication without notifying the HCA of the change, Resident #1 received the lower dosage of the medication for more than a month before the HCA was made aware.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), the facility failed to ensure his/her environment was free of accident hazards as possible, when on 06/28/25, while activity staff were assisting residents onto the elevator after an activity, they did not lock the elevator, which would have kept the door in the open position, as Resident #1 entered the elevator the door began to close and hit him/her causing him/her to fall into the elevator. Resident #1 complained of severe left leg pain and was transported to the Hospital Emergency Department (ED) for evaluation. Resident #1 was diagnosed with a left intertrochanteric fracture (break in the upper part of the thigh bone (femur), was admitted and underwent surgical intervention to repair the fracture.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff notified the Physician of medication recommendations for one Resident (#15), out of a sample of 15 residents. Specifically, the facility failed to notify the Physician and/or Nurse Practitioner, in a timely manner, of the Psychiatric Nurse Practitioner (PNP)'s recommendations to increase Remeron (an antidepressant medication) dosage and implement a Gradual Dose Reduction (GDR) for Lexapro (an anti-anxiety medication), resulting in a 43-day delay in implementing the recommendations.

Inspectors wroteBased on observations, interviews, and records reviewed for two Residents (#19 and #48) of 15 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #19, to ensure a prescriber's order for Dycem (a thin, rubberlike material known for its non-slip material, used to reduce the likelihood of sliding or shifting) to wheelchair was implemented to prevent falls; and 2. For Resident #48, to follow the prescriber's orders for 1:1 (one to one) assistance and encouragement with meals.

Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Medical Director and Director of Nurses (DON) each failed to attend one of five Quarterly QAPI meetings reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of one Resident (#27), out of a sample of 15 residents. Specifically, the facility failed: a. To ensure an MDS was accurately coded for a fall with major injury, and b. To ensure the use of a bed alarm was accurately coded on all MDS assessments.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff stored and properly labeled all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to: 1. Ensure staff properly labeled all drugs and biologicals stored in 2 of 4 medication carts once opened; and 2. Ensure staff safely and securely stored all medications in 1 of 2 medication storage rooms and 2 of 4 medication carts.

Inspectors wroteBased on observation, interview, and test tray results, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents voiced concerns regarding the quality and temperatures of the food provided by the facility.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff maintained an infection control program designed to provide a safe and sanitary environment to help prevent the development and potential spread of infections. Specifically, the facility failed to: 1. Ensure staff properly performed hand washing during COVID-19 testing to prevent the potential spread of infection; and 2. Ensure staff prepared and administered medications in a safe and sanitary manner.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents in one of four dining rooms experienced a comfortable and homelike dining experience.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to develop a comprehensive person-centered care plan for two Residents (#22 and #55), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #22, to ensure staff developed a care plan for the Resident's use of an external catheter device (condom catheter) (urinary collection device with a tube that goes to a collection bag); and 2. For Resident #55, to ensure staff developed a care plan that addressed a cancerous lesion on the Resident's left forearm.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure written notice for transfer and discharge was provided to the Resident and/or Resident Representative prior to hospital transfer for one Resident (#32), out of a total sample of 19 residents.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to provide written notification of the bed hold policy to the Resident and/or Resident Representative prior to transfer to the hospital for one Resident (#32), out of a total sample of 19 residents.

Inspectors wroteBased on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2) the Facility failed to ensure staff consistently implemented the Facility Abuse Prohibition Policy when Nurse #2 observed a potentially sexually inappropriate interaction between the two residents, and did not immediately separated them. On 9/15/23, Nurse #2 saw Resident #1 in Resident #2's room, standing at Resident #2's bedside holding up Resident #2's leg. Resident #2 who was in bed, was not wearing an incontinence brief, and the lower half of his/her body was not covered by a sheet or a blanket, therefore leaving him/her exposed. [...]