Inspection Reports for
Harborview Tifton
1451 NEWTON DRIVE, TIFTON, GA, 31794
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
22 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
349% worse than Georgia average
Georgia average: 4.9 deficiencies/year
Deficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
86% occupied
Based on a July 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Dec 3, 2025
Visit Reason
The inspection was conducted due to complaints and concerns related to resident-to-resident abuse, discharge planning, care plan participation, smoking policy violations, catheter care, bed rail use, medication storage, food safety, infection control, and antibiotic stewardship.
Complaint Details
The investigation substantiated resident-to-resident abuse in two incidents involving residents R13 and R45. Verbal abuse was also substantiated involving residents R17 and R45. The facility failed to ensure appropriate discharge planning for resident R86 discharged AMA. Additional complaints involved failure to invite residents to care plan meetings, smoking policy violations, catheter care, bed rail use, medication security, food safety, infection control, and antibiotic stewardship.
Findings
The facility was found to have multiple deficiencies including substantiated resident-to-resident abuse incidents, failure to ensure appropriate discharge planning and resident participation in care planning, inadequate smoking policy enforcement, lack of physician orders for urinary catheter use, improper bed rail assessments and use, unsecured medication storage, failure to maintain safe food temperatures and proper food storage, lapses in infection control practices including PPE use and catheter care, and inappropriate antibiotic use without positive culture confirmation.
Deficiencies (11)
F0600: The facility failed to protect residents from verbal and physical abuse in two substantiated resident-to-resident altercations occurring on 11/03/25 and 10/08/25.
F0627: The facility failed to ensure an appropriate discharge plan for one resident discharged AMA without arranging necessary post-discharge care and follow-up.
F0657: The facility failed to invite two residents to their care plan meetings, risking residents not obtaining their highest practicable level of functioning.
F0689: The facility failed to prevent accidents by inadequately managing smoking residents, including failure to assess smoking safety and enforce smoking rules, resulting in discharge notices for non-compliance.
F0690: The facility failed to obtain a physician's order for the use of an indwelling urinary catheter for one resident, risking inappropriate care.
F0700: The facility failed to properly assess and initiate bed rails after attempting alternatives for three residents, increasing risk of accidents.
F0761: The facility failed to secure overflow medications in a medication supply room, leaving the door propped open and risking medication diversion.
F0804: The facility failed to ensure food was monitored and served at safe temperatures, had broken thermometers, and failed to properly label and store food, risking foodborne illness.
F0812: The facility failed to ensure food was dated, labeled, stored properly, and that the ice machine was maintained in a sanitary manner, risking contamination and foodborne illness.
F0880: The facility failed to follow infection control procedures for two residents on contact isolation, including failure to wear PPE and catheter bag tubing touching the floor, risking infection spread.
F0881: The facility failed to ensure antibiotics were used appropriately for one resident without a positive culture, risking adverse events and antibiotic resistance.
Report Facts
Residents affected by abuse: 2
Residents affected by smoking policy: 2
Residents affected by bed rail issues: 3
Residents affected by infection control issues: 2
Residents affected by antibiotic stewardship issue: 1
Duration of antibiotic order: 28
Temperature thresholds: 135
Temperature thresholds: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Reported resident-to-resident abuse incident on 11/03/25. |
| DON | Director of Nursing | Confirmed abuse reports, smoking policy enforcement, catheter care expectations, and infection control procedures. |
| SSD | Social Services Director | Responsible for scheduling care plan meetings and smoking policy enforcement. |
| UM1 | Unit Manager | Confirmed bed rail assessments and catheter bag observations. |
| DM | Dietary Manager | Responsible for food temperature monitoring and dietary sanitation. |
| HK1 | Housekeeper | Observed not wearing PPE while cleaning contact isolation room. |
| PTA1 | Physical Therapy Aide | Observed not wearing PPE while treating resident on contact isolation. |
| IP | Infection Preventionist | Interviewed regarding antibiotic stewardship and infection control. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 5, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure to obtain consent for representative payee status, failure to prevent and respond to resident abuse, failure to timely report abuse to authorities, failure to revise care plans to address psychological needs, and failure to provide medically-related social services after an abuse allegation.
Complaint Details
The complaint investigation involved allegations that the facility failed to obtain consent for representative payee status for one resident, failed to protect a resident from abuse by another resident, failed to report the abuse to law enforcement, failed to revise the care plan to address psychological needs after abuse, and failed to provide medically-related social services after the abuse allegation. The allegations were substantiated with findings of minimal harm affecting a few residents.
Findings
The facility failed to obtain consent to become representative payee for one resident, failed to implement protections and reporting procedures for resident abuse, failed to report an abuse allegation to law enforcement, failed to revise a resident's care plan to address psychological needs after abuse, and failed to provide medically-related social services to a resident after an abuse allegation. These failures affected a few residents and were associated with minimal harm or potential for actual harm.
