Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Marina Bay during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, B-cell lymphoma, and DM had ongoing unplanned weight loss, but ordered nutritional interventions were not consistently implemented. The RD recommended diet liberalization and supplements such as Mighty Shake, Magic Cup, Glucerna, and a multivitamin, yet the chart did not show these orders were carried out or declined by the physician. The resident was also observed asleep with an untouched breakfast tray and no staff present to assist with feeding, while the daughter reported the resident was not eating and needed help at meals.
Medication administration errors resulted in an 18.52% error rate after nurses failed to follow the Five Rights during a med pass. One nurse attempted to give meds prepared for one resident to another without using two identifiers, while two other nurses gave the wrong form of Vitamin B12 and the wrong dose of calcium with vitamin D after failing to verify the orders.
Failure to report and investigate alleged resident abuse: A resident with stroke, aphasia, and severe cognitive impairment was overheard being verbally abused by a roommate, appeared frightened, and indicated fear when questioned by an RN. The facility treated the event as a roommate issue, did not report it in HCFRS, and did not provide an investigation, despite staff acknowledging that alleged abuse requires immediate reporting and investigation.
Failure to report alleged abuse: A nurse witnessed a roommate repeatedly make verbally abusive comments toward a non-verbal resident with severe cognitive impairment, and the resident appeared scared and indicated a desire to move. The incident was not reported in HCFRS because the facility later stated it did not consider the event abuse.
A resident with anxiety, insomnia, and moderate cognitive impairment received PRN Ativan/Lorazepam, but the care plan did not address the psychotropic medication, adverse effects/side effects, or targeted behaviors. Staff interviews confirmed there was no care plan in place, and the MAR did not include the required behavior or side effect monitoring.
Failure to assess trauma and identify triggers for a resident with PTSD: A resident with a history of military service, PTSD, and moderate cognitive impairment reacted to loud noises by trying to stand up and saying he/she did not like loud noises and to stop yelling. Notes also documented anxiety, fear that everyone would die, and concern about an explosion. The record showed no completed trauma assessment, no identified triggers, and no trauma-related care plan, and staff said they had not completed the assessment or linked the resident’s behaviors to possible trauma.
Bare-Hand Handling of Ready-to-Eat Food: A resident with dysphagia, legal blindness, and moderate cognitive impairment was served breakfast by a Speech Therapist who handled a biscuit with bare hands, split it apart with her fingers, applied butter and jam, and touched other tray items and the bed sheet before giving it to the resident. Facility staff later confirmed that ready-to-eat food should not be handled with bare hands and that gloves or utensils should be used.
A nurse in an LTC facility made seven medication errors out of 40 opportunities, resulting in a 17.5% error rate, affecting a resident with a history of seizure disorder, COPD, and anxiety. The nurse administered incorrect doses of Buspar, Neurontin, and Tylenol, and failed to administer prescribed inhalers and Lidocaine patches. The facility's policy on medication administration was not followed.
The facility failed to maintain food safety and sanitation standards, as observed in multiple nourishment kitchenettes with unclean microwaves and improperly labeled food items. Staff interviews revealed unclear responsibilities for maintaining cleanliness and proper labeling, contributing to the deficiencies.
A resident was not informed or involved in their baseline care plan within 48 hours of admission, as required by facility policy. Despite the facility's process for an interdisciplinary team (IDT) meeting, the resident reported not having such a meeting or receiving a care plan summary. Staff interviews and document reviews revealed discrepancies, including inaccurate documentation and failure to adhere to the required timeframe, leading to the resident's exclusion from the care planning process.
Two residents in a LTC facility experienced deficiencies in care and medication administration. One resident did not receive the required one-to-one assistance during meals, despite an active physician's order. Another resident received incorrect medication doses, and several medications were not administered as ordered, with errors documented in the MAR. Staff interviews revealed a lack of adherence to facility policies and physician orders.
The facility failed to properly label and store medications, including a vial of Lantus insulin that lacked an opening date and expiration date, and lorazepam stored in a non-permanently affixed box in a refrigerator. The insulin was found in a medication cart without proper labeling, and the controlled substance box was not secured as required by policy.
