Guam Memorial Hospital Authority

Based on record review, observation, interview, and policy review, the facility failed to ensure two of 19 residents (Resident (R) R4 and R22) had comprehensive person-centered care plans for each resident, with measurable objectives and timeframes to meet the resident's medical, nursing, mental, and/or psychosocial needs as identified during a comprehensive assessment. This failure had the potential to affect the care and/or quality of life experienced by the resident while at the facility. Findings include:1. Review of R4's facility provided undated Patient Data revealed a readmission date of 05/27/26 with diagnoses of history of cerebral vascular accident (stroke), fever from urinary tract infection, and bedbound.Observations of R4 on 06/01/26 at 11:45 AM and 1:23 PM; and 06/02/26 at 2:14 PM in bed with bilateral upper half rails in the up position with blue pads wrapped around them; and on 06/05/26 at 12:25 in bed with all four bed rails in the up position with the blue padding attached to all four rails.Observation on 06/06/26 at 9:12 AM with the Director of Nursing (DON)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to ensure routine dental services were provided for one (Resident (R)5) out of two residents reviewed for dental services in the sample of 19 residents. The facility's failure to ensure dental services were provided for R5 created the potential for the resident to experience complications and/or pain related poor dentition. Findings include: Review of R5's undated Patient Data located in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnosis of history of stroke. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/26 and found in a folder kept at the nurse's desk revealed a Brief Interview for Mental Status (BIMS) score that was not able to be completed due to the resident's poor cognition. The MDS indicated no oral or dental problems. Review of R5's Doctor's Orders Report dated 06/03/26 and found in the EMR revealed no physician's orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to ensure residents were assessed for influenza and pneumococcal vaccination status and offered and/or provided indicated vaccines, or that refusal, contraindication, or prior vaccination status was documented, for 1 of 5 residents (Resident (R) 19) reviewed for vaccinations. This failure had the potential to increase the risk for R19 to contract influenza and/or pneumococcal disease and experience adverse health outcomes. Findings include:Review of R19's undated Patient Data located in the Electronic Medical Record (EMR), revealed the resident was admitted to the facility on [DATE] and was over the age of 65 at the time of admission. Review of R19's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/21/26 and found in a folder kept at the nurse's desk, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R19's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, 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 of five residents (Resident (R) 13 and R19) reviewed for vaccinations out of a total sample of 19. This failure had the potential to increase the risk of COVID-19 infection and serious illness. Findings include: Findings include: 1. Review of R13's facility provided undated Patient Data revealed an admission date of 09/07/25. Review of R13's quarterly MDS with an Assessment Reference Date (ARD) of 03/14/26 and found in a folder kept at the nurse's desk revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicative of being cognitively intact. Review of the Infection Preventionist (IP) Nurses Note dated 09/17/25 at 3:55 PM provided by the IP revealed, COVID-l9 VACCINATION: Offered and educated resident on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure food safety standards when:1. The box of dishwasher heater booster and the storage cart were rusty.2. The hinge and handle of the food steam table had a thick whitish, black and brownish build-up.3. Staff food items were stored inside the kitchen walk-in refrigerator where the residents' food items were stored.4. Tray line or plating was not performed in a sanitary manner and food items were not measured accordingly.Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. Foodborne illness and cross contamination may result in gastrointestinal distress and in severe instances may result in death. This had the potential to affect 17 residents who received meals from the facility. Findings:1.During the initial tour of the kitchen with the Food Service Supervisor (FSS) on 08/18/25 at 9:00 AM, the box of dishwater heater booster and the two-tier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure its governing body appointed an administrator who is licensed pursuant to Guam Code Annotated (GCA), and responsible for the management of the facility, reporting to and being accountable to the governing body. The facility had no Administrator since April 2024. This failure had the potential to result in ineffective oversight and lack of accountability, leading to supplies not being consistently available to residents, including essential items such as linens and colostomy bags placing residents at risk for unmet care needs and diminished quality of life.Findings:On 08/18/25 at 08:50 AM, during the entrance conference attended by the Director of Nursing (DON) and the Medical Director (MD), both stated that the facility did not have an administrator. Without being prompted, the MD introduced himself as overseeing clinical work, with no administrative oversight of the facility. When asked, when the facility had been without an administrator, the DON stated that this had been the case since April 2024.On 08/18/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not conducting quarterly