Deficiencies (5)
F0602: The facility failed to obtain consent to become the representative payee for one resident, despite applying for this status due to nonpayment of bills.
F0607: The facility failed to implement protections and reporting components of their abuse policy when one resident alleged another resident struck him multiple times.
F0609: The facility failed to timely report an allegation of resident-to-resident abuse to law enforcement for one resident.
F0656: The facility failed to revise the care plan for one resident to address psychological needs related to an allegation of physical abuse.
F0745: The facility failed to assess psychosocial status and provide medically-related social services to one resident after an allegation of physical abuse.
Report Facts
Outstanding balance: 5512
Monthly payment: 200
SSA deposit: 718
Care cost payment: 648
Residents sampled: 15
Times resident struck: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 7, 2025
Visit Reason
A revisit survey was conducted on May 7, 2025, to verify correction of deficiencies cited in the March 12, 2025 Complaint Survey and to investigate Complaint Intake Number GA002544467.
Complaint Details
Complaint Intake Number GA002544467 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the March 12, 2025 Complaint Survey were found to be corrected. The complaint investigation for GA002544467 was unsubstantiated.
Inspection Report
Original Licensing
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
A licensure survey was conducted at Harborview Tifton from March 3, 2025 through March 12, 2025 to assess compliance with regulatory requirements.
Findings
The facility failed to implement the care plan related to wound treatment for two of three sampled residents with stage IV wounds, resulting in unaddressed pain during wound care treatment on 3/5/2025.
Deficiencies (1)
Failure to implement the care plan related to wound treatment for residents with stage IV wounds, resulting in unaddressed pain during wound care.
Report Facts
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse | Observed providing wound care and acknowledged in interviews regarding pain management failures. |
| LPN DD | Licensed Practical Nurse | Observed providing wound care and acknowledged in interviews regarding pain management failures. |
| RN FF | MDS Registered Nurse | Interviewed regarding staff adherence to pain management care plan. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 12, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from March 3, 2025 to March 12, 2025 to investigate multiple complaints. Several complaint intakes were unsubstantiated, but one complaint intake (GA00253517) was substantiated with deficiency related to pain management during wound care treatment.
Complaint Details
Complaint intake GA00253517 was substantiated with deficiency related to pain management during wound care treatment. Harm was determined to have occurred on March 5, 2025 when residents R1 and R3 experienced pain that was not addressed during wound care treatment. Other complaint intakes were unsubstantiated.
Findings
The facility failed to implement the care plan related to wound treatment for two residents (R1 and R3) with stage IV wounds, resulting in harm due to unaddressed pain during wound care on March 5, 2025. Additionally, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) during wound care and perineal care for three residents (R1, R2, and R3).
Deficiencies (2)
Failure to implement wound care plan and address pain for residents R1 and R3 during wound treatment on 3/5/2025.
Failure to ensure staff wore appropriate PPE during wound care and perineal care for residents R1, R2, and R3.
Report Facts
Wound measurement: 8.5
Wound measurement: 3.1
Wound measurement: 4.7
Wound measurement: 4
Wound measurement: 31
Wound measurement: 7.3
Wound measurement: 2.1
Medication dosage: 325
Medication dosage: 2
Medication dosage: 10
Medication dosage: 300
Medication dosage: 50
Medication dosage: 4
Glove box quantity: 50
Gown box quantity: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse / Wound Care Nurse | Observed providing wound care to residents R1, R2, and R3; failed to acknowledge pain and did not wear protective gown during care. |
| LPN DD | Licensed Practical Nurse | Assisted with wound care for residents R1 and R3; failed to acknowledge pain and did not wear protective gown during care. |
| CNA SS | Certified Nurse Aide | Provided perineal care to resident R1 without wearing protective gown. |
| CNA HH | Certified Nurse Aide | Provided perineal care to resident R1 without wearing protective gown. |
| CNA GG | Certified Nurse Aide | Assisted with perineal care to resident R1 without wearing protective gown. |
| Nurse Practitioner (NP) | Interviewed and stated staff should be educated on pre-medication and wound stages. | |
| Director of Nursing (DON) | Interviewed and stated staff should have assessed residents for pain and determined cause. | |
| Infection Control Preventionist/Registered Nurse (RN) QQ | Infection Control Preventionist / RN | Reported on gown supply and infection control practices. |
| Central Supply/Medical Record AA | Observed handling glove boxes improperly and not using hand sanitizer. | |
| Administrator | Stated staff will be retrained on PPE use and clean cart maintenance. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 12, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with healthcare regulations, focusing on wound care, pain management, and infection control practices at Harborview Tifton nursing home.
