Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Guam Memorial Hospital Authority during CMS and state inspections, most recent first.
Failure to inspect bed systems for entrapment hazards: The facility did not maintain a regular program to inspect bed rails, mattresses, and frames or measure FDA entrapment zones. The ML stated annual bed checks focused on electrical components and function, but entrapment measurements were not being done, and the DON stated all residents had bed rails because they came on the bed. Multiple residents were observed with raised bed rails, including combinations of upper and lower rails, and the facility policy called for regular bed inspections and individual bed rail evaluations.
Bed Rail Use Without Attempted Alternatives: The facility used bed/side rails for multiple residents without documenting attempted alternatives, physician orders, or care plans that addressed the specific rail use. Residents with varying cognitive status were observed with raised 1/3 rails, and staff and the DON confirmed the rails were being used for mobility or because the residents felt safer or feared falling out of bed, while records did not show education on risks or review of alternatives.
Failure to obtain informed consent for psychotropic medication: A resident with dementia and failure to thrive received Quetiapine 25 mg HS, but the EMR had no documented diagnosis for the order and no documentation that informed consent was obtained for the antipsychotic. The resident was severely cognitively impaired, and the DON stated she was not aware informed consent was required for any psychotropic medication; the facility policy provided did not address informed consent.
Incontinence Brief Sizes Not Available: A resident who was cognitively intact reported that medium briefs did not fit and that he had been using a brief with a chux tucked over the groin area because larger briefs were not available. Staff interviews and supply checks showed only medium briefs were on hand, with the DON and AO acknowledging the facility had been out of larger sizes and inventory records showing the last large brief supply was documented months earlier.
The facility failed to provide NOMNC notices to two residents before Medicare A coverage ended. One resident had a post-surgical femur fracture and the other had oxygen dependence; in both cases, the NOMNC was signed after the last covered day instead of being delivered at least two calendar days in advance, as confirmed by the HUS and the facility policy.
Unnecessary Psychotropic Medication Use: Two residents were given psychotropic medications without documented diagnoses or clear rationales. One cognitively intact resident with stroke-like symptoms and diabetes received Trazodone with no documented behavior history, side effect tracking, or evidence that non-pharmacological interventions were tried first. Another resident with dementia and failure to thrive received Quetiapine for unspecified minor outbursts, with no specific behaviors documented, no side effect tracking, and no record of non-pharmaceutical interventions before the medication was started.
Incomplete Admission MDS Assessment: The facility failed to complete and transmit a resident’s comprehensive admission MDS within the required timeframe. The MDSC confirmed the admission comprehensive MDS remained incomplete, and the RAI Manual requires comprehensive assessments to be transmitted electronically within 14 days of the Care Plan Completion Date.
Late Transmission of MDS Assessments: The facility failed to transmit multiple MDS assessments within the required timeframe for several residents. Record review showed quarterly, admission, and discharge return anticipated MDSs were left in folders at the nurse's desk and submitted late, and the MDSC and DON confirmed the assessments were expected to be transmitted timely. The validation report identified the records as late, and the RAI Manual requires transmission within 14 days of the applicable completion date.
Inaccurate MDS Antipsychotic Medication Assessment: A resident with dementia and Failure to Thrive had a quarterly MDS that stated no antipsychotic medication was being given, even though the MAR/TAR showed daily Quetiapine during the look-back period. The MDSC confirmed the assessment was inaccurate, and the DON stated MDS assessments were expected to be accurate.
PASARR screening for mental disorders or ID was not completed for a resident admitted with dementia. The EMR contained no documentation of a PASARR Level 1 screening before admission or during the stay, and the resident’s MDS showed severe cognitive impairment with a BIMS score of 5 out of 15. The DON confirmed she was responsible for PASARR completion but could not locate the screening, and the facility’s PASARR policy was not provided before survey exit.
The facility failed to develop comprehensive, person-centered care plans for two residents with assessed needs. One resident with a CVA history, UTI fever, and bedbound status had bed rails in use, including padded rails, but this was not care planned. Another resident with depression and an undiagnosed mental disability had an activity assessment identifying 1:1 and group interventions, but the care plan did not reflect a personalized activity plan. The DON confirmed both bed rail use and activities should have been care planned.
Failure to Provide Routine Dental Services: The facility failed to ensure routine dental services were provided for one resident reviewed for dental care. The resident had a history of stroke and poor cognition, and the record showed no physician order or documentation of a dental visit since admission. The SSD and DON both confirmed the resident had not been offered routine dental services, despite the facility policy requiring routine or emergency dental services to meet each resident's needs.
Failure to document and offer influenza and pneumococcal vaccinations for a resident admitted over age 65. The resident had moderate cognitive impairment per BIMS, but the EMR contained no record of vaccine assessment, administration, refusal, contraindication, or prior vaccination status. The IP and DON both confirmed the missing documentation, and facility policy required the assigned licensed nurse to assess each resident on admission for vaccine eligibility.
