Alliance Health at Marie Esther

In the surveyor’s words

From the most serious findings on record at Alliance Health at Marie Esther, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 28, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff for care, the Facility failed to ensure he/she was free from physical abuse from a staff member when on 09/09/23, Resident #1 became combative during care and Certified Nurse Aide (CNA) #1 in response to Resident #1's behavior, hit Resident #1 on the top of his/her right hand, the incident was witnessed by CNA #2 and CNA #3, who were present and also assisted CNA #1 with Resident #1 at the time of the incident. […]

• No harm, potential for more than minimal, widespreadF727Sep 5, 2025

  Based on record review, and interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required, placing all facility residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse's Aides (CNA) that the RN was responsible for overseeing with provision of resident care.Specifically, the facility failed to have an RN working at least eight consecutive hours over a 24-hour period on three days (8/16/25, 8/30/25, and 8/31/25). […]

• No harm, potential for more than minimal, patternF727Dec 1, 2021

  Based on record review and interview the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. Findings include: Review of the actual worked schedules from 11/6/21 through 11/30/21 indicated that on 11/6/21, 11/7/21, 11/20/21, 11/21/21, and 11/25/21 there were no RNs present at the facility in a 24 hour period. During an interview on 11/30/21 at 3:07 P.M., the Staff Development Coordinator/Infection Preventionist said that she did not believe there was an RN in the facility for 8 hours every day of the week. […]

• No harm, potential for more than minimal, isolatedF695Sep 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice were provided for one Resident (#1) out of a total sample of 12 residents.Specifically, for Resident #1, the facility failed to provide portable oxygen as ordered by the Physician when the Resident was out of bed (OOB) and participating in activities away from the stationary oxygen source. Findings include: Review of facility policy, titled Physician Orders, effective 11/22/16 and revised 11/14/22, include but are not limited to:>it is the policy of the facility that a physician personally approves in writing a recommendation that an individual be admitted to the facility. […]

• No harm, potential for more than minimal, isolatedF761Sep 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure that medications were stored in a safe and secure manner for one Resident (#22) out of a total sample of 12 residents.Specifically, for Resident #22, the facility failed to ensure that:-One over-the-counter medication was secured and was not left at the Resident's bedside table and readily accessible to other residents on the unit.-One prescribed medication was secured and was not left at the Resident's bedside table and readily accessible to other residents on the unit.- A Physician's order was obtained for the use of one over-the-counter and one prescribed medication.- A self-assessment of medication was completed to ensure the Resident was capable of self-administering medications. […]