Alliance Health at Marina Bay

Inspectors wroteBased on record review, observation, and interviews, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#131) with an unplanned weight loss, out of a total sample of 30 residents. Specifically, the facility failed for Resident #131 to implement dietary recommendations/interventions after weight loss had been identified, and he/she continued to lose weight.

Inspectors wroteBased on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed during a medication pass made five errors out of 27 opportunities, resulting in a medication error rate of 18.52%. Specifically,1. For Resident #161, Nurse #3 prepared his/her medications, failed to identify the Resident and attempted to administer the medications to Resident #162; and,2. For Resident #93, failed to administer the correct does of Calcium plus Vitamin D; and3. For Resident #143, failed to administer the correct form of Vitamin B.

Inspectors wroteBased on record review and interview, the facility failed to implement written policies and procedures for an allegation of abuse for one Resident (#5), out of a total sample of 30 residents. Specifically, the facility failed to initiate their abuse policy after an allegation of abuse was documented and reported on 5/1/25.

Inspectors wroteBased on record review and interviews, the facility failed to report an allegation of abuse to the state agency for one Resident (#5), out of a total sample of 30 residents.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a person-centered care plan for the use of psychotropic medications for one Resident (#163), out of a total sample of 30 residents. Specifically, the facility failed for Resident #163 to ensure a care plan had been developed for the use of Ativan/Lorazepam (anti-anxiety medication), to monitor for adverse effects/side-effects of the medication, and to monitor for targeted behaviors.

Inspectors wroteBased on interview and record review, the facility failed to assess and develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for one Resident (#160) with a history of trauma, out of a total sample of 30 residents.

Inspectors wroteBased on observation and interviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure for Resident #163 that staff performed hand hygiene and donned (put on) gloves and/or used utensils while handling ready to eat food during breakfast service/meal preparation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of greater than five percent when one of two nurses made seven errors out of 40 opportunities, totaling a medication error rate of 17.5%. These errors impacted one Resident (#14), out of three residents observed. Specifically, the nurse administered the wrong dose of Buspar (for anxiety), Neurontin (for seizures or nerve pain), and Tylenol (for mild to moderate pain), and failed to administer Anoro Ellipta (inhaler for lung conditions), Fluticasone Propionate (inhaler for lung conditions), Ipratropium Bromide (aerosol for lung conditions), and Lidocaine patches (local anesthetic for pain management) as ordered.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products, and to maintain safe and clean equipment in four of five nourishment kitchenettes.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure one Resident (#303) was informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 31 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure professional standards of care were met for two Residents (#145 and #14), out of a total sample of 31 residents. Specifically, the facility failed: 1. For Resident #145, to administer care (one to one (1:1) assist during intake by mouth (PO)) in accordance to physician's orders; and 2. For Resident #14, to follow the standard of medication preparation and administration and document missed or refused medications that were ordered by the physician.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure staff properly labeled all medications stored in one of four medication carts reviewed once opened; and 2. Provide a permanently affixed compartment for the storage of a schedule IV (potential for misuse and dependence) controlled substance in one of two medication room refrigerators reviewed.

Inspectors wroteBased on resident and staff interviews, observation, and meal test trays on two of three units, the facility failed to prepare and serve meals in a manner conserving flavor, were palatable, and served at safe and appetizing temperatures.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure for one Resident (#114), out of a total sample of three residents observed on a medication pass, infection prevention and control measures were implemented to prevent the potential transmission of infections. Specifically, the facility failed to ensure staff followed basic infection control practices, including hand hygiene, resulting in potential cross contamination (transfer of pathogens from one surface to another).

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who complained of abdominal pain and experienced multiple episodes of diarrhea for several days which interfered with his/her ability to participate in rehabilitation therapy, the Facility failed to ensure nursing notified his/her Physician in a timely manner of his/her change in condition, in an effort to obtain orders to meet his/her care and treatment needs. Findings Include: Review of the Facility Policy titled, Condition: Significant Change, dated as last revised 2/16/16, indicated that professional staff will promptly communicate with the physician, resident, and family regarding changes in condition. The Policy further indicated that the notification including date, time, and by whom, shall be documented in the clinical record by appropriate personnel. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to prevent a decline in range of motion causing the development of a contracture for one Resident (#122), out of a total sample of 31 residents.

Inspectors wroteBased on observations, policy review, and interview, the facility failed to provide a dignified dining experience for one Resident (#113), out of a total sample of 31 residents. Specifically, staff stood over the Resident while feeding him/her meals, rather than seated at eye level.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one Resident (#113) was free from restraints, out of a total sample of 31 residents. Specifically, for Resident #113 the facility failed to assess the use of pillows under the fitted sheet on both sides of the bed as a potential restraint.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to report to the Department of Public Health's (DPH's) Health Care Facility Reporting System (HCFRS) a possible misappropriation of a discharged resident's property. Specifically, a family member completed a facility Complaint/Concern/Grievance Report form, which alleged 100 dollars was taken from a drawer.

Inspectors wroteBased on observation, record reviews, and staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) assessments were coded accurately for two Residents (#85 and #142), out of a total sample of 31 residents. Specifically, the facility failed to: 1. For Resident #85, accurately code a dental status; and 2. For Resident #142, accurately code the MDS as a discharge to the community.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure two Residents (#79 and #53), who required supervision with meals, received the supervision, and failed to implement an individualized care plan for heel boots for one Resident (#44), out of a total sample of 31 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure for one Resident (#122) that nail care was provided, out of a total sample of 31 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide standards of quality care for one Resident (#65), out of a total sample of 31 residents. Specifically, the facility failed to identify areas of discoloration on Resident #65's left hand and areas of discoloration on both right and left forearms.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that a Resident (#113) received treatment and care in accordance with professional standards of practice, out of a total sample of 31 residents. Specifically, for Resident #113 the facility failed to complete a wound dressing change to bilateral heels and apply heel protectors per physician's order.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to identify a possible hazard for one Resident (#98), out of a total sample of 31 residents. Specifically, Resident #98 had a heating pad in his/her room.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 2 nurses observed made 3 errors out of 26 opportunities resulting in a medication error rate of 11.5%. Those errors impacted 2 Residents (#13 and #118), out of 4 residents observed.