ElderGrade

Inspection citations at Guam Memorial Hospital Authority

52 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 18 1
2024 17 0
2023 17 0
D August 22, 2025 Tag F0761 Corrected Oct 2025

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D August 22, 2025 Tag F0755 Corrected Oct 2025

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D August 22, 2025 Tag F0691 Corrected Oct 2025

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D August 22, 2025 Tag F0658 Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D August 22, 2025 Tag F0641 Corrected Oct 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D August 22, 2025 Tag F0605 Corrected Oct 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

No actual harm, potential for more than minimal harm

D August 22, 2025 Tag F0550 Corrected Oct 2025

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E August 22, 2025 Tag F0945 Corrected Oct 2025

Infection Control Deficiencies

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

No actual harm, potential for more than minimal harm

E August 22, 2025 Tag F0887 Corrected Oct 2025

Infection Control Deficiencies

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.

No actual harm, potential for more than minimal harm

E August 22, 2025 Tag F0584 Corrected Oct 2025

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

E August 22, 2025 Tag F0578 Corrected Oct 2025

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

F August 22, 2025 Tag F0882 Corrected Oct 2025

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

No actual harm, potential for more than minimal harm

F August 22, 2025 Tag F0880 Corrected Oct 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F August 22, 2025 Tag F0868 Corrected Oct 2025

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

No actual harm, potential for more than minimal harm

F August 22, 2025 Tag F0867 Corrected Oct 2025

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

No actual harm, potential for more than minimal harm

F August 22, 2025 Tag F0837 Corrected Sep 2025

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.

No actual harm, potential for more than minimal harm

F August 22, 2025 Tag F0812 Corrected Oct 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

G August 22, 2025 Tag F0561 Corrected Oct 2025

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Actual harm to a resident

C August 9, 2024 Tag F0880 Corrected Aug 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, minimal potential

C August 9, 2024 Tag F0837 Corrected Aug 2024

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.

No actual harm, minimal potential

C August 9, 2024 Tag F0732 Corrected Aug 2024

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

D August 9, 2024 Tag F0865 Corrected Aug 2024

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0842 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0838 Corrected Aug 2024

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0790 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0698 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0684 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0657 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0641 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0625 Corrected Aug 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D August 9, 2024 Tag F0623 Corrected Aug 2024

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, potential for more than minimal harm

E August 9, 2024 Tag F0758 Corrected Sep 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

E August 9, 2024 Tag F0686 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

E August 9, 2024 Tag F0656 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

F August 9, 2024 Tag F0645 Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D September 29, 2023 Tag F0812 Corrected Nov 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D September 29, 2023 Tag F0684 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D September 29, 2023 Tag F0660 Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

No actual harm, potential for more than minimal harm

D September 29, 2023 Tag F0610 Corrected Nov 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D September 29, 2023 Tag F0609 Corrected Nov 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.