Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fifth Avenue Health Care during CMS and state inspections, most recent first.
Pureed food was not prepared according to the facility recipe when an HC used water instead of the milk called for in the pureed spaghetti recipe and did not follow the written instructions while preparing meals for residents on a pureed diet. The DM stated staff were expected to follow puree recipes but she did not oversee compliance, and the Administrator was unaware the recipes were not being followed.
Expired Food Items Not Discarded: Surveyors found an open bag of bacon, whole milk, and thickened cranberry cocktail juice past their best-by dates in the cooler and dry storage. The DM confirmed the items were expired, and the ADM stated kitchen staff were expected to rotate stock and check expiration dates, but there was no method in place to oversee that items were being discarded as required by policy.
The facility failed to maintain an effective Legionella water management program and failed to ensure proper hand hygiene during lunch tray delivery. The Maintenance Director confirmed the facility lacked a correct water flow map or written diagram, did not test for Legionella, and only checked water temperatures and drained water heaters. In addition, two CNAs were observed delivering meal trays to residents without sanitizing or washing their hands when entering and exiting multiple resident rooms, and both CNAs acknowledged the missed hand hygiene.
Failure to Assess Resident for Self-Administration of Medication: A resident with COPD, chronic respiratory failure, DM2, ischemic heart disease, and HF had an inhaler ordered daily, but there was no physician order or documented assessment authorizing self-administration. Staff were observed leaving the inhaler at the bedside for the resident’s use and later retrieving it, and the LPN acknowledged this was not the usual protocol. The DON and Administrator confirmed no residents were authorized to self-administer meds and that meds should not be left at bedside.
Stained and mildewed ceiling tiles were observed in multiple resident rooms, including brown stains on ceiling tiles in two East Hall rooms and black substances on a ceiling tile and wall marks in a [NAME] Hall room. The Maintenance Director acknowledged roof leaks, said the stained tiles were not homelike, and confirmed the black material was probably mildew and needed to be changed. The Administrator stated she expected daily maintenance rounds and checks after heavy rain due to known roof issues.
A resident with moderate cognitive impairment and impaired vision had a care plan noting reading glasses should be available, but staff could not locate her glasses and she reported needing them to read and see her TV. The resident also used chewing tobacco daily, kept it at bedside, and staff assisted with opening the canister, yet tobacco use was not included in the care plan and staff did not monitor her use.
Resident Fell From Wheelchair Due to Improper Equipment Use: A resident with a history of falls, moderate cognitive impairment, reduced mobility, and a care plan requiring 2-person full body lift transfers and a wheelchair lap buddy fell out of a wheelchair and was sent to the hospital. CNA staff reported the resident was in the wrong wheelchair and the lap buddy was not fitted or positioned properly; when the CNA returned to complete the transfer, the resident was on the floor with her leg caught in the wheelchair and blood on the floor.
A resident with multiple health conditions fell from a faulty shower bed, resulting in a femur fracture. The incident occurred due to the dislodgement of the bed's head section, which had not been inspected or maintained since its delivery. Staff involved lacked specific training on the new equipment, contributing to the accident.
A resident with multiple health conditions fell from a faulty shower bed, resulting in a femur fracture. The facility had not conducted routine maintenance or safety inspections on the shower bed, and modifications were made post-incident against the manufacturer's guidelines.
A resident with severe cognitive impairment did not receive necessary oral hygiene care, as staff failed to provide assistance or reminders, and oral hygiene supplies were missing from the resident's room. Despite the care plan's directives, staff were unaware of the resident's needs, leading to poor oral hygiene.
An E-Kit in the Medication Room West was accessed and not replaced, compromising emergency medication availability. The facility's policy requires immediate replacement of used kits, but the ADON confirmed the kit, opened on 5/2/2024, was not replaced, despite containing Humalog, a diabetes medication.
A resident with type 2 diabetes and Alzheimer's Disease did not receive adequate blood glucose monitoring while on insulin therapy. Despite the resident's request for more frequent checks, there were no active orders for monitoring, and the last documented checks were infrequent with high glucose levels. The lapse occurred after a hospital transfer when monitoring orders were not reinstated, and staff were unaware of the deficiency.
The facility failed to discard expired medications in two medication rooms, as observed by an LPN. Expired Acetaminophen suppositories were found in both rooms, posing a risk of administration to residents with physician's orders for these medications.
