Based on interview and record review, the facility failed to ensure its governing body appointed an administrator who is licensed pursuant to Guam Code Annotated (GCA), and responsible for the management of the facility, reporting to and being accountable to the governing body. The facility had no Administrator since April 2024. This failure had the potential to result in ineffective oversight and lack of accountability, leading to supplies not being consistently available to residents, including essential items such as linens and colostomy bags placing residents at risk for unmet care needs and diminished quality of life.Findings:On 08/18/25 at 08:50 AM, during the entrance conference attended by the Director of Nursing (DON) and the Medical Director (MD), both stated that the facility… …
F837 citations in Guam
Administration Deficiencies
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.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Guam cites F837 more often than its own record predicts
102.06 times the share F837 takes of citations nationally.
Of every deficiency written in Guam in 2025, this is the portion that was F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Guam surveyors wrote
F837 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.
Based on interview, document review, policy review and review of the Guam Code Annotated (GCA), the facility failed to ensure its governing body appointed a Licensed Nursing Home Administrator (LNHA) who was licensed and responsible for the management of the facility, reporting and being accountable to the governing body. This failure had the potential to result in ineffective oversight and lack of accountability and to affect all the residents of the facility. Findings include: During an interview during entrance conference on 06/01/26 at 10:06 AM with the Director of Nursing (DON), the Administrative Officer (AO), and Medical Director, the DON confirmed she was the Acting Administrator and did not have an Administrator's licensed. …
The short window
Recent years
| Year | Share of Guam citations | vs expected |
|---|---|---|
| 2023 | 5.88% | 79.62× |
| 2024 | 5.88% | 64.53× |
| 2025 | 5.56% | 102.06× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Guam surveyors cite →
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