The facility failed to assess, offer, provide, or document COVID-19 vaccination status for two residents. One cognitively intact resident was educated and agreed to receive the vaccine, but the record did not show it was ever given or that refusal, contraindication, or prior vaccination status was documented. A second resident with moderate cognitive impairment had no documentation of assessment, offer, administration, refusal, contraindication, or prior vaccination status. The IP and DON confirmed the missing documentation and that COVID immunizations were expected to be addressed on admission.
Governing body failed to appoint a licensed LNHA responsible for facility management. The DON confirmed she was acting as Administrator without an Administrator’s license, while records showed the LNHA vacancy was discussed at multiple Board of Trustees and QA meetings and only one qualified applicant was identified. Facility policy required the governing body to appoint the Administrator, and Guam law requires nursing home operation under a licensed nursing home administrator.
Failure to Provide Disclosure of Ownership: The facility failed to present the Disclosure of Ownership during the extended survey. The AO stated the responsible department was closed and the document would be emailed later, but it had not been provided by the time of the survey exit.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care.
Surveyors identified multiple food safety and sanitation deficiencies, including rusty equipment, unclean food contact surfaces, improper storage of staff food with residents' food, and unsanitary food handling practices such as inadequate hand hygiene and improper use of gloves and utensils during meal service.
The facility did not have a licensed administrator in place for several months, as confirmed by the DON, MD, and governing board members. The hospital CEO, who was overseeing the SNU, did not hold the required Nursing Home Administrator license. This lack of proper administrative oversight led to inconsistent availability of essential supplies, including linens and colostomy bags, for residents.
The facility did not hold required QAPI meetings for three quarters and failed to address ongoing supply shortages, including linens and colostomy bags, when a meeting was eventually held. The QAPI plan was outdated, and there was no system for incorporating staff or resident feedback into quality monitoring, resulting in unresolved care issues such as missed showers for a resident.
The facility did not hold QAA committee meetings for three consecutive quarters due to the absence of an administrator and failed to include required members such as the administrator, owner, or board member. The issue was identified when a covering physician called for a QAPI meeting, and records showed the most recent agenda lacked committee member names.
Multiple lapses in infection prevention and control were observed, including improper hand hygiene and glove use by nursing and food service staff, an inadequate water management plan lacking protocols for Legionella prevention, and insufficient staff training and education on infection control and COVID-19 vaccination. These deficiencies were confirmed through staff interviews, record reviews, and direct observation of care provided to two residents.
The facility did not assign a qualified infection preventionist to oversee the infection prevention and control program, resulting in a lack of appropriate oversight for this critical area.
The facility did not provide required advance directive information to several residents, failed to maintain copies of advance directives in medical records, and lacked clear policies and staff responsibility for the process. Residents with cognitive or communication impairments were documented as having received information they could not understand, and documentation was often missing or inaccessible to staff.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely.
The facility did not provide education on the benefits, risks, and potential side effects of the COVID-19 vaccine to 73 out of 75 employees. Only two staff members received handouts, and interviews confirmed that most staff did not recall receiving any education. The facility's policy did not address the requirement for staff education on the vaccine.
The facility did not provide required in-service training on infection prevention and control, including current COVID-19 vaccination requirements and Enhanced Barrier Precaution (EBP) practices, to its staff. Multiple staff members reported not receiving recent or specific training, and training records confirmed the absence of documented education on these topics, despite facility policy requiring such training.
Two residents were assisted with meals by a CNA who stood over them rather than sitting at eye level, contrary to facility policy and training. Both residents were in bed with the head elevated and ended their meals after a few spoonfuls. The CNA acknowledged knowing the correct procedure but did not follow it, and the DON confirmed staff are expected to sit and maintain eye contact during feeding.
A resident with dementia was given an increased dose of quetiapine, an antipsychotic, without documented behavioral justification or attempts at gradual dose reduction, despite ongoing monitoring showing no behaviors. Staff and consultant pharmacist interviews revealed a lack of awareness of GDR requirements, and the facility lacked a policy addressing gradual dose reduction for psychotropic medications.
Two residents did not receive accurate or complete MDS assessments. One resident's MDS incorrectly indicated receipt of insulin and a diuretic, despite no such medications being ordered or administered, while another resident's discharge MDS was not completed as required.
A resident with complex medical needs experienced significant, rapid weight fluctuations while receiving tube feeding, but staff did not document or communicate these changes to the RD or discuss them in IDT meetings. Although facility procedures required assessment and notification for such variances, these steps were not followed, and there was no specific weight monitoring policy in place.
A resident requiring colostomy, urostomy, or ileostomy care did not receive the appropriate care or services needed for their condition.
A nurse administered a multivitamin with minerals to a resident instead of the prescribed multivitamin alone, as specified in the physician's order. The nurse, who was unfamiliar with the resident's morning medications, did not verify the medication against the order, resulting in administration of the incorrect product.
A medication cart was found unlocked and unattended in a hallway while the nurse responsible was assisting a resident in a nearby room. An RN confirmed the cart should have been secured, in accordance with facility policy requiring all medications to be stored in locked carts or drawers when not in use.