The facility failed to serve meals at safe and appetizing temperatures, as confirmed by resident feedback and test trays. Residents reported concerns about cold food, and test trays showed that several food items were not within appropriate temperature ranges. The Dietitian acknowledged the issue, noting that trays should not be delivered on a pushcart to maintain proper temperatures.
A nurse in an LTC facility failed to follow infection control protocols during a medication pass for a resident with Type II Diabetes. The nurse handled spilled tablets with bare hands, did not perform hand hygiene before or after administering medications and insulin injections, and failed to wear gloves during injections. These actions were against the facility's policies and posed a risk of cross-contamination.
Failure to Implement Nutritional Interventions for Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for one resident who had an unplanned weight loss. Resident #131 was admitted with diagnoses including B-cell lymphoma and diabetes mellitus, and the MDS indicated severe cognitive impairment. The resident’s weight declined from 186.6 lbs. on 10/2/24 to 161.6 lbs. on 3/31/25, and then to 150.5 lbs. on 9/30/25, reflecting continued weight loss over 12 months. The resident’s daughter reported that the resident was losing weight, was not eating, and needed assistance with feeding, and she requested staff help at meals because the resident had difficulty using utensils. The record showed dietary recommendations were made in response to the weight loss, including Mighty Shake, Magic Cup, Glucerna, Multivitamin with Minerals, and liberalizing the diet to House. However, the diet order did not reflect liberalization, and the physician orders and MAR did not show that Mighty Shake, Magic Cup, Multivitamin with Minerals, or Glucerna had been ordered or implemented. The nursing and physician progress notes also did not show that the RD recommendations had been reviewed and declined by the physician. Staff interviews indicated the communication process for RD recommendations was inconsistent and confusing, with emails and progress notes not matching and orders not reliably being entered. During observation, the resident was found asleep in bed with an uncovered breakfast tray in front of them and no staff present to assist with feeding. The resident’s daughter had already reported that breakfast was not being eaten and that assistance was needed at every meal. The RD and unit manager both acknowledged that recommendations were being missed, that some recommendations in the progress notes did not match the emails, and that ordered interventions had not been implemented.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% after two of three nurses observed during a medication pass made five errors in 27 opportunities, resulting in an 18.52% medication error rate. The facility policy required medications to be administered as prescribed, using the Five Rights and two forms of resident identification before administration. During observation, Nurse #3 prepared medications for Resident #161 but entered Resident #162's room and attempted to give the medications to Resident #162 without checking two identifiers. Nurse #3 told Resident #162 the medications were morning medications and later acknowledged he had intended the medications for Resident #161 and had not verified the resident before attempting administration. In a separate observation, Nurse #2 administered Vitamin B12 Complex to Resident #143 even though the physician's order was for Vitamin B-12 500 mcg, one tablet daily, and later stated the wrong form had been given. Also, Nurse #4 administered Calcium 600 mg + Vitamin D3 10 mcg to Resident #93 when the order was for Calcium 600 mg + Vitamin D3 5 mcg, one tablet twice daily, and stated she had grabbed the wrong bottle and had not verified the dose.