meetings for three consecutive quarters, and when a meeting was held in July 2025, the team failed to address an ongoing supply concern. In addition, there was no system in place for obtaining feedback and input for direct care staff and residents, including how such input would be used to identify and address problems. These failures limited the facility's ability to identify systemic problems, implement corrective actions, and monitor effectiveness, placing residents at risk for unmet needs.Findings:Review of the QAPI plan submitted during the entrance conference titled QAPI Plan 2024, revealed indicators and measures derived from survey results spanning 2019 through 2023. The QAPI plan did not contain indicators, measures, or performance improvement projects for 2025.On 08/22/25 at 03:01 PM, an interview and concurrent review of the facility's QAPI program was conducted with the Director of Nursing (DON),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly and evaluated activities under the Quality Assurance Performance Improvement (QAPI) program, including identifying issues related to QAA activities and implementing performance improvement projects (PIP) as required. In addition, the facility's QAA committee failed to include the administrator, owner, board member or designee.This failure had the potential to result in failure to identify and correct systemic problems, such as supply shortages, leading to unresolved issues that negatively impact the quality of care and services provided to residents.Findings:On 08/22/25 at 03:01 PM, an interview and concurrent review of the facility's QAA and QAPI program was conducted with the Director of Nursing (DON), Medical Director (MD), and Compliance Officer (CO). The DON stated the Skilled Nursing Unit (SNU) had not held QAA committee meetings because there was no administrator in place to oversee the process. The CO stated she played a supportive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control program in accordance with internal policies and procedures, nationally recognized infection control guidelines and regulations when:1. Hand hygiene was not performed before entering the kitchen and tray line and in between changing of gloves during medication preparation. 2. The facility water management plan (WMP) did not include testing protocols, acceptable ranges for control measures, and corrective actions when control limits are not maintained to prevent growth of opportunistic waterborne pathogens such as Legionella bacteria. According to the Centers for Disease Control and Prevention (CDC), Legionella is a type of bacteria that causes Legionnaires' disease a serious lung infection. 3. Staff were not provided with updated infection control training and education. (Refer to F945) 4. The Facility Infection Control Policy was not updated to reflect current federal requirements. (Refer to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Infection Control Officer (ICO) was performing the duties of an infection preventionist (IP) who is responsible for implementing programs and activities to prevent and control infection.This failure resulted in improper implementation of the facility's Infection Prevention and Control Program (IPCP) that may contribute to cross contamination of infection and jeopardize the health and safety of residents and staff.Findings: In an observation on 08/19/25 at 01:36 PM, Licensed Practical Nurse (LPN) 1 don on gloves and started mixing the intravenous antibiotics. LPN1 removed the gloves, did not perform hand hygiene and took the medication inside the room.On 08/20/25 at 08:29 AM, Registered Nurse (RN) 1 did not perform hand hygiene in between tasks during administration of Resident 10's medication. RN1 was observed using the same gloves throughout the entire medication administration process and hand hygiene was not performed.On 08/20/25 at 09:56…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 5 of 5 residents (Resident[R]1, 5, 7, 13, 15) reviewed for advance directives were provided with information about advance directives. In addition, the facility failed to obtain and maintain a copy of the advance directive in the medical record so that it was readily retrievable by any facility staff. The facility did not develop policy and procedure to implement advance directives.This failure put the resident at risk for not having his wishes for treatment known and had the potential for the resident's decision regarding his healthcare and treatment options not being honored. For R5: Review of face sheet (admission record) revealed R5 was admitted to the facility 12/12/24. Review of the Minimum Data Set (MDS, a standardized assessment tool) with assessment reference date of 06/19/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R5 had no cognitive impairment. Review of the hospital’s Advance Directive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an adequate supply of bed and bath linens to meet the care needs of 19 of 19 residents residing in the Skilled Nursing Unit (SNU). This failure resulted in residents not receiving scheduled showers and having unchanged bed linens. The lack of adequate linens had the potential to compromise resident dignity, comfort, and hygiene, and increased the risk for skin breakdown and infection.Findings:On 08/19/25 at 09:35 AM, an interview was conducted with Resident (R) 28, the facility's Resident Council President, inside her room. R28 stated the facility had been short of linens. R28 reported that she goes to dialysis three times a week and, on dialysis days, she prefers to take a shower. However, staff informed her that there were no linens available, so showers could not be provided. Instead, the Certified Nursing Assistants (CNAs) would provide a wipe down. R28 