Guam Memorial Hospital Authority

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to implement a regular maintenance program to ensure bed systems, including bed rails, mattresses, and frames, were inspected for safety and potential entrapment hazards. The facility did not conduct routine assessments of mattress fit or measure potential entrapment zones in accordance with Food and Drug Administration (FDA) guidance. This had the potential to affect 14 of 19 sampled residents (Resident (R) R2, R3, R5, R8, R11, R12, R4, R9, R13, R22, R23, R25, R26 and R27) who used bed rails and had the potential to result in injury related to bed entrapment or bed system malfunction.

Inspectors wroteBased on observation, interview, record review, review of the Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure alternatives were attempted prior to the use of bed/side rails for 6 of 19 sampled residents (Resident (R) R2, R3, R5, R8, R11 and R12) reviewed for bed/side rails. This failure had the potential to increase the risk of resident accidental entrapment, suffocation, serious injury, or death.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to advise one of five residents (R12) reviewed for unnecessary medications of the risks and benefits for psychotropic medication use. This failure had the potential to affect the care provision, discharge planning, and/or informed consent for psychotropic medications.

Inspectors wroteBased on interview, record review, observation and document review, the facility failed to ensure appropriate sized incontinence products were available for one (Resident (R) 13) of 19 residents in the survey sample. This failure had the potential to negatively affect R13's dignity and skin integrity.

Inspectors wroteBased on record review, interviews, and policy review the facility failed to ensure require Notification of Medicare Non-Coverage (NOMNC advisements were provided to two of three residents (Resident (R) 29 and R30) to ensure that residents were give two days in advance notice of Medicare A services ending. This failure had the potential for residents to incur unauthorized expenses and/or forfeit the time granted for an appeal to Medicare.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure two Residents (R)2 and R12) out of five residents reviewed for unnecessary medication was free from potential chemical restraints. The facility's failure to ensure residents were free from unnecessary chemical restraints created the potential for this and other residents to receive medication that is not necessary or desired related to their psychiatric/mental health care.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a comprehensive admission Minimum Data Set (MDS) assessment was completed within the time frame required by the RAI Manual for one of 19 sampled residents (Resident (R) 21). This failure had the potential for inaccurate or incomplete care planning and/or provision of care to the resident, and/or inaccurate reimbursement for services. During the tour of the facility, R21 was observed in his room on 06/01/26 at 11:02AM. Review of the facility provided resident matrix document did not indicated that R21 was a new admission admitted within the past 30 days. Review of the facility provided Patient Data sheet revealed R21 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessments were transmitted within the timeframes specified in the RAI manual for nine of 19 residents (Resident (R)1, R4, R7, R9, R22, R27, R2, R3 and R12) MDSs reviewed during the survey. This failure had the potential for inaccurate or incomplete care planning and/or provision to the resident, the resident being discharged may not be able to receive services elsewhere because Medicare was not aware of the discharge status, and/or a lack of appropriate payment for services to the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one of 19 residents (Resident (R) 12) reviewed. The MDS did not accurately reflect the resident's receipt of antipsychotic medication during the look-back period. This failure had the potential to result in inaccurate information being used for care planning an clinical decision-making.

Inspectors wroteBased on record review and interviews, the facility failed to ensure Pre admission Screening and Resident Review (PASARR) Level 1 evaluation was completed for one (Residents (R)12) out of one resident reviewed for PASARR. The facility's failure to ensure the appropriate PASARR assessment was completed created the potential for residents to have unmet psychological/psychiatric needs while residing in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, document review, policy review and review of the Guam Code Annotated (GCA), the facility failed to ensure its governing body appointed a Licensed Nursing Home Administrator (LNHA) who was licensed and responsible for the management of the facility, reporting and being accountable to the governing body. This failure had the potential to result in ineffective oversight and lack of accountability and to affect all the residents of the facility.

Inspectors wroteBased on interview, the facility failed to present a Disclosure of Ownership during the extended survey. This failure could affect the accuracy of records for Centers of Medicare and Medicaid Services (CMS) and has the potential to affect all of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the rights of one of one resident (Resident(R)28) reviewed for choices to make decisions about their care. Specifically, staff failed to provide showers for R28 prior to going to dialysis treatments due to lack of available linens. This failure resulted in R28 experiencing psychosocial harm as exhibited by decreased engagement in social activities, apathy and withdrawal, and refusal of care.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations and interview, the facility failed to ensure the daily nurse staffing data was maintained for a minimum of 18 months.

Inspectors wroteBased on interview with the Administrator, review of the Guam Code Annotated (GCA) Title 10 - Chapter 15 Health and Safety, and the Skilled Nursing Unit (SNU) job requirements for administrator, the Governing body did not assure a licensed Administrator managed operations of the SNU.

Inspectors wroteBased on observation, policy review and staff interview the facility failed to establish and maintain an infection prevention and control program to include review and update their Infection Prevention & Control-Infection Surveillance Criteria policy annually. This deficient practice encourages the development and transmission of communicable diseases and infections and has the potential to affect all residents in the facility.