Findings
The facility failed to implement adequate care plans for wound treatment and pain management for two residents with stage IV wounds, resulting in actual harm. Additionally, staff did not consistently wear appropriate personal protective equipment (PPE) during wound care and perineal care, violating infection prevention protocols.
Deficiencies (3)
F 0656: Develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions. The facility failed to implement the care plan related to wound treatment for two residents with stage IV wounds, resulting in unaddressed pain during wound care on 3/5/2025.
F 0697: Provide safe, appropriate pain management for residents requiring such services. The facility failed to ensure two residents were free from pain during wound care treatment on 3/5/2025, with pain not addressed and no pain medication administered as ordered.
F 0880: Provide and implement an infection prevention and control program. The facility failed to ensure staff wore appropriate PPE during wound care and perineal care for three residents, despite enhanced barrier precautions being in place.
Report Facts
Wound measurements: 8.5
Wound measurements: 3.1
Wound measurements: 4.7
Wound measurements: 4
Wound measurements: 31
Wound measurements: 7.3
Wound measurements: 2.1
Pain medication order: 325
Pain medication dosage: 2
Protective gown boxes: 2
Protective gown box size: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse / Wound Care Nurse | Observed providing wound care and failed to acknowledge resident pain or wear protective gown |
| LPN DD | Licensed Practical Nurse | Observed assisting with wound care, failed to acknowledge resident pain, and did not wear protective gown |
| CNA SS | Certified Nurse Aide | Observed providing perineal care without wearing protective gown |
| MDS RN FF | MDS Registered Nurse | Interviewed regarding pain management care plan noncompliance |
| NP | Nurse Practitioner | Interviewed about staff education on pre-medication and wound pain management |
| DON | Director of Nursing | Interviewed about staff responsibilities for pain assessment and management |
| CNA HH | Certified Nurse Aide | Interviewed about not wearing protective gown during perineal care |
| CNA GG | Certified Nurse Aide | Interviewed about not wearing protective gown during perineal care |
| Infection Control Preventionist RN QQ | Registered Nurse | Interviewed about PPE supplies and infection control |
| Central Supply/Medical Record AA | Interviewed about glove box handling and PPE supply management | |
| Administrator | Interviewed about staff retraining on PPE use and clean cart maintenance |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
A State Licensure survey was conducted at Harborview Tifton from June 25, 2024 through July 2, 2024 to assess compliance with state health regulations.
Findings
The survey revealed no State Health deficiencies were cited during the inspection period.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA00246303 and GA00247905.
Complaint Details
Complaint GA00246303 was unsubstantiated with no deficiencies. Complaint GA00247905 was substantiated with deficiencies and actual harm identified.
Findings
Complaint GA00246303 was unsubstantiated with no deficiencies. Complaint GA00247905 was substantiated with deficiencies, including actual harm when a resident was transferred incorrectly resulting in a chest wall hematoma and anemia requiring a blood transfusion.
Deficiencies (1)
Resident was transferred in a stand-up lift incorrectly resulting in chest wall hematoma and subsequent anemia requiring blood transfusion.
Report Facts
Facility census: 86
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 2, 2024
Visit Reason
The investigation was conducted due to a complaint regarding the facility's failure to use the correct mechanical lift for transferring a resident, which resulted in injury.
Complaint Details
The complaint investigation substantiated that the facility failed to use the correct mechanical lift for a resident who could not bear weight, resulting in injury. The resident was transferred improperly on 6/13/2024, causing bruising and hematoma. Three CNAs involved were terminated. The facility initiated a Project Improvement Plan starting 6/21/2024 to address safe transfer techniques.
Findings
The facility failed to develop a care plan specifying the use of a mechanical swing lift for transfers of a resident who required it. This failure led to the resident sliding down in the sling of a stand lift causing a chest wall hematoma and anemia requiring a blood transfusion. Three CNAs involved were terminated for improper transfer technique. The facility implemented a plan of correction including staff re-education and transfer competency assessments.
Deficiencies (2)
F 0656: The facility failed to develop care plan interventions specifying the use of a mechanical swing lift for transfers of a resident requiring it, resulting in actual harm when the resident slid in a stand lift sling causing injury.
F 0689: The facility failed to ensure safe transfer using the correct mechanical lift, causing a resident to slide in a stand lift sling and sustain a chest wall hematoma with subsequent anemia requiring blood transfusion.
