Federal Nursing-Home Survey Record
GUAM MEMORIAL HOSPITAL AUTHORITY
Does GUAM MEMORIAL HOSPITAL AUTHORITY have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), GUAM MEMORIAL HOSPITAL AUTHORITY (CCN 655000), in BARRIGADA, GU, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 18 deficiencies; the most serious carries scope/severity G on CMS's A–L scale, a level CMS classifies as actual harm. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $13,247 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
At its most recent federal inspection, CMS cited this facility for 1 actual-harm deficiency.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Civil money penalties on file
$13,247
CMS has $13,247 in civil money penalties on file against this facility. CMS also records 61 day(s) of payment denial.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 2 · CMS state average: 2.0
Deficiency timeline — full federal history
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Provide and implement an infection prevention and control program.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
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.
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
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.
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.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Ensure each resident receives an accurate assessment.
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Ensure services provided by the nursing facility meet professional standards of quality.
34 citations from earlier inspection cycles — historical, not current (expand)
PASARR screening for Mental disorders or Intellectual Disabilities
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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.
Ensure each resident receives an accurate assessment.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide routine and 24-hour emergency dental care for each resident.
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.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Have a plan that describes the process for conducting QAPI and QAA activities.
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.
Post nurse staffing information every day.
Provide and implement an infection prevention and control program.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide and implement an infection prevention and control program.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Respond appropriately to all alleged violations.
Plan the resident's discharge to meet the resident's goals and needs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Document what happened
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