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Deficiency Records for Guam Memorial Hospital Authority
View the most recent health deficiencies and inspection results for Guam Memorial Hospital Authority. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Guam Memorial Hospital Authority. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-08-22 | 2025-10-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-08-22 | 2025-10-06 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2025-08-22 | 2025-10-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-08-22 | 2025-10-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2025-08-22 | 2025-10-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-22 | 2025-10-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-08-22 | 2025-10-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-08-22 | 2025-10-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-08-22 | 2025-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-08-22 | 2025-10-06 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2025-08-22 | 2025-10-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2025-08-22 | 2025-10-06 | 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 | 2025-08-22 | 2025-10-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2025-08-22 | 2025-10-06 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2025-08-22 | 2025-10-06 | 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 | 2025-08-22 | 2025-10-06 | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2025-08-22 | 2025-10-06 | 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 | 2025-08-22 | 2025-09-19 | 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 | 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 | 2024-08-09 | 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 |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 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 (including nights and weekends) and emergencies. | Health | 2024-08-09 | 2024-08-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-09 | 2024-08-22 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-08-09 | 2024-08-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-09 | 2024-08-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-09 | 2024-08-16 | 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 |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-29 | 2023-11-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-29 | 2023-11-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-29 | 2023-11-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-29 | 2023-11-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-29 | 2023-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-29 | 2023-11-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-29 | 2023-11-07 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-09-29 | 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 |
| 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 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 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 |
| 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 |
| 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 |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-09-26 | 2022-10-17 | 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 |