Failure to Inspect Bed Systems for Entrapment Hazards
Penalty
Summary
The facility failed to implement a regular maintenance program to ensure bed systems, including bed rails, mattresses, and frames, were inspected for safety and potential entrapment hazards. The report states that the facility did not conduct routine assessments of mattress fit or measure potential entrapment zones in accordance with FDA guidance, despite having a policy that called for regular inspection of all bed systems and individual bed rail evaluations. The Maintenance Leader stated that annual bed inspections were performed for electrical components and bed functionality, but entrapment measurements were not being done, and later stated that FDA-recommended testing had been done in 2023 but not since. Observations showed multiple residents using bed rails in their rooms and beds. R2 was repeatedly observed in bed with raised 1/3 bed rails, including two rails at the head of the bed and, at times, a rail at the foot of the bed; R2 stated he thought the rails were there to keep him from falling out of bed. R3, R5, R8, R11, and R12 were also observed in bed with combinations of raised 1/3 rails, including some observations with rails at both the head and foot of the bed. Additional residents, including R4, R9, R13, R22, R23, R25, R26, and R27, were observed with bilateral upper bed rails raised, and some were also observed with a lower rail raised. The DON stated that all residents had bed rails because they came on the bed. The facility policy titled Safe and Effective Bed Rail Use stated that the facility would identify and reduce safety risks associated with bed rail use through regular bed maintenance and individual bed rail evaluations, including regular inspection of rails, frames, mattresses, and operational components. The policy also described FDA potential zones of entrapment and dimensional recommendations, but the maintenance records reviewed did not show that entrapment measurements were performed as part of an ongoing process.
Bed Rail Use Without Attempted Alternatives
Penalty
Summary
The facility failed to ensure alternatives were attempted before using bed/side rails for 6 of 19 sampled residents: R2, R3, R5, R8, R11, and R12. The report states that the facility did not ensure the residents were assessed for safety risk, did not document review of risks and benefits with the resident or representative, did not document informed consent, and did not document that alternatives were attempted before the rails were used. The deficiency was identified through observation, interview, record review, review of FDA guidance, and policy review. For R2, the record showed a history of stroke-like symptoms, a BIMS score of 14, and no physician order for bed rails. The care plan did not address bed rail use, and the bed rail risk assessment stated the rails were being used for mobility and safety per the resident’s request, but it did not address attempted alternatives. Clinical notes did not show that alternatives were tried or that education on bed rail risks was provided. Observations showed R2 in bed with raised 1/3 rails on multiple occasions, and the DON confirmed the resident used the rails to move around in bed and that no alternatives had been attempted. For R3, R5, R8, R11, and R12, the records similarly showed bed rail use without physician orders, without care plans that addressed the specific reason, type, or size of rails, and without documentation of attempted alternatives or education on risks. R3 was cognitively intact with a BIMS of 15 and was observed with four 1/3 rails raised; staff stated she requested the rails because they made her feel safe. R5 had poor cognition and dementia, was dependent for bed mobility and transfers, and was observed with three 1/3 rails raised; staff stated he used the rails to move in bed because he was afraid of falling out. R8 was cognitively intact and was observed with three 1/3 rails raised; staff stated he had rails because he was afraid of falling out of bed. R11 was cognitively intact and was observed with four 1/3 rails raised; staff stated the resident used the rails to move in bed, and the DON stated four rails should never be raised on any resident’s bed. R12 had severe cognitive impairment and dementia, was observed with two or three 1/3 rails raised, and staff stated the rails were used to assist with mobility in bed and because she was afraid to fall out of bed. In each case, the DON confirmed no alternatives had been attempted and stated the rails were integral to the bed.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to advise one resident with dementia and failure to thrive of the risks and benefits of psychotropic medication use. Review of the resident’s records showed an order for Quetiapine 25 mg at bedtime, an antipsychotic medication, with no diagnosis documented in the EMR for the order. The resident’s quarterly MDS showed a BMS score of 5 out of 15, indicating severe cognitive impairment. The MARs showed the resident received Quetiapine as ordered from 06/01/26 through 06/06/26. Review of the resident’s EMR found no documentation that informed consent had been obtained for the antipsychotic medication. During interview, the DON stated she was not aware informed consent was to be obtained for the administration of any psychotropic medication. The facility policy provided to surveyors addressed administration of psychotropic medication but did not address informed consent for its administration.
Incontinence Brief Sizes Not Available
Penalty
Summary
The facility failed to ensure appropriate sized incontinence briefs were available for one resident who was cognitively intact with a BIMS score of 15 out of 15. During interview and observation, the resident stated the medium briefs did not fit and asked whether large briefs were available. When the resident was later observed, a brief was being used under him with an absorbent bed pad tucked over the top of the groin area, and the resident stated this had been going on for a while and that the arrangement was uncomfortable, embarrassing, and undignified. Record review and staff interviews showed the facility had only medium briefs available in the clean utility room and PAR level supply room, while the CSR room did not contain briefs. The DON stated the facility normally had the larger size but CSR was out, and the AO stated she had been told it was January when the large size was last available. Facility inventory documentation showed the last supply of large incontinence briefs was documented on 02/02/26, and staff stated they had been using medium briefs for the past couple of months. The resident reported he had not had large briefs since February and had been told the facility was out of stock.