Report Facts
Resident weight: 342
Number of CNAs terminated: 3
Number of nursing staff re-educated: 38
Total nursing staff: 43
Sampled residents: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Involved in improper transfer resulting in resident injury |
| CNA BB | Certified Nursing Assistant | Involved in improper transfer resulting in resident injury |
| CNA CC | Certified Nursing Assistant | Involved in improper transfer resulting in resident injury |
| Director of Nursing | Director of Nursing | Conducted investigation and re-education of staff |
| Administrator | Facility Administrator | Notified of incident and involved in investigation |
Inspection Report
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Harborview Tifton, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
A Health Revisit survey was conducted to verify correction of deficiencies cited in the April 2, 2024, Recertification Survey.
Findings
All deficiencies cited in the prior April 2, 2024 Recertification Survey were found to be corrected during this revisit.
Inspection Report
Life Safety
Deficiencies: 0
Date: May 14, 2024
Visit Reason
A Life Safety Code Revisit survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the Life Safety Code Revisit survey.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 2, 2024
Visit Reason
A State Licensure survey was conducted at Harborview Tifton from March 26, 2024 through March 28, 2024 and April 1, 2024 through April 2, 2024 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including expired medications in the medication storage room, improper storage of resident personal care items leading to potential cross-contamination, medication administration errors with a 9.38% error rate, unsecured unauthorized medications at a resident's bedside, failure to implement oxygen therapy care plans correctly, and unsafe storage of oxygen tanks in resident rooms.
Deficiencies (6)
Expired medications including calcium 600 mg, aspirin 325 mg, and liquid multivitamin were found in the medication storage room.
Resident personal care items such as bath pans and urinals were not labeled or bagged properly in adjoining bathrooms, risking cross-contamination.
Medication error rate of 9.38% observed with three medication errors out of 32 opportunities involving incorrect dosages and routes for three residents.
One resident had unsecured unauthorized medications stored at the bedside, including prescription and over-the-counter creams brought in by family.
Care plans for two residents receiving oxygen therapy were not followed, with oxygen flow rates set incorrectly and missing humidifier bottles.
Oxygen tanks were found unsecured and free-standing in three resident rooms, posing a safety hazard.
Report Facts
Medication error rate: 9.38
Medication errors: 3
Medication administration opportunities: 32
Residents involved in medication errors: 3
Residents receiving oxygen therapy with care plan issues: 2
Residents rooms with unsecured oxygen tanks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN OO | Registered Nurse | Confirmed expired medications in medication storage room and removed unauthorized medications from resident bedside. |
| KK | Central Supply Clerk | Confirmed expired medications in medication storage room. |
| MT NN | Medication Tech | Administered medications involved in medication errors. |
| RN JJ | Registered Nurse Unit Manager | Reviewed medication errors and confirmed unsecured oxygen tank hazard. |
| LPN VV | Licensed Practical Nurse | Confirmed unsecured oxygen tanks in resident rooms. |
| RNC | Regional Nurse Consultant | Confirmed unlabeled and unbagged bath pans and soiled urinal during rounding. |
| DON | Director of Nursing | Provided expectations for medication monitoring, care plan adherence, and confirmed findings during rounding. |
Inspection Report
Routine
Census: 79
Deficiencies: 8
Date: Apr 2, 2024
Visit Reason
A standard survey was conducted at Harborview Tifton from March 26, 2024 through April 2, 2024, including investigation of multiple complaint intake numbers.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. Several complaints were found unsubstantiated, some substantiated without deficiencies, and others substantiated with deficiencies cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsecured medications at bedside, failure to follow oxygen therapy care plans and orders, medication errors exceeding 5%, expired medications in storage, improper food storage and labeling, and infection control issues related to unlabeled and unbagged bath pans and urinals.
Deficiencies (8)
Failure to ensure one resident did not have unsecured unauthorized medications stored at bedside.
Failure to implement care plans for oxygen therapy for two residents, specifically oxygen flow rates.
Failure to provide a safe environment by ensuring proper storage and securing of oxygen tanks in resident rooms.
Failure to ensure two residents receiving oxygen therapy were administered oxygen according to physician orders, including correct flow rates and humidifier use.
Medication error rate exceeded 5% with errors in administration for three residents.
Failure to discard expired medications in the facility medication storage room.
Failure to label and date food items in freezer, improper storage of raw meat, expired food products, and inadequate sanitizing solution concentration in three-compartment sink.
Failure to ensure resident personal care items (bath pans and urinals) were labeled and bagged to prevent cross-contamination in shared bathrooms.
