Inspection Report Summary
The most recent inspection on June 18, 2025, identified deficiencies related to resident dignity, participation in care planning, and timely assistance during a respiratory emergency that resulted in a resident’s death. Earlier inspections showed a mix of issues including infection control lapses, oxygen therapy errors, recreational activity shortcomings, and life safety code deficiencies such as smoke barrier construction and sprinkler system maintenance. Complaint investigations were mostly unsubstantiated, though some substantiated complaints did not result in additional deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility demonstrated correction of prior deficiencies during follow-up surveys in 2024, but recent findings suggest some ongoing challenges in resident care and safety practices.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
94 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 3
Date: Jun 18, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaint numbers, initiated on June 5, 2025, and concluded on June 18, 2025.
Complaint Details
The visit was complaint-related, investigating multiple complaint numbers (GA00251959, GA00252668, GA00253282, GA00253871, GA00254343, GA00255244). The facility was found compliant with infection control but had other deficiencies as noted.
Findings
The facility was found in compliance with infection control regulations but had deficiencies including failure to promote resident dignity by staff not knocking before entering rooms and standing while feeding residents. The facility also failed to ensure resident participation in care plan meetings and failed to provide timely assistance to a resident in respiratory distress, resulting in the resident's death.
Deficiencies (3)
Failure to promote care in a manner that maintained or enhanced resident dignity; staff were standing while feeding a resident and did not knock or identify themselves before entering rooms.
Failure to ensure resident or family participation in scheduled 72-hour care plan meeting for one resident.
Failure to provide timely assistance to one resident who was in respiratory distress, resulting in death.
Report Facts
Census: 94
Deficiencies cited: 3
BIMS score: 8
BIMS score: 15
Care plan meeting date: 72
Therapy frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Observed entering resident rooms without knocking |
| CNA GG | Certified Nursing Assistant | Observed feeding resident while standing and repositioning resident without privacy |
| Staffing Coordinator II | Staffing Coordinator | Observed entering resident room without knocking; acknowledged proper procedure |
| Director of Nursing | Director of Nursing | Interviewed regarding staff education on resident rights and response to unresponsive resident |
| Resident Assessment Coordinator EE | Resident Assessment Coordinator | Confirmed care plan meeting procedures and lack of meeting for Resident R1 |
| Speech-Language Pathologist | Speech-Language Pathologist | Interviewed about care plan meeting and therapy for Resident R1 |
| LPN BB | Licensed Practical Nurse | Responded to unresponsive resident R1 and failed to document incident |
| Occupational Therapist AA | Occupational Therapist | Provided therapy to Resident R1 during respiratory distress incident |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Educated on resident mealtimes and response to unresponsive residents |
| Certified Nursing Assistant DD | Certified Nursing Assistant | Educated on response to unresponsive residents |
Inspection Report
Routine
Deficiencies: 1
Date: Jun 18, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted at Harborview Rome from June 5, 2025, through June 18, 2025, to assess compliance with infection control and resident care standards.
Findings
The facility failed to promote care in a manner that maintained or enhanced residents' dignity, respect, and individuality. Staff were observed standing while feeding a resident and entering resident rooms without knocking or identifying themselves, violating privacy and dignity policies.
Deficiencies (1)
Failure to promote care that maintained or enhanced resident dignity, respect, and individuality, including staff standing while feeding a resident and not knocking or identifying themselves before entering resident rooms.
Report Facts
Survey period: 14
BIMS score: 8
Number of sampled residents with dignity issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Certified Nursing Assistant (CNA) | Observed feeding resident R8 while standing; interviewed about feeding practices |
| HH | Licensed Practical Nurse (LPN) | Observed entering resident rooms without knocking; interviewed about this practice |
| JJ | Treatment Nurse (TN) | Observed repositioning resident R8 without providing privacy |
| Staffing Coordinator II | Observed entering resident room without knocking; interviewed about knocking policy | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding staff education on resident rights including knocking before entering rooms |
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/1/2024 Recertification Survey.
Findings
All deficiencies cited in the prior 8/1/2024 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the Recertification-Complaint Survey concluded on 2024-08-01.
Findings
All deficiencies cited in the prior Recertification-Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies have been corrected.
Inspection Report
Life Safety
Census: 90
Capacity: 100
Deficiencies: 2
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to review Harborview Rome's Emergency Preparedness Program and to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility's Emergency Preparedness Program was found not in substantial compliance due to inconsistent documentation of plan updates across locations. Additionally, the Life Safety Code Survey identified that smoke barriers were not constructed to be smoke tight to the roof deck, potentially placing 30 residents at risk during a smoke or fire event.