Late NOMNC Notices for Medicare Coverage Ending
Penalty
Summary
The facility failed to ensure that Notification of Medicare Non-Coverage (NOMNC) advisements were provided to two residents, R29 and R30, at least two days before Medicare A services ended. For R29, the record showed an admission date of 01/19/26 with a diagnosis of post-surgical right femur fracture. The facility’s NOMNC worksheet listed 01/19/26 as the start of Medicare A services and 02/02/26 as the last covered day, and the NOMNC form showed R29 signed on 02/02/26. During interview, the Hospital Utilization Specialist confirmed the NOMNC was supposed to be issued two days in advance of the last covered day and confirmed it was not provided two days prior to the end of Medicare A services. For R30, the record showed an admission date of 04/12/26 with a diagnosis of oxygen dependence. The facility’s NOMNC worksheet listed 04/12/26 as both the start date and the last covered day of Medicare A services, and the NOMNC form showed R30 signed that she did not consent, with a facility representative signature dated 04/21/26. During interview, the Hospital Utilization Specialist stated R30 was transferred to the SNF because of the typhoon and needing hospital beds, and confirmed R30 required no skilled care and that the NOMNC was signed nine days after the end of the service date. The facility policy stated the NOMNC must be delivered at least two calendar days before Medicare covered services end.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure two residents were free from potential chemical restraints related to psychotropic medications. One resident, admitted with stroke-like symptoms and type 2 diabetes, had a BIMS score of 14 out of 15 and no behaviors documented during the assessment period, yet was receiving Trazodone 25 mg three times daily. The order had no diagnosis or rationale documented, the MAR showed the medication was being given, agitation was being monitored related to the medication, and there was no documentation of side effect tracking. The resident's care plan did not include anything specific related to antidepressant use, and the record contained no documentation that non-pharmaceutical methods were attempted before the Trazodone was started. Another resident, admitted with dementia and failure to thrive, had a BIMS score of 5 out of 15 and was receiving Quetiapine 25 mg at bedtime. The order had no diagnosis associated with it, the MAR showed the medication was administered, and confusion was being monitored related to the medication, but there was no documentation of side effect tracking. The resident's antipsychotic medication care plan stated Quetiapine was related to minor outbursts, but no specific behaviors were identified in the plan. The record also contained no documentation that non-pharmaceutical methods were attempted before Quetiapine was initiated. During interview, the DON confirmed that specific behaviors and side effects should be monitored, non-pharmacological interventions should be attempted before psychotropic medication is given, and a clear diagnosis or rationale should be documented for each psychotropic medication order.
Incomplete Admission MDS Assessment
Penalty
Summary
The facility failed to ensure a comprehensive admission MDS assessment was completed within the time frame required by the RAI Manual for one of 19 sampled residents, Resident 21. During the facility tour on 06/01/26 at 11:02 AM, Resident 21 was observed in his room. Review of the facility-provided resident matrix did not indicate that Resident 21 was a new admission within the past 30 days, and the facility-provided Patient Data sheet showed that Resident 21 was admitted to the facility on [DATE]. During an interview on 06/03/26 at 3:45 PM, the MDS Coordinator provided a note indicating that Resident 21's admission comprehensive MDS with an ARD of 04/21/26 was still incomplete. The MDS Coordinator stated she used the RAI Manual as a reference. Review of the RAI Manual dated October 2025 stated that comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments must be submitted within 14 days of the MDS Completion Date.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that MDS assessments were transmitted within the timeframes specified in the RAI Manual for 9 of 19 residents reviewed. Record review showed that quarterly, admission, and discharge return anticipated MDS assessments for residents including R1, R4, R7, R9, R22, R27, R2, R3, and R12 were found in folders kept at the nurse's desk and were not transmitted until 06/02/26 or 06/03/26, despite assessment reference dates in April and May 2026. The validation report identified each of these records as late, stating that the submission date was more than 14 days after the assessment. Interviews with the MDS Coordinator and the DON confirmed that MDS assessments were expected to be transmitted timely. The MDS Coordinator stated that she used the RAI Manual as a reference and confirmed that all of the cited assessments were submitted late. Review of the October 2025 RAI Manual stated that comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments must be submitted within 14 days of the MDS Completion Date.
Inaccurate MDS Antipsychotic Medication Assessment
Penalty
Summary
Ensure each resident receives an accurate assessment. Record review and interviews revealed that the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, R12. R12 was admitted with diagnoses of dementia and Failure to Thrive and had an order for Quetiapine 25 mg once daily at bedtime, an antipsychotic medication, with an initial order date of 07/18/25. The quarterly MDS with an Assessment Reference Date of 01/24/26, located in a folder at the nurse's desk, showed a BIMS score of 5 out of 15, indicating severe cognitive impairment, but it indicated the resident was not receiving an antipsychotic medication. Review of the MAR/TAR for 01/2026 showed R12 received Quetiapine daily during the seven-day look-back period for that MDS. During interview, the MDSC confirmed the quarterly MDS was inaccurate regarding antipsychotic medication administration, and the DON confirmed MDS assessments were expected to be accurate.