stated, like yesterday, I only got a wipe down.I am also speaking for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure 73 out of 75 employees are provided with education regarding benefits and risks and potential side effects associated with COVID-19 vaccine. This failed practice prevented employees to make an informed decision about COVID-19 vaccination.Findings:In an interview on 08/21/25 at 02:51 PM, the Infection Control Officer (ICO) stated that she oversees infection control training and education for the staff.In an interview on 08/22/25 at 01:49 PM, Licensed Vocational Nurse (LVN) 1 stated that she did not received education regarding COVID-19 vaccination. In an interview on 08/22/25 at 01:56 PM, the ICO stated that only three out of 75 total employees were updated on COVID-19 vaccination. ICO explained that COVID-19 vaccination education was provided to the staff by giving them handouts.In a follow-up interview on 08/22/25 at 02:16 PM, ICO stated that all of the staff are not provided with education about benefits and risks and potential side effects associated with COVID-19 vaccination. ICO explained, COVID [19]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff received an infection prevention and control program in-service training to support current scope and standard of practice specifically for current COVID-19 vaccination requirement and Enhanced Barrier Precaution (EBP) practices for six of six staff (RN1, RN2, LPN1, CNA1, CNA3 and CNA4) reviewed over 75 total facility staff.This failure could affect the proper implementation of current infection prevention practices and placed residents at risk of not receiving appropriate care and services that could jeopardize their health and safety. Findings:In an interview on 08/21/25 at 02:41 PM, Registered Nurse (RN) 1 stated, I cannot remember the last time we received in-service or training for infection control. RN1 stated that the EBP was implemented because the previous [CMS] surveyor taught us what to do. Who is the patient needs EBP. We (staff) implement it ourselves. We did not receive in-service training about it. In an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that staff provided care in a manner that promoted dignity and respect for two of 19 residents (Resident(R)5 and R12) during dining observation. A Certified Nursing Assistant (CNA) was observed standing over R5 and R12 while assisting the residents with their meals. This failure had the potential to negatively impact the residents.Findings:For R12:On 08/18/2025 at11:38 AM, R12 was observed in bed with the head of the bed elevated to approximately 90 degrees, Bed was in low position. CNA5 was observed assisting R12 with lunch while standing over the resident. R12's eye level was observed at approximately the level of CNA5's chest. After a few spoonfuls of food, R12 stated she was done.For R5:On 08/18/2025 at 11:49 AM, R5 was observed in bed with the head of bed elevated to approximately 45 degrees after CNA5 adjusted the bed at the resident's request. CNA5 was observed spoon-feeding R5 while standing over the resident. At that time, R5's eye level was approximately at the level of CNA5's chest. After…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident(R)6) reviewed for unnecessary medications was free from unnecessary psychotropic drug use. Specifically, R6's antipsychotic medication was increased on 10/23/24 despite no documented behaviors and did not attempt a gradual dose reduction (GDR) even though no behaviors had been documented since the increase through present. This failure had the potential to result in oversedation, worsening cognitive decline, increased confusion, and loss of independence. Findings: On 08/18/25 at 10:43 AM, R6 was observed seated in her wheelchair in the activities area, doing coloring activity with another resident led by recreation staff. R6 responded when greeted Review of Face sheet (admission record) revealed R5 was admitted to the facility 07/18/24, with diagnoses including dementia.Review of a physician's order dated 10/23/24, revealed an order for quetiapine (antipsychotic medication) 25 mg tablet, give one tablet by mouth at bed time for Alzheimer's with behavioral adjustment.Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate and complete for 2 of 19 sampled residents (Resident(R)19 and 23). R19's MDS indicated she was receiving insulin and diuretic, when she was not.R23's discharge MDS was not completed.These failures had the potential to result in inaccurate care planning and failure to meet the residents' care needs.Findings:For R19:Review of Face sheet (admission record) revealed R19 was admitted to the facility 07/20/25 with diagnoses including left hip fracture.Review of the MDS with assessment reference date of 07/25/25 revealed Section N for medications, which showed that the number of injections received by R19 during the last 7 days was coded as 7. The number of days insulin injections were received during the last 7 days was also coded as 7. The MDS further indicated that R19 was taking a diuretic.However, review of the physician's orders and the Medication Administration Record (MAR) for July 2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff adhered to professional standards related to addressing weight variance for one of three residents (Resident [R] 7) reviewed for nutrition. The deficient practice could potentially delay the implementation of appropriate measures to prevent unintended weight loss or weight gain before complications arise. Findings:Review of R7's medical record indicated, R7 was re-admitted in the facility after hospitalization on 08/01/25 with diagnoses including recurrent urinary tract infection (UTI) and stage IV decubitus ulcer (severe form of skin