Based 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. Findings include: Review of R12's undated Patient Data located in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia and Failure to Thrive. …
F641 citations in Guam
Accuracy of assessments · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Guam cites F641 more often than its own record predicts
3.02 times the share F641 takes of citations nationally.
Of every deficiency written in Guam in 2025, this is the portion that was F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Guam surveyors wrote
F641 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.
The short window
Recent years
| Year | Share of Guam citations | vs expected |
|---|---|---|
| 2024 | 5.88% | 3.49× |
| 2025 | 5.56% | 3.02× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Guam surveyors cite →
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