Missing PASARR Screening for Resident with Dementia
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident, R12, who was admitted with a diagnosis of dementia. Review of the resident’s EMR showed no documentation that a PASARR Level 1 screening had been completed prior to admission or at any time during the stay. The resident’s quarterly MDS with an ARD of 04/24/26 showed a BIMS score of 5 out of 15, indicating severe cognitive impairment. During interview, the DON confirmed she was responsible for ensuring PASARR Level 1 evaluations were completed for each resident, but she could not locate R12’s PASARR Level 1 screening. She also stated that each resident was expected to have a PASARR Level 1 screening prior to admission and again with any change in psychiatric status or addition of psychiatric medication to the plan of care. The facility’s PASARR policy was requested but not received prior to survey exit.
Incomplete Care Plans for Bed Rail Use and Activities
Penalty
Summary
The facility failed to ensure that two residents had comprehensive person-centered care plans with measurable objectives and timeframes to address needs identified in their assessments. One resident was readmitted with diagnoses including a history of cerebral vascular accident, fever from a urinary tract infection, and being bedbound. Observations showed the resident in bed with bilateral upper half rails in the up position with blue pads wrapped around them, and later with all four bed rails up with blue padding attached to all four rails. The facility’s care plan did not include the use of bed rails, and the DON stated that bed rail use should be care planned. Another resident was admitted with diagnoses of depression and an undiagnosed mental disability. Observations showed the resident in bed on multiple occasions. The resident’s activity assessment identified interventions including 1:1 conversation, exercise, music therapy, group bingo social activity, and outdoor sunshine/socialization, with a frequency of 5 to 7 times per week for 1:1/group activity. However, the care plan did not include a personalized activity care plan based on that assessment. The DON confirmed that activities should be care planned. The facility policy stated that comprehensive care plans must include measurable objectives and timetables based on the comprehensive assessment.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided for one resident, identified in the record as R5, who was reviewed for dental services. R5 was admitted with a diagnosis of history of stroke, and the quarterly MDS dated 03/22/26 indicated the resident's BIMS could not be completed due to poor cognition. The MDS also indicated no oral or dental problems. Review of the doctor's orders report dated 06/03/26 showed no physician's orders for the resident to see an oral health professional. R5's dental care plan dated 06/15/25 indicated the resident was expected to maintain good oral health and included a referral to an oral health professional, but the EMR contained no documentation that the resident had been seen by a dentist or oral health professional for routine dental care since admission. During interviews, the SSD stated residents were to be offered or receive routine dental services at least every six months and confirmed R5 had not been offered routine dental services since admission. The DON also confirmed R5 did not have a physician order for routine dental care and stated her expectation was that all residents should be offered routine dental care at least once every six months. The facility policy stated it must provide or obtain routine or emergency dental services to meet each resident's needs.
Failure to Document and Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that Resident 19 was assessed for influenza and pneumococcal vaccination status and that the indicated vaccines were offered and/or provided, or that refusal, contraindication, or prior vaccination status was documented. Resident 19’s undated patient data in the EMR showed admission to the facility and that the resident was over age 65 at the time of admission. The admission MDS with an ARD of 04/21/26, located in a folder at the nurse’s desk, showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Review of Resident 19’s immunization records dated 06/04/26 in the EMR showed no documentation that the facility assessed, offered, or provided influenza or pneumococcal vaccines, and no documentation of refusal, contraindication, or prior vaccination status. During interview, the IP stated influenza and pneumococcal vaccines were to be offered upon admission or at the hospital prior to transfer, and confirmed there was no documentation of Resident 19’s immunization status. The DON also confirmed that influenza and pneumococcal immunizations were expected to be offered and administered prior to or upon admission and that it was the facility’s responsibility to ensure this was done. The facility’s policies for administering pneumococcal and influenza vaccines both stated that upon admission the assigned licensed nurse would assess every resident for inclusion in the high-risk target group.
Failure to Document and Provide COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure residents were assessed for COVID-19 vaccination status and offered and/or provided the COVID-19 vaccine, or that refusal, contraindication, or prior vaccination status was documented for two residents reviewed for vaccinations. One resident had an admission date of 09/07/25, a BIMS score of 15 out of 15, and an IP nurse note dated 09/17/25 stating the resident was offered education on the vaccine and agreed to receive it when available. However, the clinical record contained no documentation that the vaccine was later administered, and there was no documentation of refusal, contraindication, or prior vaccination status. The IP confirmed there was no record the resident had received the COVID vaccine, and the DON stated the resident should have received whichever COVID vaccine he was due for. A second resident had an admission MDS with a BIMS score of 12 out of 15, indicating moderate cognitive impairment, and immunization records in the EMR showed no documentation that the facility assessed, offered, or provided the COVID-19 vaccine, or documented refusal, contraindication, or prior vaccination status. The IP stated COVID vaccines were to be offered upon admission or at the hospital prior to transfer and was not sure how the resident's immunization status had been missed. The DON confirmed COVID immunizations were expected to be offered and administered or documented as refused prior to or upon admission, and that it was the facility's responsibility to ensure this was done.