damage). In an interview on 08/19/2025 at 10:06 AM, Licensed Practical Nurse (LPN) 1 explained that staff weigh residents on the first and 15th day of the month.Review of R7's weight records indicated the following:08/01/25 = 89.5 kilograms (kgs)08/15/25 = 85.9 kgs (4% weight loss in two weeks)08/17/25 = 92.8 kgs (8% weight gain in two days)On 08/20/25, at 09:38 AM, the Registered Dietician (RD)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two residents with a colostomy (a surgical opening in the abdomen that allows waste to pass into a bag) had an adequate supply of colostomy bags (special pouches used to collect waste from the opening) required for proper care. Due to lack of supply, staff washed the colostomy bags. This resulted in residents being required to use rewashed bags, which are not designed for reuse. This deficient practice resulted in R28's reports of humiliation and embarrassment related to odor and the awareness that others might notice it.Findings:On 08/19/25 at 09:35 AM, an interview was conducted with R28, inside her room. R28 stated she has a colostomy, pointing to a bulge on her left abdominal area, and reported that the facility often runs out of colostomy bags. R28 stated, this is not reusable. R28 reported that Certified Nursing Assistants (CNAs) wash out the colostomy bags when no new ones are available.When asked when this last…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services that assure accurate administration of medications to meet the needs of 1 of 5 residents (Resident(R)16) observed during medication administration. Specifically, the facility failed to follow the physician's order when administering medication to R16. This failure had the potential to result in ineffective treatment.Findings:On 08/20/2025 at 8:43 AM, during a medication administration observation for R16, Registered Nurse (RN) 1 was observed preparing and administering medications, including one tablet of multivitamin with minerals. R16 swallowed all oral medications without difficulty.However, review of the physician's order dated 08/17/25 revealed an order for multivitamin, one tablet by mouth daily. The order did not include minerals.On 08/20/25 at 11:55 AM, an interview and concurrent review of the R16's physician's order was conducted with RN 1. RN 1 verified the order was for multivitamin only, but she administered a multivitamin with minerals. RN 1 stated she was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe storage of medications for one of two medication cart observation when the first side medication cart was not locked and left unattended.The deficient practice had potential for unauthorized people to have access to medications.Findings:On 08/20/2025, at 8:22 AM, the first side medication cart was observed in front of room [ROOM NUMBER] not locked and unattended.In an interview with Registered Nurse (RN) 1 on 08/20/2025, at 8:23 AM, RN1 opened the medication cart and stated, It's not locked. It should be closed and secured or locked for safety reasons. Someone can steal medications. RN 1 explained that the nurse in charge of the medication cart was attending to a resident inside the room.Review of the facility policy, titled Storage of Medications in Patient Care Areas, dated 07/01/2009 indicated, Medication will be stored in secured carts or drawers at all times when not in use.

Based on interviews, record review and review of policy, the facility failed to ensure that Level I PASARR (Preadmission Screening and Resident Review) (screening for mental disorders (MD) and intellectual disabilities (ID)) was completed for 13 out of 13 residents who resided in the facility. The deficient practice resulted in the potential for residents with MD and/or ID not being identified, evaluated, and/or receiving care and services in the most integrated setting appropriate to their needs. Findings include: During an interview conducted on 08/06/24 at 1:45 PM with the Social Worker (SW) she stated that she did not know what a PASARR was. She stated that she had not been doing them. On 08/07/24 at 2:05 PM an interview was conducted with the MDS (Minimum Data Set) (comprehensive resident assessment) Coordinator. She stated that she had heard of the PASARR but was trained only as it related to information on the MDS assessment in Section A1500. She stated that she thought it was her responsibility but that they did not do them there. On 08/09/24 at 8:23 AM an interview was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of records, and policy, the facility failed to ensure the Comprehensive Care Plans were complete for 2 of 13 sampled residents (residents (R) R55, R51, and R106). Specifically: 1) The facility failed to ensure that foot wounds were included for R51; and 2) The facility failed to ensure that poor dentition was included for R51 and R106. As a result of this deficient practice, staff did not have the information necessary to adequately care for residents and/or to ensure that measurable objectives and timeframes were determined to meet the residents' physical, mental, and psychosocial needs identified in the comprehensive assessment in order to meet their highest practicable well-being. Findings include: For R51: R51 admitted to the facility on [DATE] and subsequently readmitted on [DATE]. According to the resident's Face Sheet, her admitting diagnosis was an infected decubitus (pressure) ulcer to the sacrum. Regarding foot wounds: On 07/05/24 at 1:35 PM a physician progress note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and policy, the facility failed to ensure pressure ulcer care and treatment was provided to one of one sampled residents reviewed for pressure ulcers (Resident (R) 51) in accordance with professional standards of practice. Specifically: 1) The facility did not document an admission wound assessment that included measurements, a description of the wound bed and surrounding tissue, or any exudate (drainage). 