Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alliance Health At Marie Esther during CMS and state inspections, most recent first.
The facility failed to provide RN coverage for at least eight consecutive hours a day on multiple days. Review of the staffing schedule showed no RN in the building for the required hours, and the Assistant Administrator could not provide evidence that the DON was present to cover those shifts. The Administrator stated the facility follows the federal RN coverage requirement but does not have a policy on RN staffing.
Failure to provide ordered portable O2: A resident with COPD and chronic respiratory failure was ordered continuous O2 at 2 LPM via NC and portable O2 while OOB, but was observed in the dining room and during activities without oxygen in place. The resident said a CNA removed the tubing during dressing and did not replace it; an RN and the DON confirmed the resident should have had oxygen continuously as ordered.
A resident with COPD and age-related cognitive decline had an antifungal powder and an oral rinse left on the bedside table and readily accessible. The resident said both products had been used independently for over a year, but the chart did not show physician orders for either medication, and no medication self-assessment was found to confirm the resident could self-administer. The DON and nurses stated bedside possession was not allowed under facility practice and policy.
Unpasteurized eggs were used to prepare over easy eggs for breakfast trays. Facility policy required pasteurized egg products, but invoices showed the eggs purchased were not pasteurized, and surveyors observed staff serving over easy eggs in the kitchen. The FSD stated that three residents typically requested over easy eggs and said he was not aware pasteurized eggs were required for egg dishes that are not fully cooked.
Failure to Offer Updated Pneumococcal Vaccination: The facility did not offer updated pneumococcal immunization to two residents after admission. One resident had severe cognitive impairment and an invoked HCP, with prior PCV13 documented and CDC guidance indicating PCV20 or PCV21 was due; the other resident was cognitively intact, had prior pneumococcal vaccine history, and CDC guidance indicated PCV15, PCV20, or PCV21 was recommended. In both cases, the record lacked evidence of a medical contraindication or that the vaccine was offered, received, or declined, and the IP could not provide proof that the updated vaccines were offered.
RN Coverage Not Provided for Required Hours
Penalty
Summary
The facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week as required. Review of the Facility Assessment Tool, last updated 7/23/25 and reviewed by the QAPI committee on 8/27/25, stated that staffing should be evaluated against federal and state minimum staffing requirements and that federal law requires use of an RN for at least eight consecutive hours a day, seven days a week. Review of the As Worked Nursing Schedule showed that an RN did not work in the building for eight consecutive hours on 8/16/25, 8/30/25, and 8/31/25. During an interview on 9/4/25, the Assistant Administrator said the DON was providing RN coverage but could not provide evidence that the DON was in the building and providing eight consecutive hours of RN coverage on those dates. During an interview on 9/5/25, the Administrator said the facility follows the federal regulation on RN coverage and does not have a policy pertaining to RN staffing.
Failure to Provide Ordered Portable Oxygen
Penalty
Summary
The facility failed to provide portable oxygen as ordered for a resident with COPD, bronchitis, and chronic respiratory failure with hypoxia. The resident was cognitively intact with a BIMS score of 14 and had physician orders for continuous oxygen at 2 LPM via nasal cannula and for portable oxygen use while out of bed. The care plan also identified a need for oxygen related to respiratory distress and included intervention for oxygen as ordered. During observation, the resident was seen in bed with oxygen in use, but later was observed in the main dining room eating breakfast and participating in an activity without portable oxygen being administered. The resident was also observed seated in a wheelchair in the dining room without oxygen. The resident stated that oxygen was always used and reported that a CNA had removed the tubing when helping with dressing and did not put it back on. Nurse #1 stated the resident should always have portable oxygen as ordered and that it had been removed when the CNA assisted with dressing. The DON stated the resident required oxygen continuously as ordered and that not having it applied as ordered could lead to oxygen desaturation and shortness of breath.