Failure to Report and Investigate Alleged Resident Abuse
Penalty
Summary
The facility failed to implement its written abuse policies and procedures after an allegation of abuse involving a resident with severe cognitive impairment and aphasia. The resident was admitted in March 2025 with diagnoses of cerebral infarction and aphasia, and the MDS dated 7/4/25 showed a BIMS score of 5 out of 15. The resident was non-verbal but could make himself/herself understood and could understand others. On 5/1/25, a nurse documented that the resident’s roommate was repeatedly verbally abusive, making derogatory and profane comments within the resident’s hearing. The note stated the resident appeared frightened, with bulging eyes, and responded by nodding yes when asked if the roommate was yelling at him/her. The nurse offered a room change, and the resident wrote that he/she would move. The resident was moved to another room on 5/2/25. The facility did not report the incident to the state agency in HCFRS, and no investigation was provided to surveyors at exit. During interviews, staff described the event as a roommate issue or intermittent conflict and stated that the facility did not consider it abuse. The Director of Social Services said any abuse or alleged abuse needed to be reported and investigated, but also stated the incident was not viewed as a resident-to-resident altercation and that no investigation note had been written at the time. The Administrator stated that if the incident had been considered abuse, it would have been reported and investigated, but later said the facility had not considered it abuse and therefore did not have an investigation to provide.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency for one resident. The facility policy titled Abuse Prohibition required all alleged violations of resident abuse to be reported to the appropriate state agency through the proper online reporting system, with the initial report submitted immediately but no later than two hours after the allegation was made. The policy also stated that all alleged violations involving abuse, mistreatment, neglect, involuntary seclusion, or misappropriation of resident property were to be reported to the Department of Public Health upon receipt of the facility's basic findings. Resident #5 was admitted in March 2025 with diagnoses of cerebral infarction and aphasia. The MDS dated 7/4/25 showed severe cognitive impairment with a BIMS score of 5 out of 15; the resident was non-verbal but able to make himself/herself understood and able to understand others. On 5/1/25, a nurse documented witnessing the resident's roommate repeatedly make verbally abusive comments in the resident's earshot, including statements that the resident wanted to "lay there like a lump," "sh**s the [expletive] bed," and caused problems with the TV and sleep. The nurse observed the resident with eyes bulging as if scared, noted the resident nodded yes when asked if the roommate was yelling, and documented that the resident wrote that he/she would move if another room was available. Review of the HCFRS showed no report submitted for this allegation, and the Administrator later stated the facility did not consider the incident abuse and therefore did not report it.
Failure to Care Plan and Monitor PRN Ativan Use
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for the use of psychotropic medication for Resident #163. The resident was admitted in August 2023 with diagnoses including senile adjustment disorder with anxiety and insomnia, and the 9/23/25 MDS showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The comprehensive care plan did not identify that the resident was taking psychotropic medication, and it did not include monitoring for adverse effects or side effects of the medication, or monitoring for targeted behaviors. The active physician orders included Lorazepam/Ativan 0.5 mg every 4 hours PRN during the review period, including an order to continue Ativan for 14 days and then reassess. The physician orders did not indicate monitoring for adverse effects/side effects or targeted behaviors. During interviews on 10/2/25, Nurse #7, the Unit Manager, and the DON each stated that a care plan should have been in place and was not, and that targeted behavior monitoring and side effect monitoring should have been on the MAR but were not. The DON also stated that CNAs documented to regular behavior sheets, while nurses documented targeted behaviors for psych meds on the MAR.
Failure to Assess Trauma and Identify Triggers for Resident With PTSD
Penalty
Summary
The facility failed to assess and develop a person-centered plan of care that included trauma-informed approaches and identified triggers to avoid potential re-traumatization for one resident with a history of trauma. Resident #160 was admitted with diagnoses including PTSD and had a MDS assessment showing moderate cognitive impairment with a BIMS score of 11 out of 15. The facility’s trauma-informed care policy required residents to be screened for past trauma and traumatic stress on admission and for the interdisciplinary team to create a culturally sensitive plan of care with identified triggers, prevention, intervention, and treatment services when trauma was present. During observation, Resident #160 was seen in the dining room reacting to loud noises by attempting to stand from the wheelchair and stating, “I don’t like loud noises” and “stop yelling.” Nursing progress notes documented anxiety, statements that “everyone will die tonight,” praying, and increased anxiety about an explosion, with the resident kept on 1:1 supervision because he/she tried to get up when not being watched. Review of the medical record and assessments showed no completed trauma assessment, no identified triggers, and no trauma-related care plan. Staff interviews confirmed awareness of the resident’s military service, PTSD, anxiety, agitation, and startle response, but the nurse and social worker stated they had not completed a trauma assessment or identified triggers.