2) The facility failed to document weekly wound assessments. 3) The facility failed to ensure wound assessments were complete and thorough. The deficient practice increased the resident's risk for pain, infection, and rehospitalization. Findings include: R51 admitted to the facility on [DATE] and subsequently readmitted on [DATE]. According to the resident's Face Sheet, her admitting diagnosis was an infected decubitus (pressure) ulcer. A risk for pressure ulcer care plan with a start date of 01/12/23 related to sacral ulcer and DTI (deep tissue injury) to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of policy, the facility failed to ensure 2 out of 5 residents reviewed (Residents (R) 55 and R54) did not receive psychotropic medications without 1) adequate indication and 2) behavior monitoring. The deficient practice increased the risk for residents to receive psychotropic medications unnecessarily. Findings include: For R55: R55 was readmitted to the facility on [DATE] with a diagnosis of acute pulmonary edema (a life-threatening condition that occurs when fluid builds up in the lungs, making it difficult to breathe.) A physician's progress note dated 07/17/24 at 8:37 PM included that the resident's History and Present Illness included a history of behavioral disorder (maladaptive behavior (actions that prevent people from adapting to life and participating in daily activities), personal distress (anxiety, worry, discomfort), statistical rarity (behaviors that are uncommon or rare in a population), violation of social norms (actions that go against what most…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, review of records, and policy, the facility failed to provide a written notice to the resident and/or the resident's representative of an emergency transfer for 1 of 2 sampled residents reviewed for hospitalization (Resident (R) 51). This failure did not afford the resident and/or their representative to make informed decisions about transfers and prohibited access to an advocate who could inform the resident/representative of their options and rights. Findings include: Review of the Active Problems list dated 10/22/22 revealed the resident admitted to the facility with diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm) and congestive heart failure (a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply). Review of the Transfer to emergency room Department dated 06/06/24 at 08:13 AM revealed the resident was transferred to the ER (Emergency Room) for stroke-like symptoms and tachycardia. A nursing progress note dated 06/06/24 at 02:04 PM included that the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and policy, the facility failed to ensure 1 of 2 sampled residents reviewed for hospitalization (Resident (R) 51) received a written bed-hold notice/policy upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents transferred emergently to the hospital. Findings include: Review of the Active Problems list dated 10/22/22 revealed R51 admitted to the facility with diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm) and congestive heart failure (a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply). Review of the Transfer to emergency room Department dated 06/06/24 at 08:13 AM revealed the resident was transferred to the ER (Emergency Room) for stroke-like symptoms and tachycardia. A nursing progress note dated 06/06/24 at 02:04 PM included that the resident returned from the ER via transport around 12:55 PM. However, the facility was unable to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment tool) was accurate for one of 9 sampled residents (Resident (R) 51). This failure posed the risk of the resident not receiving an individualized plan of care based upon their specific needs. Findings include: Review of the Active Problems list dated 10/22/22 revealed R51 admitted to the facility with diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm) and congestive heart failure (a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply). The annual MDS assessment dated [DATE] included Section L, Oral/Dental Status. Review of the assessment indicated the resident had no dental issues, including obvious or likely cavity or broken natural teeth. A Dietician Note dated 04/25/24 at 11:36 AM indicated the resident's dentition status included broken teeth or cavities. The Quarterly MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record and policy, the facility failed to ensure the comprehensive care plan was updated/revised for one of one resident reviewed for pressure ulcers (Resident (R) R51). As a result of the deficient practice the resident did not meet her targeted goals in response to the current interventions. Findings include: R51 admitted to the facility on [DATE] and subsequently readmitted on [DATE]. According to the resident's Face Sheet, her admitting diagnosis was an infected decubitus (pressure) ulcer. A risk for pressure ulcer care plan with a start date of 01/12/23 related to sacral ulcer and DTI (deep tissue injury) to bilateral heels had a long-term goal to be free of pressure ulcers, redness, blisters, or discolorations. Interventions included to assess, document, and report skin status or any appearance of blisters, redness, ulcer: size, color, stage. Review of the physician's notes dated 01/26/23 through 02/29/23 revealed the sacral wound was stable/slow progress. Physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of records and policy, the facility failed to ensure that one of two residents reviewed for skin conditions (Resident (R) 51) received