Report Facts
Residents observed for medication self-administration: 23
Medication error rate: 9.38
Residents receiving oxygen therapy with care plan deficiencies: 2
Oxygen flow rate incorrect for resident R3: 5
Oxygen flow rate incorrect for resident R64: 2
Expired medication bottles: 8
Residents census: 79
Food items unlabeled or undated: 7
Bath pans not labeled or bagged: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN OO | Registered Nurse | Confirmed removal of unauthorized medications, identified expired medications, changed oxygen flow rate for resident R64. |
| LPN VV | Licensed Practical Nurse | Confirmed oxygen tank hazards, corrected oxygen flow rate error for resident R3. |
| MT NN | Medication Technician | Administered medications with errors to residents R69, R63, and R243. |
| RN JJ | Registered Nurse | Reviewed medication errors and verified orders. |
| Central Supply Clerk KK | Responsible for checking medications and supplies, confirmed expired medications in storage. | |
| DON | Director of Nursing | Provided expectations for medication administration, oxygen therapy, and medication storage. |
| CDM | Certified Dietary Manager | Confirmed food storage and labeling deficiencies. |
| RNC | Regional Nurse Consultant | Confirmed unlabeled and unbagged bath pans and urinals. |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 2, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with healthcare regulations and facility policies at Harborview Tifton nursing home.
Findings
The facility was found deficient in multiple areas including medication self-administration, oxygen therapy management, medication error rates, expired medication storage, food safety and sanitation, and infection control practices related to personal care item storage. Deficiencies were generally of minimal harm but affected several residents.
Deficiencies (8)
F 0554: The facility failed to ensure one resident had a completed assessment for self-administration of medications and had unsecured unauthorized medications at bedside.
F 0656: The facility failed to implement care plans for two residents receiving oxygen therapy, resulting in oxygen flow rates not following physician orders.
F 0689: The facility failed to ensure oxygen tanks were stored safely and secured in residents' rooms, posing accident hazards.
F 0695: The facility failed to provide safe respiratory care by administering oxygen at incorrect flow rates and not connecting humidifier bottles as ordered for two residents.
F 0759: The facility failed to maintain a medication error rate below 5%, with a 9.38% error rate observed in three residents.
F 0761: The facility failed to ensure expired medications were discarded in the medication storage room, including calcium, aspirin, and multivitamins.
F 0812: The facility failed to label and date food items in the freezer, improperly stored raw meat allowing drippings onto other foods, and failed to maintain sanitizing solution concentration in the three-compartment sink.
F 0880: The facility failed to ensure residents' personal care items such as bath pans and urinals were labeled, bagged, and stored properly to prevent cross-contamination in shared bathrooms.
Report Facts
Medication error rate: 9.38
Residents affected: 23
Residents affected: 2
Residents affected: 3
Residents affected: 2
Expired medication counts: 7
Food items unlabeled: 6
Residents affected: 73
Residents affected: 79
Bath pans unlabeled: 8
Urinals soiled: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN OO | Registered Nurse | Confirmed removal of unauthorized medications and expired medications; reported missing humidifier bottle. |
| LPN VV | Licensed Practical Nurse | Confirmed oxygen liter flow errors and unsecured oxygen tanks. |
| MT NN | Medication Technician | Administered medications incorrectly leading to medication errors. |
| RN JJ | Registered Nurse | Verified medication errors during interview. |
| Central Supply Clerk KK | Central Supply Clerk | Confirmed expired medications in storage room. |
| CDM | Certified Dietary Manager | Confirmed food safety violations including unlabeled food and lack of sanitizer. |
| DON | Director of Nursing | Reported expectations for staff compliance with oxygen orders and medication management. |
| RNC | Regional Nurse Consultant | Confirmed infection control deficiencies related to bath pans and urinals. |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 2, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with healthcare regulations and facility policies at Harborview Tifton nursing home.
Findings
The facility was found deficient in multiple areas including medication self-administration, oxygen therapy management, medication error rates, expired medication storage, food safety and sanitation, and infection control practices related to personal care item storage.
Deficiencies (8)
F 0554: The facility failed to ensure one resident had no unsecured unauthorized medications at bedside, risking unauthorized access.
F 0656: The facility failed to implement care plans correctly for two residents receiving oxygen therapy, with incorrect oxygen flow rates observed.
F 0689: The facility failed to ensure oxygen tanks were properly secured in three resident rooms, creating a hazard.
F 0695: The facility failed to provide oxygen therapy as prescribed for two residents, including incorrect flow rates and missing humidifier bottle.
F 0759: The facility failed to maintain a medication error rate below 5%, with a 9.38% error rate observed for three residents.
F 0761: The facility failed to discard expired medications found in the medication storage room.
F 0812: The facility failed to label and date food items, store raw meat properly, discard expired food, and maintain sanitizer concentration in the three-compartment sink.
F 0880: The facility failed to ensure personal care items like bath pans and urinals were labeled, bagged, and stored properly to prevent cross-contamination.