Governing Body Failed to Appoint a Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to ensure its governing body appointed a Licensed Nursing Home Administrator (LNHA) who was licensed and responsible for the management of the facility, reporting and being accountable to the governing body. During the entrance conference on 06/01/26, the DON confirmed she was serving as the Acting Administrator and did not have an Administrator’s license. Review of records provided on 06/02/26 showed that a LNHA job posting was completed in January 2025 and resulted in one qualified applicant. The file also showed the Board of Trustees Human Resources Subcommittee discussed the LNHA opening at multiple meetings, including 01/13/25, 02/10/26, 03/17/26, 04/28/26, and 05/13/26. During an interview on 06/06/26, the QPSRCA confirmed the LNHA position opening was also included on the facility’s Quality Assurance agenda. Review of the facility’s Governing Body policy stated the governing body is responsible for establishing and implementing policies for the management and operation of the Skilled Nursing Unit and appointing the Administrator. Review of the Guam Code Annotated, Chapter 15, stated no nursing home shall operate except under the supervision of a nursing home administrator, and no person shall be a nursing home administrator unless licensed under that chapter.
Failure to Provide Disclosure of Ownership
Penalty
Summary
The facility failed to present a Disclosure of Ownership during the extended survey. On 06/04/26 at 10:18 AM, the Disclosure of Ownership document was requested from the Administrative Officer (AO). During the exit conference on 06/06/26 at 6:00 PM, the AO stated that the department responsible for completing and providing the Disclosure of Ownership document was closed and that the document would be emailed on Monday. As of 06/10/26 at 5:30 AM, the facility had not provided the Disclosure of Ownership document.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain food safety standards in several key areas, as observed during a kitchen tour and food service operations. Surveyors found that the box of the dishwasher heater booster and a stainless-steel storage cart were rusty, and the hinge and handle of the food steam table had a thick whitish, black, and brownish build-up. Additionally, staff personal food items were stored inside the kitchen walk-in refrigerator alongside residents' food items, contrary to facility policy requiring separate storage. Staff confirmed that personal food was kept in a designated bin within the same refrigerator as residents' food. Further deficiencies were observed in food handling and hygiene practices. A food service worker entered the kitchen from the dining area without washing hands and acknowledged the lapse. During tray line and food distribution, the same worker wore a glove on only one hand, touched food directly with the gloved hand, and moved between tasks without changing gloves or performing hand hygiene. Serving utensils were observed resting inside food trays, and food items were not measured according to meal tickets due to a lack of proper scoops. These actions were witnessed by supervisory staff, who intervened to address the improper practices.
Failure to Appoint Licensed Administrator Resulting in Oversight Lapses
Penalty
Summary
The facility failed to ensure that its governing body appointed a licensed administrator, as required by Guam Code Annotated (GCA) Chapter 15, to manage and oversee the facility. Interviews with the Director of Nursing (DON), Medical Director (MD), and Compliance Officer (CO) confirmed that the facility had been without an administrator since April 2024. The Medical Director clarified that he only oversaw clinical work and had no administrative oversight, while the hospital CEO, who was overseeing the Skilled Nursing Unit (SNU), acknowledged she did not possess a Nursing Home Administrator license as required by law. The CO further confirmed that the position had been vacant for some time, with ongoing but unsuccessful recruitment efforts due to salary expectations. As a result of not having a licensed administrator, the facility experienced lapses in oversight and accountability. This led to inconsistent availability of essential supplies for residents, such as linens and colostomy bags, as noted in the findings. The absence of a licensed administrator was verified through interviews and record review, and it was acknowledged by multiple members of the facility's leadership and governing body.
Failure to Maintain Effective QAPI Program and Address Supply Shortages
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not conducting required quarterly Quality Assessment and Assurance (QAA) committee meetings for three consecutive quarters. When a QAPI meeting was eventually held, the team did not address ongoing supply concerns, such as linen and colostomy bag shortages. The QAPI plan in use was outdated, containing indicators and measures only up to the previous year, with no current performance improvement projects or measures for the present year. The absence of an administrator was cited as a reason for the lack of QAA meetings, and there was confusion among leadership regarding oversight and responsibility for the QAPI process. Additionally, there was no established system for obtaining or incorporating feedback from direct care staff and residents into the QAPI process. Reports from staff and residents about shortages affecting care, such as missed showers due to lack of linens and colostomy bags, were not systematically reviewed or addressed in QAPI meetings. Documentation from the most recent QAPI meeting did not include discussion of these ongoing concerns, and leadership was unable to describe how such feedback would be used to identify or resolve problems.
