Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
GUAM MEMORIAL HOSPITAL AUTHORITY
BARRIGADA, GU · 40 certified beds · Last Life Safety survey August 9, 2024
CMS Certification Number 655000 · first certified January 1968
Ownership
Independently operated (no chain recorded by CMS) · Government - State
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within GU
20 citations — more than 0% of the 1 certified nursing homes in GU. Compared within GU rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (August 2025 to January 2026), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Nursing homes nationally are typically surveyed 12–17 months after the last one (median 14), measured over 19,385 consecutive surveys in the last two years of CMS records. GU has too few recent surveys to measure on its own, so the national interval is used.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 20 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
- F-0909 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.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in GU, and nationally. Surveyors differ markedly between states, so the GU figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in GU | 20 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 26, 2022 | 8 |
| September 29, 2023 | 6 |
| August 9, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2024-08-09 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-09-29 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2023-09-29 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2024-08-09 |
| K-0791 | Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | 1 | 2022-09-26 |
| E-0022 | Establish policies and procedures for sheltering. | 1 | 2022-09-26 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-09-29 |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | 1 | 2023-09-29 |
What the citations cover
- Smoke Deficiencies 10
- Emergency Preparedness Deficiencies 4
- Egress Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Emergency Preparedness Deficiencies | 4 |
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 9, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (September 1, 2024) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (August 16, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (August 16, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 22, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 16, 2024) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Waiver has been granted (August 29, 2024) |
September 29, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 7, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 7, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (November 7, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 7, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 7, 2023) |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Deficient, Provider has date of correction (November 7, 2023) |
September 26, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (November 4, 2022) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (October 17, 2022) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (November 4, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 4, 2022) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (September 26, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 26, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 26, 2022) |
| K-0791 | Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Deficient, Provider has date of correction (November 5, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.