Report Facts
Medication error rate: 9.38
Medication administration opportunities: 32
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 73
Residents affected: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN OO | Registered Nurse | Confirmed removal of unauthorized medications and oxygen therapy issues. |
| LPN VV | Licensed Practical Nurse | Confirmed oxygen liter flow error and unsecured oxygen tanks. |
| MT NN | Medication Technician | Administered medications involved in errors. |
| RN JJ | Registered Nurse | Reviewed medication errors and verified orders. |
| Central Supply Clerk KK | Central Supply Clerk | Confirmed expired medications in storage. |
| CDM | Certified Dietary Manager | Confirmed food safety violations. |
| DON | Director of Nursing | Provided expectations on oxygen therapy and medication management. |
| RNC | Regional Nurse Consultant | Confirmed infection control deficiencies related to personal care items. |
Inspection Report
Life Safety
Census: 81
Capacity: 100
Deficiencies: 7
Date: Apr 1, 2024
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 with life safety requirements, including issues with aisle/corridor width, emergency lighting operation, hazardous area compartmentation, fire alarm system testing and maintenance, electrical component installation, and oxygen cylinder storage.
Deficiencies (7)
Failed to maintain clear access to exits; exit access impeded by wheelchairs and activity carts in Therapy Room.
Failed to ensure proper operation of emergency lighting affecting the generator.
Failed to maintain compartmentation of hazardous areas; storage room door propped open affecting the Kitchen.
Failed to ensure proper inspection, testing, and maintenance of the fire alarm system; no documentation of sensitivity test for smoke detection system.
Failed to ensure proper installation of electrical components; loose covers for junction boxes affecting entire facility.
Open space in electrical panel affecting Dining Room Hall.
Failed to maintain proper storage of oxygen cylinders; oxygen cylinder storage not properly marked affecting North Hall.
Report Facts
Certified beds: 100
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings and corrected some citations during the survey |
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 0
Date: Apr 24, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 9, 2023 Abbreviated/Partial Extended Survey.
Findings
All deficiencies cited in the prior March 9, 2023 survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
A Life Safety Code (LSC) Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.
Inspection Report
Routine
Deficiencies: 3
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, wound care, and feeding tube management at Harborview Tifton nursing home.
Findings
The facility failed to maintain functional drainage in one shower room, timely initiate and continue wound treatment for residents with pressure ulcers, and properly document and administer feeding tube nutrition and flushes as ordered.
Deficiencies (3)
F 0584: The facility failed to ensure one of two shower rooms had a functional drainage system, causing water backup and slow drainage.
F 0686: The facility failed to timely initiate wound treatment for one resident and ensure continued treatment for another, resulting in actual harm from untreated pressure ulcers.
F 0693: The facility failed to document and administer feeding tube formula and water flushes as ordered for one resident with feeding tube orders.
Report Facts
Deficiencies cited: 3
Wound measurements: 7.5
Wound measurements: 5.4
Wound measurements: 9.5
Wound measurements: 8
Wound measurements: 0.1
Wound measurements: 7
Wound measurements: 4.6
Wound measurements: 1.6
Feeding tube rate: 60
Feeding tube flush volume: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse EE | Licensed Practical Nurse | Reported awareness of shower water backup incident and feeding tube documentation issues. |
| Licensed Practical Nurse GG | Wound Nurse | Observed and treated wounds, reported wound care issues and documentation difficulties. |
| Registered Nurse AA | Registered Nurse | Provided information on wound care and feeding tube management. |
| Director of Nursing | Director of Nursing | Reported expectations for wound care and feeding tube formula administration. |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Reported observations related to feeding tube use. |
| Registered Dietitian FF | Registered Dietitian | Reported absence from facility and lack of resident assessment. |
| Maintenance Director | Reported prior plumbing issues and clearing shower drain blockage. | |
| Administrator | Reported contacting plumbing contractor and facility issues with shower drainage. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 9, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint intake numbers (GA00232380, GA00232687, GA00232777, and GA00232943) initiated on February 28, 2023 and concluded on March 9, 2023.
Complaint Details
The survey was initiated based on complaint intake numbers GA00232380, GA00232687, GA00232777, and GA00232943. Actual harm was identified on 3/1/23 for Resident #4 related to untreated pressure ulcers.
Findings
Deficiencies were cited including failure to maintain functional drainage in one shower room, failure to timely initiate and continue wound treatment for residents with pressure ulcers, and failure to document and implement feeding tube orders as prescribed. Actual harm was identified for Resident #4 due to untreated pressure ulcers.
Deficiencies (3)
Facility failed to ensure one of two shower rooms had a functional drainage system to prevent water backup and slow drainage.
Facility failed to timely initiate wound treatment for one resident and failed to ensure continued wound treatment for another resident, resulting in actual harm.
Facility failed to ensure documentation of water flushes and feeding formula being implemented as ordered for one resident with feeding tube orders.