Pureed Food Prepared Contrary to Recipe
Penalty
Summary
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature was not met when the facility failed to prepare pureed food in a manner that preserved the nutrient value of resident meals. The facility policy titled Preparing Pureed Foods stated that pureed food should be prepared following the recipe for the regular textured foods and should have the same flavor as the regular texture counterpart. The recipe for pureed spaghetti noodles instructed staff to use 2% white milk and butter or margarine, then add thickener and process briefly until mixed. During observation, the Head Cook filled a plastic pitcher with an unmeasured amount of water and used it to puree spaghetti noodles for residents on the pureed diet, adding small increments of water until the desired consistency was reached. In interview, the Head Cook stated she did not refer to the puree recipes while preparing the meal and acknowledged using water instead of the milk called for in the recipe because it pureed faster. The Certified Dietary Manager stated she expected staff to follow the puree recipes but was not aware they were not being followed and did not provide oversight to ensure compliance. The Administrator stated she was unaware kitchen staff were not following the recipes and acknowledged that failing to follow them could compromise the nutritional value of the food.
Expired Food Items Not Discarded
Penalty
Summary
The facility failed to discard food items past the best-by date, affecting 66 of 66 residents receiving an oral diet. During observation of the walk-in cooler, surveyors found a box containing one open bag of bacon with a best by date of 8/23/2025 and a rolling cart containing six 240 ml boxes of whole milk with a best by date of August 2025. During observation of the dry food storage area, surveyors also found three 14-ounce boxes of thickened cranberry cocktail juice with a best by date of July 2025. The facility policy titled Food Storage Guidelines, last revised August 2017, stated that items were to be discarded up to the expiration and/or used by date on the product. The DM confirmed the expired or past-best-by items during the observation. In a follow-up interview, the DM stated that kitchen staff were responsible for checking expiration dates on stored food items and that she did not currently have a method in place to oversee whether stored food was being rotated and discarded according to best by dates. The Administrator stated she was unaware that expired food items were not being removed and discarded properly and expected kitchen staff to rotate goods and check expiration dates regularly.
Failed Water Management Program and Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to develop an effective Legionella water management program. Review of the facility policy showed that the water management program was to be overseen by the water management team, but the Maintenance Director’s binder contained a water flow map from a different facility. A separate binder showed that water temperatures were checked weekly. During interview, the Maintenance Director stated that he checked water temperatures weekly in resident rooms, shower rooms, and other rooms with sinks, drained water heaters monthly, and did not test the water for Legionella. He confirmed that the map in the binder was not for this facility and that the facility did not have a written diagram or map tracing water flow for this facility. The Administrator confirmed there was no other water management program binder, no map or written diagram of water flow, and that she was not aware of any Legionella testing for the facility. The facility also failed to perform hand hygiene when staff served lunch trays to residents. During observation, two CNAs were seen passing lunch trays from an open tray cart to residents in their rooms in the East hallway without washing or sanitizing their hands when entering or exiting multiple resident rooms. Both CNAs acknowledged that hand hygiene was required between residents and when entering and exiting rooms, and both admitted they failed to wash or sanitize their hands while serving lunch trays. The Administrator stated she was unaware staff were not practicing proper hand hygiene during tray distribution and confirmed she expected staff handling resident trays to perform hand hygiene between each resident.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess one of 41 sampled residents, R12, for self-administration of medication. R12 was admitted with diagnoses including COPD, chronic respiratory failure with hypercapnia, type 2 diabetes mellitus, ischemic heart disease, and heart failure. The quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact, and also showed partial to moderate assistance with several ADLs, with independence in oral hygiene and set-up assistance with toileting. The facility policy stated residents may self-administer medication only when specifically authorized by the attending physician and in accordance with self-administration procedures. Review of the EHR showed R12 had an order for Arnuity Ellipta inhalation aerosol powder, one puff daily, but there were no orders authorizing self-administration and no documentation of a self-administration assessment. During observation, the inhaler was found in an orange and white container on R12's bedside table, and R12 stated the nurse brought it in the morning, left it at bedside for use, and returned later to retrieve it, which she said happened frequently. The LPN confirmed she tended to leave the inhaler at the bedside and later picked it up after delivering medications to other residents, and acknowledged this was not the usual protocol. The DON and Administrator both stated there were no residents authorized to self-administer medications and confirmed medications should not be left at the bedside.
