Guam Memorial Hospital Authority

Ensure that residents are fully informed and understand their health status, care and treatments.

Rule F0552. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 31, 2026.

Reasonably accommodate the needs and preferences of each resident.

Rule F0558. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 1, 2026.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Rule F0582. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Jul 31, 2026.

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

Rule F0605. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 31, 2026.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Rule F0636. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 31, 2026.

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Rule F0640. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 31, 2026.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 31, 2026.

PASARR screening for Mental disorders or Intellectual Disabilities

Rule F0645. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 1, 2026.

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

Rule F0656. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 1, 2026.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Rule F0700. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 1, 2026.

Provide or obtain dental services for each resident.

Rule F0791. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 1, 2026.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Rule F0883. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 31, 2026.

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.

Rule F0887. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 31, 2026.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Rule F0909. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 15, 2026.

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.

Rule F0837. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Sep 25, 2026.

Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

Rule F0844. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Aug 15, 2026.

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

Rule F0561. G: actual harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0550. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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.

Rule F0578. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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.

Rule F0584. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0605. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0658. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0691. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0755. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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.

Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0812. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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.

Rule F0837. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 19, 2025.

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

Rule F0867. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0868. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

Provide and implement an infection prevention and control program.

Rule F0880. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0882. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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.

Rule F0887. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0945. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Oct 6, 2025.

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

Rule F0623. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

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.

Rule F0625. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

Ensure each resident receives an accurate assessment.

Rule F0641. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 28, 2024.

PASARR screening for Mental disorders or Intellectual Disabilities

Rule F0645. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 30, 2024.

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

Rule F0656. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

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

Rule F0657. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

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

Rule F0684. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

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

Rule F0686. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

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

Rule F0698. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

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.

Rule F0758. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 4, 2024.

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

Rule F0790. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

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.

Rule F0838. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 28, 2024.

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

Rule F0842. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Sep 4, 2024.

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

Rule F0865. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Aug 30, 2024.

Post nurse staffing information every day.

Rule F0732. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Aug 28, 2024.

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.

Rule F0837. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Aug 29, 2024.

Provide and implement an infection prevention and control program.

Rule F0880. C: no actual harm, potential for minimal harm. Correction date, as CMS recorded it: Aug 30, 2024.