Report Facts
Deficiency severity levels: 3
Wound measurements: 7.5
Wound measurements: 9.5
Wound measurements: 7
Wound measurements: 4.6
Wound measurements: 1.6
Tube feeding rate: 60
Flush volume: 50
Flush volume: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN GG | Wound Nurse | Named in wound care deficiency findings for Residents #4 and #5 |
| LPN EE | Licensed Practical Nurse | Interviewed regarding shower drainage issues and feeding tube documentation |
| RN AA | Registered Nurse | Interviewed regarding wound care and feeding tube administration |
| Administrator | Interviewed regarding shower drainage issues and plumbing vendor contact | |
| Director of Nursing | DON | Interviewed regarding wound care expectations and feeding tube administration |
| CNA DD | Certified Nurse Aide | Observed providing perineal care to Resident #4 |
| CNA CC | Certified Nursing Assistant | Interviewed regarding feeding tube observations |
| LPN HH | Unit Manager | Assisted wound nurse during observation of Resident #5 |
| RD FF | Registered Dietitian | Interviewed regarding lack of assessment for Resident #1 |
Inspection Report
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Tifton, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not specify any deficiencies or findings.
Inspection Report
Re-Inspection
Census: 79
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
A revisit was conducted at Harborview of Tifton to verify correction of deficiencies cited during the January 15, 2023 Recertification Survey.
Findings
All deficiencies cited as a result of the January 15, 2023 Recertification Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Mar 1, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility failed to keep sprinkler piping clear of external loads, had an open space in the breaker panel servicing the therapy wing, and had several open junction boxes and exposed wiring splices throughout the facility. These findings were confirmed by staff during the tour.
Deficiencies (3)
Failed to keep sprinkler piping clear of external loads affecting the entire facility above-ceiling.
Open space in the breaker panel servicing the therapy wing.
Several open junction boxes and exposed/open wiring splices affecting the entire facility above-ceiling, south dayroom, north annex, and north hall.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to sprinkler piping, breaker panel, and electrical wiring during facility tour. |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including PASRR screening, care planning, oxygen administration, fluid restriction, restorative nursing services, and respiratory care.
Findings
The facility failed to submit Level II PASRR applications for two residents with positive Level I PASRRs, did not develop a comprehensive care plan for oxygen use for one resident, failed to monitor and document fluid restrictions for one resident, did not provide a left hand splint as recommended for one resident, and failed to follow physician orders for oxygen administration for one resident while another resident was receiving oxygen without a physician's order.
Deficiencies (5)
F0645 PASARR screening for Mental disorders or Intellectual Disabilities was not submitted for two residents with positive Level I PASRRs.
F0656 The facility failed to develop and implement a comprehensive care plan for oxygen use for one resident receiving oxygen therapy.
F0684 The facility failed to ensure fluid restriction guidelines were followed, monitored, documented, and communicated for one resident as ordered by the physician.
F0688 The facility failed to provide a left hand splint and consistent passive range of motion exercises as recommended for one resident with limited range of motion.
F0695 The facility failed to follow a physician's order for oxygen administration for one resident and failed to have a physician's order for oxygen use for another resident.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Named in oxygen care plan and care planning deficiencies for Resident #66 |
| LPN EE | Licensed Practical Nurse | Interviewed regarding fluid restriction and oxygen administration issues |
| CNA DD | Certified Nursing Assistant | Interviewed regarding fluid restriction and restorative nursing care |
| RNA FF | Restorative Nursing Assistant | Responsible for restorative care and splint application for Resident #12 |
| LPN AA | Licensed Practical Nurse | Interviewed regarding oxygen administration for Resident #66 |
| LPN CC | Licensed Practical Nurse | Acknowledged lack of physician order for oxygen for Resident #83 |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for PASRR, oxygen administration, and restorative nursing |
| Social Services Director | Social Services Director | Interviewed regarding failure to submit Level II PASRR for Resident #51 |
| Therapy Manager | Therapy Manager | Manages restorative nursing program and restorative aides |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 15, 2023
Visit Reason
The inspection was conducted as a State Licensure survey from January 13, 2023 through January 15, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to develop a comprehensive care plan related to the use of oxygen for one of 24 residents (#66), which had the potential to affect the plan of care for residents receiving oxygen therapy.
Deficiencies (1)
Failure to develop a comprehensive care plan related to oxygen use for resident #66.
Report Facts
Number of residents affected: 1
Oxygen flow rate: 4
Oxygen order flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Interviewed regarding care plan responsibility and oxygen administration |
| Director of Nursing | Interviewed regarding expectations for care plan development |
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 5
Date: Jan 15, 2023
Visit Reason
A standard survey was conducted from January 13, 2023 through January 15, 2023, including investigation of Complaint Intake Number GA00230586, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00230586 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to submit Level II PASRR applications for two residents, failure to develop a comprehensive care plan for oxygen use, failure to monitor and document fluid restrictions for a resident, failure to provide a prescribed left hand splint to prevent contractures, and failure to follow physician orders for oxygen administration including lack of an order for one resident.