Deficiencies (2)
Emergency Preparedness Plan was not consistently updated across all copies, with discrepancies between the Nurses Station and Administrator's Office.
Smoke barriers were not constructed to be smoke tight to the roof deck, specifically the smoke wall at hall 3 rear did not continue to the ridge cap of the roof line.
Report Facts
Residents at risk: 30
Census: 90
Total licensed capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to Emergency Preparedness Plan and smoke barrier deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 1, 2024
Visit Reason
A State Licensure survey was conducted at Harborview Rome from July 30, 2024, through August 1, 2024, to assess compliance with state health regulations and facility policies.
Findings
The inspection revealed deficiencies in infection control practices during medication administration by one nurse and failure to provide resident-centered recreational activities for two residents with moderate cognitive deficits and physical limitations.
Deficiencies (2)
Failure to ensure infection control practices were followed by a nurse who touched medication with bare hands and placed a dropped medication cup back on a clean stack.
Failure to provide suitable recreational activities meeting resident-centered and personal preferences for two bed bound and dependent care residents.
Report Facts
Number of nurses observed: 5
Number of sampled residents: 35
BIMS score: 12
BIMS score: 10
One-on-one activity dates logged: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed failing to follow infection control procedures during medication administration |
| Director of Nursing | Director of Nursing (DON) | Confirmed infection control expectations and facility policies |
| Activities Director | Activities Director (AD) | Planned and performed activities, confirmed lack of one-on-one activity scheduling and documentation |
| Administrator | Facility Administrator | Confirmed role of Activities Director and oversight of activity logs and MDS completion |
| Regional Coordinator | Regional Coordinator | Participated in interview regarding activities and facility operations |
Inspection Report
Routine
Census: 84
Deficiencies: 4
Date: Aug 1, 2024
Visit Reason
A standard survey was conducted from July 30, 2024 through August 1, 2024, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Harborview Rome.
Complaint Details
Complaint Intake Numbers GA00248963 and GA00237635 were substantiated without deficiencies; Intake numbers GA00244903, GA00236391, GA00243299, and GA00236058 were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate resident assessments, failure to provide activities meeting resident interests for two residents, improper oxygen therapy administration for two residents, and failure to follow infection control practices during medication administration.
Deficiencies (4)
Failed to accurately assess one of 35 sampled residents (R34) regarding oxygen therapy in the MDS assessment.
Failed to ensure residents (R49 and R36) received activities meeting their individual needs and preferences.
Failed to ensure oxygen therapy was administered according to physician orders for two residents (R34 and R14), with oxygen flow rates set higher than ordered.
Failed to ensure infection control practices during medication administration; nurse picked up a dropped medication cup and touched medication with bare hands.
Report Facts
Resident census: 84
Sampled residents: 35
Oxygen flow rate: 2
Observed oxygen flow rate: 3
BIMS scores: 15
BIMS scores: 14
BIMS scores: 12
BIMS scores: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in infection control deficiency and oxygen therapy administration findings |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control and activities program |
| Activities Director | Activities Director | Interviewed regarding activities program and resident participation |
| Administrator | Administrator | Interviewed regarding activities program and MDS completion |
| Regional Coordinator | Regional Coordinator | Interviewed regarding activities program |
| MDS Resident Assessment Coordinator | MDS Resident Assessment Coordinator | Interviewed regarding MDS assessment accuracy |
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 0
Date: Jul 18, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaint #GA00237074.
Complaint Details
Complaint #GA00237074 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated, no regulatory violations were cited, and the facility was found to be in compliance with infection control regulations and CDC recommended practices for COVID-19 preparation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 20, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 10/18/22 through 10/20/22 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from 10/18/22 through 10/20/22.
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Oct 20, 2022
Visit Reason
A standard survey was conducted from October 18, 2022 through October 20, 2022 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 82
Capacity: 100
Deficiencies: 4
Date: Oct 19, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to deficiencies in the sprinkler system installation and maintenance, including missing hydraulic data plate, informational signage, head legend on the spare head cabinet, and missing spare sprinkler heads.
Deficiencies (4)
Hydraulic Data Plate was not provided on the dry sprinkler riser.
General Informational sign was not provided on dry sprinkler riser.
Spare Head Cabinet was not provided with a head legend.
Spare Sprinkler Head of all types being used were not provided in the spare head box.
Report Facts
Census: 82
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed sprinkler system deficiencies during facility tour |
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