Failure to Hold Required QAA Meetings and Include Required Members
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee met at least quarterly and included the required members, such as the administrator, owner, board member, or designee. According to interviews and record reviews, the Skilled Nursing Unit (SNU) had not held QAA committee meetings for the past three quarters due to the absence of an administrator to oversee the process. The Compliance Officer reported discussing QAPI at the hospital level and offered to chair the committee in the future, but this had not yet occurred. When the Medical Director was on leave, the covering physician discovered the lack of QAPI meetings and called for one, but prior to that, no meetings had been held. Additionally, the QAPI agenda for the most recent meeting did not list any QAA committee members.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as evidenced by multiple observed lapses in hand hygiene and glove use among staff during medication administration and food service. Specifically, a nurse was observed not performing hand hygiene after removing gloves and before entering a resident's room to administer intravenous antibiotics. Food service staff were seen entering the kitchen without washing hands, wearing gloves improperly, and failing to change gloves or perform hand hygiene between different food handling tasks. Additionally, during medication administration to two residents, a nurse did not perform hand hygiene or change gloves between tasks such as administering oral medications, subcutaneous injections, and applying topical creams, despite facility policy requiring hand hygiene before and after patient contact and after glove removal. The facility's water management plan was found to be inadequate, lacking specific testing protocols, acceptable ranges for control measures, and corrective actions when control limits are not maintained to prevent the growth of waterborne pathogens such as Legionella. The acting maintenance supervisor was unable to explain the laboratory tests being conducted on water samples and there was no documentation of annual review of the water management program. The policy did not address necessary control measures or corrective actions, and staff were not familiar with the requirements for monitoring and responding to changes in water quality or potential Legionella contamination. Staff training and education on infection control were also deficient. There was no documented evidence of infection control education or in-service training for staff since 2023, and only a small fraction of employees had updated COVID-19 vaccination status. The facility's policy on COVID-19 vaccination did not include requirements for providing staff education on the benefits, risks, and potential side effects of the vaccine. Interviews with staff confirmed the lack of recent infection control training and incomplete education regarding COVID-19 vaccination.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a qualified infection preventionist to be responsible for the infection prevention and control program. This omission resulted in the infection prevention and control program lacking appropriate oversight by a qualified individual, as required.
Failure to Provide and Maintain Advance Directive Information and Documentation
Penalty
Summary
The facility failed to ensure that residents were provided with information about advance directives, did not obtain or maintain copies of advance directives in the medical record, and lacked a policy and procedure for implementing advance directives. For multiple residents, including those with cognitive impairment or communication barriers, the facility did not verify or provide appropriate advance directive information upon admission. In several cases, forms were completed at the hospital prior to transfer, but the facility did not follow up to ensure residents or their representatives received or understood the information, nor did they confirm the presence of advance directive documentation in the medical record. For one resident with no cognitive impairment, the hospital's documentation indicated a durable power of attorney (DPOA) for healthcare was provided, but the facility did not have a copy in either the electronic or physical chart. Another resident, who was rarely understood and had moderate cognitive impairment, was made to sign an advance directive acknowledgement form at the hospital, but facility staff confirmed the resident could not comprehend the information. Staff interviews revealed confusion about who was responsible for advance directives, with social workers and nurses stating they did not handle or verify this documentation, and in some cases, copies of DPOA were kept in private offices rather than in the medical record. Additional residents with significant communication or cognitive barriers, such as being non-verbal or legally blind, were documented as having received written materials about advance directives, but staff acknowledged these residents could not understand or read the information. In several instances, family members or representatives were identified as decision-makers, but the facility did not ensure they received the necessary information or that documentation was properly maintained and accessible. Staff interviews consistently indicated a lack of clarity and responsibility regarding the advance directive process within the facility.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Provide COVID-19 Vaccine Education to Staff
Penalty
Summary
The facility failed to provide education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine to 73 out of 75 employees. Interviews with staff, including the Infection Control Officer (ICO) and a Licensed Vocational Nurse (LVN), revealed that most employees did not receive any education on COVID-19 vaccination. The ICO initially stated that three employees had been updated on COVID-19 vaccination, but later corrected this to only two housekeeping staff members who received handouts. The ICO also confirmed that education was only provided to staff who agreed to receive the vaccine, and there was no evidence that the remaining staff received the required education. A review of the facility's policy on mandatory COVID-19 vaccination indicated that the policy did not address the requirement to provide staff education on the benefits, risks, and potential side effects of the vaccine. Interviews with additional staff, such as a Certified Nursing Assistant (CNA), further confirmed the lack of recollection of any education being provided. Documentation reviewed by surveyors supported the finding that the majority of staff did not receive the necessary education as required.
Failure to Provide Required Infection Control and COVID-19 Training
Penalty
Summary
The facility failed to provide mandatory in-service training on infection prevention and control, specifically regarding current COVID-19 vaccination requirements and Enhanced Barrier Precaution (EBP) practices, to its staff. Interviews with multiple staff members, including RNs, LPNs, and CNAs, revealed that they had not received recent or specific training on these topics. The Infection Control Officer (ICO) confirmed that no documented infection control education or in-service training had been provided from 2023 to the present, with the last recorded session occurring in July 2023. Staff reported learning about EBP informally from a previous surveyor rather than through formal training, and there was no evidence of education on COVID-19 vaccination requirements or related benefits, risks, and side effects. Review of training records for several staff members showed no completed training for EBP or COVID-19 vaccination requirements. The facility's own infection control policy requires in-service education for all employees, with emphasis on hand hygiene, PPE use, and infection control practices, but this was not followed. The ICO stated that COVID-19 vaccination education was only provided to those who agreed to receive the vaccine, and that the hospital's web-based training did not cover infection control topics relevant to the current requirements. This lack of documented and comprehensive training was confirmed through both staff interviews and record reviews.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide care in a manner that promoted dignity and respect for two residents during dining observations. Both residents were observed in bed while being assisted with meals by a CNA who stood over them, resulting in the residents' eye level being at the CNA's chest. One resident had the head of the bed elevated to approximately 90 degrees, while the other had it at about 45 degrees. After a few spoonfuls of food, both residents indicated they were done eating. The CNA confirmed that she was aware of the expectation to sit at eye level with residents during feeding, as taught in her training, but did not follow this practice during the observed incidents. The facility's policy on feeding emphasizes the importance of creating a pleasant dining experience, including sitting next to the resident, making eye contact, and engaging in respectful conversation. The Director of Nursing acknowledged the observations and stated that staff are expected to sit and maintain eye level with residents during meals. The failure to follow these procedures was directly observed and confirmed through staff interviews and review of facility policy.