Deficiencies (5)
Failed to submit an application for Level II PASRR for two residents with positive Level I PASRR for mental illness.
Failed to develop a comprehensive care plan related to oxygen use for one resident.
Failed to ensure fluid restriction guidelines were followed, monitored, documented, and communicated for one resident.
Failed to provide left hand splint to prevent contractures as recommended by Occupational Therapist for one resident.
Failed to follow physician's order for oxygen administration for one resident and failed to have a written order for oxygen use for another resident.
Report Facts
Resident census: 87
Oxygen flow rate: 2
Oxygen flow rate observed: 4
Fluid restriction: 1500
Splint application frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding failure to apply for Level II PASRR for Resident #51 |
| Director of Nursing | Director of Nursing | Interviewed regarding Level II PASRR application and oxygen administration expectations |
| Registered Nurse BB | Registered Nurse | Interviewed regarding care plan development for oxygen therapy |
| Licensed Practical Nurse EE | Licensed Practical Nurse | Interviewed regarding fluid restriction monitoring and splint use |
| Certified Nursing Assistant DD | Certified Nursing Assistant | Interviewed regarding fluid restriction monitoring and splint use |
| Therapy Manager | Therapy Manager | Interviewed regarding restorative nursing program and splint application |
| Restorative Nursing Assistant FF | Restorative Nursing Assistant | Interviewed regarding splint application and passive range of motion exercises |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed regarding oxygen administration for Resident #66 |
| Licensed Practical Nurse CC | Licensed Practical Nurse | Interviewed regarding oxygen use for Resident #83 |
Inspection Report
Life Safety
Census: 85
Capacity: 100
Deficiencies: 5
Date: Jan 14, 2023
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including deficiencies in sprinkler system maintenance, portable fire extinguisher servicing, and electrical component maintenance. Specific issues included a missing sprinkler escutcheon ring at the main entrance, sprinkler piping loaded by wires above ceilings, an unserviced fire extinguisher in the dining hall, an open breaker panel space in the therapy wing, and several open junction boxes and exposed wiring splices throughout the facility.
Deficiencies (5)
Sprinkler head missing escutcheon ring at the front porch main entrance.
Sprinkler piping and hangers externally loaded by wires above ceiling.
Fire extinguisher near dining hall not serviced since 2021.
Open space in breaker panel servicing therapy wing.
Several open junction boxes and exposed/open wiring splices in multiple areas including above ceiling, south dayroom, north annex, and north hall.
Report Facts
Census: 85
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 17, 2023 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on November 17, 2023; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the November 17, 2023 Complaint Survey were found to be corrected.
Report Facts
Census: 88
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Harborview Tifton, indicating a regulatory inspection was completed.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
The inspection was conducted as a complaint survey from November 8, 2022 through November 17, 2022.
Complaint Details
Complaint survey conducted with no deficiencies cited.
Findings
No State Health Deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 17, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints initiated on November 8, 2022, and concluded on November 17, 2022. The complaints were unsubstantiated, but additional concerns were identified and substantiated with deficiencies.
Complaint Details
The survey investigated complaints GA00225921, GA00226532, GA00226225, GA00228343, GA00228789, and GA00229464. All complaints were unsubstantiated.
Findings
The facility failed to ensure that gabapentin 100 mg was administered as ordered for one resident (R#18). The medication was not available from the pharmacy as ordered, and there was no evidence the resident received the medication from November 6 through November 15, 2022. The pharmacy did not refill the medication due to an incorrect pill count in their system, and nursing staff did not use the emergency medication supply prior to November 16, 2022.
Deficiencies (1)
Failed to ensure that gabapentin 100 mg was available and administered as ordered for one resident (R#18).
Report Facts
Resident affected: 1
Medication doses missed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) BB | Observed medication administration and reported medication was on order. | |
| Unit Manager EE | Obtained gabapentin from medication room for administration. | |
| CC | Interim Director of Nursing (DON) | Confirmed nurses did not use emergency medication supply and explained pharmacy refill issue. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 23, 2022
Visit Reason
This document is a statement of deficiencies and plan of correction for Harborview Tifton, indicating regulatory oversight and corrective actions following an inspection.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed on this page.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Date: May 23, 2022
Visit Reason
A revisit was conducted to verify correction of deficiencies cited in the Abbreviated/Partial Extended Survey conducted on 3/21/2022.
Findings
All deficiencies cited in the prior survey were found to be corrected as of 5/5/2022.
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