Based on interview and record review the facility failed to report an injury of unknown source (dislocated shoulder) experienced by R56 to the proper authorities within prescribed timeframes. Failure to report injuries of unknown source may result in failure to identify abuse or neglect. Findings: Record review: review of the electronic health record (EHR) and the documents located in the chart at the nurse station. R56 readmitted from the hospital to the facility on [DATE] for physical therapy following a left [CONDITION(S)] with surgical repair. R56 suffered the [CONDITION(S)] in a ground level fall at home. R56 had stage 4 pressure ulcers with recent necrotizing soft tissue infection and required long term intravenous antibiotic therapy at the nursing home. …
F609 citations in Guam
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2023
Guam cites F609 more often than its own record predicts
2.97 times the share F609 takes of citations nationally.
Of every deficiency written in Guam in 2023, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Guam surveyors wrote
F609 findings written in Guam, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
What else Guam surveyors cite →
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