Failure to Ensure Unnecessary Psychotropic Drug Use Was Prevented
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use. A resident with dementia was prescribed quetiapine, an antipsychotic medication, which was increased from 12.5 mg to 25 mg at bedtime despite no documented behavioral changes or rationale for the increase. Staff documentation and behavior monitoring forms showed no evidence of confusion or agitation from the time of the dose increase through the present. The neurologist's consultation and subsequent medication order did not include documentation of behaviors warranting the dose increase, and the facility's monitoring process did not prompt a review or discussion regarding the absence of behaviors. Interviews with nursing staff, the consultant pharmacist, and the Director of Nursing revealed a lack of awareness and action regarding the requirement for a gradual dose reduction (GDR) for psychotropic medications. The consultant pharmacist continued to document the same assessment and plan for the medication each month, without addressing the absence of behaviors or the need for a GDR. The facility did not have a policy specific to GDR for psychotropic medications, and staff did not provide a rationale for not attempting a dose reduction, despite regular interdisciplinary team meetings to discuss psychotropic medication use.
Inaccurate and Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy and completeness of Minimum Data Set (MDS) assessments for two residents. For one resident admitted with a left hip fracture, the MDS assessment indicated that she received insulin and a diuretic during the assessment period, but a review of the physician's orders and Medication Administration Record (MAR) confirmed that she had not been prescribed or administered either medication during that time. For another resident, the required discharge MDS was not completed following the resident's discharge, as verified through medical record review. These deficiencies were confirmed during an interview and record review with the MDS Coordinator, who acknowledged the inaccuracies and omissions in the MDS documentation.
Failure to Address and Communicate Significant Weight Variances
Penalty
Summary
The facility failed to ensure staff adhered to professional standards regarding the monitoring and response to significant weight variances for a resident who was re-admitted after hospitalization with diagnoses including recurrent urinary tract infection and a stage IV decubitus ulcer. The resident experienced notable fluctuations in weight over a short period, including a 4% weight loss in two weeks and an 8% weight gain in two days. Despite these changes, there was no documentation that the weight variances were addressed by nursing staff or communicated to the Registered Dietician (RD), nor were they discussed in the Interdisciplinary Team (IDT) meetings during the relevant period. Interviews with staff revealed that while there was an expectation to re-weigh residents and notify the RD in cases of significant weight discrepancies, these actions were not documented or carried out for this resident. The RD confirmed she was not informed of the weight changes and emphasized the importance of being notified to review and adjust nutritional interventions, especially for residents receiving tube feeding. The Director of Nursing confirmed that the facility did not have a specific weight policy and instead followed the Lippincott procedure, which requires assessment and notification of practitioners for significant weight changes, but this protocol was not followed in this instance.
Failure to Provide Appropriate Ostomy Care
Penalty
Summary
A resident who required colostomy, urostomy, or ileostomy care did not receive appropriate care or services as needed. The report identifies a failure to provide the necessary ostomy care for a resident with such a medical requirement. Specific details regarding the actions or omissions that led to this deficiency are not provided in the report.
Failure to Administer Medications as Ordered by Physician
Penalty
Summary
A registered nurse (RN) administered a multivitamin with minerals to a resident during a medication pass, despite the physician's order specifying only a multivitamin without minerals. The RN acknowledged the discrepancy during an interview and review of the resident's medication orders, confirming that she was unfamiliar with the resident's morning medications as she typically works the night shift. Facility policy requires that medications be administered only as ordered by a privileged provider and that the medication selected must match the order and product label prior to administration. The failure to verify and administer the correct medication as ordered resulted in a deviation from the physician's instructions.
Unattended and Unlocked Medication Cart
Penalty
Summary
A deficiency occurred when a medication cart was observed unlocked and unattended in front of a resident's room. The incident was noted during an observation at 8:22 AM, when the cart was left without supervision. Upon interview, a registered nurse confirmed that the cart was not locked and acknowledged that it should have been secured for safety reasons, as leaving it open could allow unauthorized access to medications. The nurse explained that the staff member responsible for the cart was inside a resident's room at the time. Review of the facility's policy indicated that medications are required to be stored in secured carts or drawers at all times when not in use.
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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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