Bare-Hand Handling of Ready-to-Eat Food
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional food service safety standards when staff handled ready-to-eat food with bare hands during breakfast service. The report cites the FDA Food Code and the facility policy requiring food to be handled as little as possible and for plastic gloves or utensils to be used in the production and serving of all foods. Staff interviews confirmed that food should not be handled with bare hands and that gloves should be used when picking up food such as a roll or biscuit. Resident #163 was admitted with dysphagia, legal blindness, and macular degeneration, and the MDS indicated moderate cognitive impairment and moderate vision impairment. During breakfast, the Speech Therapist picked up the resident’s biscuit with bare hands, asked about butter or jam, then returned and again handled the biscuit with bare hands, pushed fingers into it to split it into two halves, held the halves in her bare hand, and applied butter and jam with a knife. She then touched cups, utensils, and the bed sheet before handing the biscuit to the resident and wiping her hands with a dry tissue.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by one nurse making seven errors out of 40 opportunities, resulting in a 17.5% error rate. These errors affected one resident, who was observed to have received incorrect doses of Buspar, Neurontin, and Tylenol. Additionally, the nurse failed to administer Anoro Ellipta, Fluticasone Propionate, Ipratropium Bromide, and Lidocaine patches as prescribed. The facility's medication administration policy requires reviewing the five rights three times, checking the Medication Administration Record (MAR) for orders, and verifying the label against the MAR order, which were not adhered to in this instance. The resident involved had a medical history that included seizure disorder, joint replacement of the right shoulder, COPD, and anxiety. During the medication administration, the nurse mistakenly gave the nighttime dose of Buspar, administered an incorrect dose of Neurontin, and failed to replace a dropped Tylenol tablet. The nurse also did not administer the inhalers and patches, citing the resident's refusal and the presence of a shoulder brace as reasons. The Assistant Director of Nursing expressed that the expectation is for nurses to administer medications as ordered by the physician.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. Observations made by the surveyor revealed that nourishment kitchenettes across multiple units were not maintained in a clean and sanitary condition. Specifically, microwaves in the Cityside, Harborside One, Harborside Two, and Seaport Units were found with food residue and splatter, and some had peeling and burnt plastic. Additionally, refrigerators contained food items that were not properly labeled or dated, such as grapes and soup without resident identification, and a Styrofoam container and a candy bar with no date or resident identification. Interviews with staff indicated a lack of clarity and execution in responsibilities related to maintaining cleanliness and proper labeling in the nourishment kitchenettes. Dietary Staff #2 mentioned that stocking dietary items was her responsibility, while Housekeeping Staff #1 stated that she was responsible for cleaning the microwaves and refrigerators. The Dietitian confirmed that the equipment should be clean and in good working condition, and that food items should be labeled with the resident's name and date. However, the observations made by the surveyor indicated that these standards were not being consistently met, leading to the identified deficiencies.
Failure to Involve Resident in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #303, was informed of and actively participated in their baseline plan of care within the first 48 hours following admission. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, involving an interdisciplinary team (IDT) meeting with the resident to discuss individual goals and plans. However, Resident #303 reported not having a meeting with the IDT or being offered a summary of their care plan or initial goals during their short-term stay. Interviews and document reviews revealed discrepancies in the facility's documentation and process. The case manager stated that the IDT should meet with each resident within two days of admission, but Resident #303 did not have a signed baseline care plan summary in their record. The Unit Manager (UM) and Social Worker (SW) attempted to provide Resident #303 with a care plan summary form, insisting that a meeting had occurred on a specific date, which the resident disputed. The resident's roommate corroborated that no meeting took place on the claimed date, as Resident #303 was out of the facility for a significant portion of that day. Further interviews with staff, including the Director of Nurses (DON) and a consultant, confirmed that the baseline care plan process was not followed as expected. The staff acknowledged that the dates on the care plan form were inaccurate and that the resident was not involved in the process within the required timeframe. The facility's failure to adhere to its policy and regulatory requirements resulted in Resident #303 not being informed or involved in their care planning process as intended.