care and services for foot wounds consistent with professional standards of practice. The deficient practice placed the resident at risk for pain, infection and rehospitalization. Findings include: R51 admitted to the facility on [DATE] and subsequently readmitted on [DATE]. According to the resident's Face Sheet, her admitting diagnosis was an infected decubitus (pressure) ulcer to the sacrum. The SNF (Skilled Nursing Facility) admission assessment dated [DATE] indicated that the residents health history included diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), uncontrolled, with complications. However, review of the resident's comprehensive plan of care provided no evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and review of the record, the facility failed to provide an assessment of the hemodialysis (HD) access site following off-site dialysis for one of one residents, Resident (R) 107, who received hemodialysis (HD) treatments. This deficient practice could result in complications from dialysis not being addressed timely requiring interventions or hospitalization. Findings include: Review of [NAME]'s Caring for a patient's vascular access for hemodialysis -- Maintaining vascular access for hemodialysis included A PATIENT IN END-STAGE kidney disease relies on dialysis to mechanically remove fluid, electrolytes, and waste products from the blood. For the most effective hemodialysis, the patient needs good vascular access with an arteriovenous (AV) fistula or an AV graft that provides adequate blood flow. Follow your facility's policies and procedures and these clinical tips to protect and preserve the vascular access and avoid complications such as infection, stenosis, thrombosis, and hemorrhage: .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of records, and policy, the facility failed to ensure one of two residents reviewed for dental services (Resident (R) 51) was provided with routine dental care to meet her needs. This deficient practice had the potential for the resident's routine dental needs to worsen and become emergent needs. Findings include: Review of the Active Problems list dated 10/22/22 revealed R51 admitted to the facility with diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm) and congestive heart failure (a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply). A physician's note dated 10/05/23 included SS (Social Service) for dental appointment; no dental coverage; request PHSS (Preparedness Health and Safety Services) for coverage; she is not able to sit up in dental chair and may be a barrier for dental care. A follow up entry in the progress notes indicated - dental appt 10/13. However, no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Facility Assessment (FA), the facility failed to conduct, document, and annually review its facility-wide assessment. The facility used a facility assessment tool as a template in place of an up to date and accurate assessment to identify the needs of its residents. The deficient practice placed all residents in the facility at an increased risk of harm. Findings include: Review the Facility assessment dated [DATE] included an Administrator [Administrator 2] and Medical Director [Medical Doctor 2 (MD)] that was no longer at the facility. The assessment also indicated that it have been reviewed by the Quality Assurance Performance Improvement committee on February 28, 2023. Review of the Quality Assurance Assessment Committee included a new medical director [MD 1] and listed the Director of Nursing (DON) as both the Nursing Unit Supervisor and Long-Term Care Administrator. During an interview conducted 08/09/24 at 11:28 AM, the DON stated they had taken over as the Administrator in April of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to make copies of medical records readily accessible to CMS surveyor requests when the staff unnecessarily delayed requested records during an annual recertification survey. Good documentation is important to protect patients, promotes patient safety and quality of care. Complete and accurate medical recordkeeping can help ensure that patients get the right care at the right time (from a transcript for audio podcast: Importance of Documentation, the office of the Inspector General). These failures have the potential to negatively impact resident care and safety. The deficient practice has the potential to affect all residents residing in the facility. Findings include: A request for medical records for Resident 107 (R) was provided to the facility on [DATE] at 01:40 PM. On 08/08/24 at 02:02 PM an email was sent to get a status update on the requested records for R107. The response was the facility was still working on getting the records. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the QAPI program made a good faith attempt to implement corrective actions implemented corrective actions for non-compliance identified in September of 2023. The facility continues to not allow residents to received off-site Hemodialysis (HD) from anyone other than Guam Memorial Hospital (GMH). Administrative decisions and lack of action to advocate for SNF resident rights to choose physician and medical providers created barriers to receive care in accordance with medical needs and resident preferences. Findings include: Review of the Visit Summary located in the Electronic Health Record (EHR) indicated Resident (R) 107 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Anterior STEMI (ST-elevation myocardial infarction, heart attack), ESRD (End-Stage Renal Disease, medical condition in which a person's kidneys cease functioning) on HD (Hemodialysis, a treatment to filter wastes and water from your blood), seizure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.