Guam Memorial Hospital Authority
Inspection history, citations, penalties and survey trends for this long-term care facility in Barrigada, GU.
- Location
- 449 N Sabana Dr, Barrigada, GU 96913
- CMS Provider Number
- 655000
- Inspections on file
- 14
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Guam Memorial Hospital Authority during CMS and state inspections, most recent first.
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 The QAPI plan was outdated, and there was no system for incorporating staff or resident feedback into quality monitoring, resulting in unresolved care issues such as missed showers for a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 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.
Latest citations in GU
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.
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.
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