Deficiencies in Care and Medication Administration
Penalty
Summary
The facility failed to meet professional standards of care for two residents, leading to deficiencies in the administration of care and medication. For one resident, the facility did not adhere to the physician's order for one-to-one assistance during oral intake. Despite the order being active, the resident was observed eating alone multiple times, without the required supervision. The staff, including CNAs and the unit manager, were either unaware of the order or did not follow it, resulting in the resident consuming meals without the necessary assistance. The speech-language pathologist confirmed the need for supervision, but the order was not updated or followed until after the surveyor's inquiry. Another resident experienced deficiencies in medication administration. The nurse failed to follow the standard procedure of verifying the five rights and three checks, leading to incorrect doses of medications being administered. Additionally, several medications were not given as ordered, and the nurse documented them as administered in the Medication Administration Record (MAR). The nurse admitted to errors in medication preparation and documentation, including administering the wrong dose of Buspar and Neurontin, and failing to provide the correct amount of Tylenol. The resident's refusal of certain medications was not documented, and the nurse incorrectly signed off on the MAR. Interviews with the nursing staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that the facility's expectations for medication administration were not met. The nurse did not notify the physician of the medication errors or complete a medication error form. The facility's policies on medication administration and physician orders were not followed, leading to these deficiencies in care and documentation.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to accepted professional principles. Specifically, one of the deficiencies involved a multidose vial of Lantus insulin that was not labeled with the date it was opened or the new expiration date. This vial was found in a medication cart without its packaging box, and the nurse responsible was unaware of when it had been opened. The Director of Nursing, Administrator, and Consulting Staff confirmed that the insulin should have been labeled with the date it was opened and its expiration date, as it is only effective for 28 days after opening. Another deficiency was observed in the storage of a schedule IV controlled substance, lorazepam, in a medication room refrigerator. The controlled substance was stored in a locked box that was not permanently affixed to the refrigerator, as required by the facility's policy. Although the box was double locked, it could be removed from the refrigerator because the shelf it was attached to was not secured. The nurse acknowledged the issue and mentioned that maintenance had been asked multiple times to fix it, but they were unable to do so. Consulting Staff confirmed that the policy required the box to be permanently affixed, but it was not due to the refrigerator being locked instead.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that meals were prepared and served at safe and appetizing temperatures, as evidenced by resident and staff interviews, observations, and meal test trays conducted by surveyors. During a Resident Council Meeting, all 14 residents present expressed concerns about receiving cold food across all mealtimes. A review of the Resident Council Meeting Minutes from June also indicated similar concerns about food temperatures. These issues were further substantiated by test trays conducted on two separate occasions, which revealed that food items were not within appropriate temperature ranges. On one occasion, a lunch test tray on the Harborside Two Unit showed that the sweet and sour chicken was served at 138.8°F, while mixed vegetables and rice were significantly below the expected temperature, being cold to taste. Strawberries and milk were also served at inappropriate temperatures, with the milk being too warm. Similarly, a breakfast test tray on the Cityside Unit revealed that oatmeal and a muffin were served at cool temperatures, and the milk was again too warm. The Dietitian confirmed that the meal temperatures were not within appropriate ranges and noted that trays should not be delivered on a pushcart, as this could contribute to the temperature issues observed.
Infection Control Deficiency During Medication Pass
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during a medication pass for a resident diagnosed with Type II Diabetes. Nurse #1 was observed preparing and administering medications without adhering to the facility's hand hygiene policy. Specifically, Nurse #1 spilled two tablets onto the medication cart, picked them up with bare hands, and placed them back into the medication cup. This action was contrary to the facility's policy, which requires discarding contaminated medications. Additionally, Nurse #1 did not perform hand hygiene before entering the resident's room or after administering medications and insulin injections. The nurse also failed to wear gloves while administering insulin injections, which is a requirement to prevent contact with bodily fluids. These actions were observed by the surveyor and confirmed during interviews with the nurse, the Assistant Director of Nurses (ADON), and the Director of Nursing (DON). The ADON and DON both stated that the facility's expectations were not met, as medications touched with bare hands should be discarded, and hand hygiene should be performed before and after medication administration. Gloves are also required for injections to reduce the risk of cross-contamination. The failure to follow these infection control guidelines resulted in a potential risk of cross-contamination and transmission of infections.
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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 Quincy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bostonian Nursing Care & Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| St Joseph Rehab & Nursing Care Center | 1.5 mi | ★★★★★ | 5 | 0 |
| Boston Home, Inc (the) | 2.1 mi | ★★★★★ | 0 | 0 |
| Marian Manor | 2.9 mi | — | 0 | 0 |
| Care Village At Mattapan | 3.6 mi | ★★★★★ | 14 | 0 |
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