Guam Memorial Hospital Authority

In the surveyor’s words

From the most serious findings on record at Guam Memorial Hospital Authority, in the surveyor’s own words.

• Actual harm, isolatedF561Aug 22, 2025

  Based on observation, interview, and record review, the facility failed to honor the rights of one of one resident (Resident(R)28) reviewed for choices to make decisions about their care. Specifically, staff failed to provide showers for R28 prior to going to dialysis treatments due to lack of available linens.This failure resulted in R28 experiencing psychosocial harm as exhibited by decreased engagement in social activities, apathy and withdrawal, and refusal of care. Findings:On 08/18/25 at 10:58 AM, R28 was observed lying in bed in her room, watching television. R28 was alert and stated she wanted to share her concerns; however, she is going to dialysis so would like to speak the next day. Transport arrived after a couple of minutes. […]

• No harm, potential for more than minimal, widespreadF909Jun 6, 2026

  Based on observation, interview, record review, and policy review, the facility failed to implement a regular maintenance program to ensure bed systems, including bed rails, mattresses, and frames, were inspected for safety and potential entrapment hazards. The facility did not conduct routine assessments of mattress fit or measure potential entrapment zones in accordance with Food and Drug Administration (FDA) guidance. This had the potential to affect 14 of 19 sampled residents (Resident (R) R2, R3, R5, R8, R11, R12, R4, R9, R13, R22, R23, R25, R26 and R27) who used bed rails and had the potential to result in injury related to bed entrapment or bed system malfunction. […]

• No harm, potential for more than minimal, widespreadF812Aug 22, 2025

  Based on observations and interviews, the facility failed to ensure food safety standards when:1. The box of dishwasher heater booster and the storage cart were rusty.2. The hinge and handle of the food steam table had a thick whitish, black and brownish build-up.3. Staff food items were stored inside the kitchen walk-in refrigerator where the residents' food items were stored.4. Tray line or plating was not performed in a sanitary manner and food items were not measured accordingly.Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. […]

• No harm, potential for more than minimal, widespreadF837Aug 22, 2025

  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… […]

• No harm, potential for more than minimal, widespreadF867Aug 22, 2025

  Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not conducting quarterly meetings for three consecutive quarters, and when a meeting was held in July 2025, the team failed to address an ongoing supply concern. In addition, there was no system in place for obtaining feedback and input for direct care staff and residents, including how such input would be used to identify and address problems. […]