Stained and Mildewed Ceiling Tiles in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, homelike environment in two rooms on East Hall and one room on [NAME] Hall. In two East Hall rooms, ceiling tiles were observed with brown stains, including stains above a bed and above a window in one room and a brown stain above the bed in the other room. In the [NAME] Hall room, surveyors observed a buildup of black substances on the ceiling by the window in the corner of the room, along with black marks on the wall behind the bed. During interview, the Maintenance Director acknowledged that there had been leaking from the roof and said he was working with roofers to patch things up. He stated the stained ceiling tiles were not a homelike environment and said they would be replaced. Regarding the black substances, he confirmed the material on the ceiling tile and stated it was probably mildew, that he had not realized the ceiling was in that condition, and that it needed to be changed. The Administrator stated the facility was working on the roof and changing ceiling tiles as needed, and that she expected the Maintenance Director to make daily rounds and check ceiling tiles after heavy rain because of known roof issues.
Failure to Care Plan for Vision Needs and Tobacco Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with impaired vision and tobacco use. The resident’s MDS showed a BIMS score of 9, indicating moderate cognitive impairment, and the vision section identified impaired vision. The care plan, initiated on 7/17/2025, documented impaired visual function and that the resident wore reading glasses at times, with a goal to keep the resident safe and an intervention to ensure reading glasses were available. However, the record contained no evidence of tobacco use being included on the care plan. An Activities Assessment dated 7/7/2025 showed the resident had an interest in reading and audiobooks and stated she wore reading glasses only. During interviews and observations, the resident stated she needed her glasses and had not seen them since moving into the facility. Staff interviews confirmed that no one had seen her glasses recently. The resident also had chewing tobacco at her bedside, stated she used it once a day, and said she usually had someone open it because of limited hand function. Staff confirmed the tobacco was kept at the bedside, that they assisted with opening the canister, and that they did not monitor her tobacco use. One LPN stated the tobacco should be care planned, and the Unit Manager confirmed the tobacco use was not care planned.
Resident Fell From Wheelchair Due to Improper Equipment Use
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and that adequate supervision was provided when R28 fell from a wheelchair to the floor. R28 had diagnoses including history of falling, acquired absence of the right leg below knee, contracture of the left ankle, long-term drug therapy, and reduced mobility. The quarterly MDS showed a BIMS score of 9, indicating moderate cognitive impairment, and Section GG showed extensive assistance was needed for ADLs with two or more-person assistance for transfers. The care plan identified R28 as at risk for falls and stated she required 2 staff with a full body lift for transfers, used a wheelchair for mobility, and had a lap buddy while in the wheelchair. After eating, CNA EE placed R28 in her room and told her she would return with the lift to transfer her to bed. When the CNA returned, R28 was on the floor. CNA EE stated R28 was not in the correct wheelchair and the wheelchair buddy was not fitted for her and was not on the wheelchair properly. Staff observed R28 with her leg wrapped up/caught in the back of the wheelchair, her face on the floor, and blood on the floor. R28 was sent to the hospital by EMS, and later observation showed purple areas around her left eye and forehead; R28 stated she fell out of the wheelchair and required stitches, but could not explain how the fall occurred.
Resident Injury Due to Faulty Shower Bed
Penalty
Summary
The facility failed to provide an environment free from accident hazards, resulting in harm to a resident who fell from a faulty shower bed. The incident occurred when the support part of the head section of the shower bed became dislodged, causing the resident to slide off the bed and sustain a closed right peritrochanteric femur fracture. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, and Alzheimer's Disease, was unable to communicate effectively, as indicated by the inability to complete the Brief Interview for Mental Status (BIMS) assessment. The incident was reported by the CNAs who were preparing the resident for a shower. They noted that the shower bed and Hoyer lift were already in place, and while adjusting the resident, they heard a snap sound, leading to the fall. The shower bed had been in use for approximately three months without any maintenance or safety inspections. The Maintenance Director later added self-locking nuts and bolts to the C-Clamp of the shower bed, although the owner's manual advised against modifications. Interviews with staff revealed that there was no specific training provided for the use of the new shower bed, and the CNAs involved had limited experience with it. The facility's Administrator confirmed that the shower bed was delivered pre-assembled and had not undergone any safety inspections prior to the incident. The lack of maintenance and training contributed to the accident, highlighting a deficiency in ensuring a safe environment for residents.