Unsafe Bedside Medication Storage and Missing Orders
Penalty
Summary
Medication storage was not maintained in a safe and secure manner for one resident in the sample. Resident #22, who was admitted with diagnoses including COPD and age-related cognitive decline, had a BIMS score of 15 out of 15 on the most recent MDS, indicating cognitive intactness. During observation, the resident was awake and seated at the edge of the bed, and two medications were seen on the nightstand table: an antifungal powder with miconazole nitrate 2% and TheraBreath Dentist Formulated Fresh Breath Oral Rinse. At the time of the observation, the resident stated both products had been used for over a year and that the resident could administer them independently without nursing assistance. The resident also stated the antifungal powder was being used on a cut on the top of the right thigh and had been given by the wound doctor. Review of the physician orders did not show an order for either the antifungal powder or the oral rinse, and the medications were observed again on the bedside table later that morning. The DON stated the resident was not allowed to keep prescribed medications at the bedside for safety reasons and said the facility should have obtained a physician order for the antifungal powder and oral rinse. The DON also stated a medication self-assessment should have been completed to determine whether the resident was capable of self-administering medications. Review of the clinical record did not find evidence that a self-assessment for medication had been completed. A nurse also stated the resident was not allowed to keep prescribed medications at the bedside, and another nurse identified the oral rinse as an OTC medication but acknowledged the facility policy did not allow bedside possession without the required process.
Unpasteurized Eggs Used for Over Easy Breakfast Orders
Penalty
Summary
The facility failed to follow professional standards of practice for food safety by not using pasteurized eggs when preparing over easy eggs for residents who requested them at breakfast. The facility policy titled Food Purchasing stated that only Grade A eggs should be purchased and that frozen and packaged egg products shall be pasteurized. However, review of facility invoices showed that the eggs purchased from the vendor were not pasteurized. During observation in the main kitchen, surveyors saw staff serving breakfast trays that included eggs cooked over easy, and when the Food Service Director was asked to observe the eggs being used, the eggs were noted to not be pasteurized. In interview, the Food Service Director stated that three residents typically requested over easy eggs for breakfast and said he was not aware that eggs used for dishes that are not fully cooked were required to be pasteurized.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer pneumococcal vaccination to two residents after admission, despite review of immunization history and CDC guidance showing they were eligible for updated vaccination. Resident #2 was admitted in January 2023, was over age 50, had severe cognitive impairment with a BIMS score of 7, and had an invoked HCP. MIIS showed prior receipt of PCV13 on 5/25/16, and the CDC PneumoRecs VaxAdvisor indicated a dose of PCV20 or PCV21 was recommended at least 1 year after PCV13. The resident’s representative said he/she could not recall whether the vaccine had been offered but would want an updated vaccine if offered. The medical record did not show a medical contraindication or that the vaccine had been offered, received, or declined since admission. Resident #22 was admitted in July 2024, was over age 50, and was cognitively intact with a BIMS score of 15. The MDS indicated pneumococcal vaccination was not up-to-date and had not been offered. MIIS showed a history of an unspecified pneumococcal vaccine on 2/1/15, and the CDC PneumoRecs VaxAdvisor recommended PCV15, PCV20, or PCV21, with PPSV23 needed after PCV15. The resident stated no staff had approached him/her to offer an updated vaccination and that he/she would want one if offered. The medical record did not show a medical contraindication or that the vaccine had been offered, received, or declined since admission. The Infection Preventionist stated the facility reviews immunization history on admission and uses MIIS to review vaccination history, including pneumococcal vaccines, and said she was unable to provide evidence that updated pneumococcal vaccinations were offered to either resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marlborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Reservoir Center For Health & Rehabilitation, The | 2.6 mi | ★★★★★ | 11 | 0 |
| Sudbury Pines Extended Care | 3.2 mi | ★★★★★ | 0 | 0 |
| Oak Knoll Rehabilitation And Healthcare Center | 4.1 mi | ★★★★★ | 2 | 0 |
| Marlborough Hills Rehabilitation & Health Care Cen | 4.2 mi | ★★★★★ | 1 | 0 |
| St Patrick's Manor | 4.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.