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Deficiency Records for Guam Memorial Hospital Authority
A list of the most recent deficiencies for Guam Memorial Hospital Authority. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Guam Memorial Hospital Authority. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-08-09 | 2024-09-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-09 | 2024-09-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-08-16 | 2024-09-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-09 | 2024-08-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-08-09 | 2024-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-09 | 2024-08-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-09 | 2024-08-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-08-09 | 2024-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-09 | 2024-08-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-09 | 2024-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-09 | 2024-08-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-09 | 2024-08-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-09 | 2024-08-29 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-08-09 | 2024-08-29 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-08-09 | 2024-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-09 | 2024-08-28 | N |
| Post nurse staffing information every day. | Health | 2024-08-09 | 2024-08-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-08-09 | 2024-08-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-09-29 | 2023-12-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-29 | 2023-12-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-29 | 2023-12-05 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-09-29 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-29 | 2023-11-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-29 | 2023-11-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-28 | 2023-11-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-28 | 2023-11-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-28 | 2023-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-28 | 2023-11-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-28 | 2023-11-07 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-09-28 | 2023-11-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-29 | 2023-11-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-29 | 2023-11-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-29 | 2023-11-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-29 | 2023-11-03 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-29 | 2023-11-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-29 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-29 | 2023-11-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-29 | 2023-11-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-29 | 2023-11-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-29 | 2023-11-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-29 | 2023-10-01 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2022-09-26 | 2022-11-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-26 | 2022-11-04 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-09-26 | 2022-11-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-26 | 2022-11-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-26 | 2022-11-03 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-26 | 2022-11-03 | N |
| Honor the resident's right to choose his or her attending physician. | Health | 2022-09-26 | 2022-11-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-26 | 2022-11-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-26 | 2022-10-31 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-09-26 | 2022-10-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-26 | 2022-10-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-26 | 2022-10-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-26 | 2022-10-29 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-26 | 2022-10-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-26 | 2022-10-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-26 | 2022-10-17 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-09-26 | 2022-10-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-26 | 2022-10-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-26 | 2022-10-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-26 | 2022-10-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-26 | 2022-10-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-26 | 2022-10-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-26 | 2022-10-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-26 | 2022-10-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-26 | 2022-09-26 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-09-26 | 2022-09-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-26 | 2022-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-26 | 2022-09-26 | N |
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