Failure to Maintain Safe Shower Bed Leads to Resident Injury
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition, resulting in harm to a resident. The incident occurred when a resident, who was dependent on staff for bathing due to conditions such as hemiplegia, aphasia, Alzheimer's Disease, and severe obesity, fell from a faulty shower bed. The fall resulted in a closed right peritrochanteric femur fracture, necessitating hospital admission. The shower bed's head section support became dislodged, causing the resident to slide off the bed while being prepared for a shower by two CNAs. Interviews with the facility's Administrator and Maintenance Director revealed that the shower bed had not undergone routine maintenance or safety inspections prior to the incident. The Administrator acknowledged that the shower bed was delivered pre-assembled and that the PVC C-Clamp failure led to the accident. The Maintenance Director confirmed the absence of prior inspections and mentioned modifications made to the shower bed post-incident, which were contrary to the manufacturer's guidelines. The owner's manual explicitly advised against modifications and emphasized the importance of regular inspections and maintenance.
Failure to Provide Oral Hygiene Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain good oral hygiene for a resident with severe cognitive impairment. The resident, who was diagnosed with dementia, metabolic encephalopathy, and Alzheimer's disease, was observed with a foul odor and buildup on his teeth, indicating a lack of oral hygiene care. Despite the care plan directing staff to assist and remind the resident to complete oral care, the resident reported not receiving assistance or reminders from the staff. Additionally, the resident was unaware of the location of his oral hygiene supplies, which were not found in his room during an observation. Interviews with facility staff revealed a lack of awareness and action regarding the resident's oral hygiene needs. A CNA familiar with the resident's care needs incorrectly assumed the resident was independent with oral hygiene, despite acknowledging the resident's memory issues. The LPN was uncertain about the resident's ability to remember or perform oral hygiene tasks. The ADON confirmed there was no documented evidence of assistance or encouragement for the resident's oral care, highlighting a failure in the facility's adherence to the care plan and the resident's needs.
Emergency Medication Kit Not Replaced
Penalty
Summary
The facility failed to ensure that an emergency medication kit (E-Kit) was readily available for use in a resident emergency in one of the two medication rooms observed. The facility's policy, dated 4/1/2016, requires that emergency pharmacy services be available on a 24-hour basis, with emergency medications supplied in portable, sealed containers. These containers must be replaced as soon as possible after use. However, during an observation on 6/19/2024, a red color-coded E-Kit in the Medication Room West was found to have been accessed and opened on 5/2/2024, and not replaced by the pharmacy. The Assistant Director of Nursing (ADON) confirmed during an interview that the E-Kit had been opened and not replaced, despite the facility's process requiring the pharmacy to be notified for replacement. The pharmacy record inside the E-Kit indicated that Humalog, a diabetes medication, had been used. This oversight in replacing the E-Kit compromised the facility's ability to meet emergency medication needs as per their policy.
Inadequate Blood Glucose Monitoring for Insulin-Dependent Resident
Penalty
Summary
The facility failed to ensure adequate blood glucose monitoring for a resident receiving insulin, which was identified as a deficiency. The resident, who has a medical history of type 2 diabetes, metabolic encephalopathy, and Alzheimer's Disease, expressed concerns about infrequent blood glucose checks. Despite receiving insulin injections, there were no active physician orders for blood glucose monitoring, and the last documented checks were significantly spaced apart, with high glucose levels recorded. Interviews with facility staff revealed that the resident's blood glucose monitoring order was not reinstated after a hospital transfer. The Licensed Practical Nurse assigned to the resident was unaware of the lack of monitoring orders and results, indicating a lapse in communication and care continuity. The attending physician acknowledged that monitoring should occur with the administration of fast-acting insulin, despite the resident's history of refusing checks, emphasizing the need for documented attempts and refusals.
Expired Medications Found in Medication Rooms
Penalty
Summary
The facility failed to ensure the proper disposal of expired medications in two medication rooms, leading to a deficiency. During an observation in Medication Room East, an LPN discovered 32 Acetaminophen suppositories with an expiration date of September 2023 stored in the refrigerator. Similarly, in Medication Room West, five expired Acetaminophen suppositories were found. The LPN acknowledged that these expired medications should not have been stored due to the risk of administering them to residents. A review of facility records indicated that five residents had physician's orders for Acetaminophen suppositories to be administered every six hours as needed for elevated temperature. This oversight in medication management posed a potential risk of expired medications being given to these residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 80 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rome
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Etowah Landing | 1.4 mi | ★★★★★ | 7 | 0 |
| Magnolia Place Nursing And Rehabilitation | 2.3 mi | ★★★★★ | 0 | 0 |
| Harborview Rome | 2.4 mi | ★★★★★ | 6 | 0 |
| Pruitthealth - Rome | 2.8 mi | ★★★★★ | 7 | 0 |
| Winthrop Health And Rehabilitation | 2.9 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Fifth Avenue Health Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.