Below average — CMS composite of the measures below.
The next survey window likely opens 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 Harborview Rome during CMS and state inspections, most recent first.
Failure to implement a resident’s communication care plan. A resident with severe cognitive impairment, stroke-related left-sided weakness, and total-care needs did not speak English, and staff reported relying on gestures and family to communicate. The care plan called for use of a translator or language app and for staff to anticipate needs and monitor nonverbal signs of distress, but interviews showed no staff spoke the resident’s primary language and the family also could not communicate in English.
Failure to Perform Hand Hygiene During Wound Care: An RN provided wound care to a resident with multiple chronic conditions and moderate cognitive impairment without performing hand hygiene before donning PPE, between glove changes, after handling contaminated and clean items, or before touching dressing supplies. The RN confirmed sanitizer was available but not used, and the DON stated hand hygiene was expected before and after resident room entry and before and after gloves and other PPE.
A deficiency was cited for not ensuring that each resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report does not provide further details about the specific events or individuals involved.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff were observed standing while feeding a resident with moderate cognitive impairment and entering residents' rooms without knocking or identifying themselves, contrary to facility policy. Additionally, staff did not provide privacy during resident care by failing to close curtains or doors. These actions did not maintain or enhance resident dignity and respect.
A resident with intact cognition and her family representative were not invited to participate in required care plan meetings, and there was no documentation of their involvement in the development or review of the care plan, despite facility policy mandating such participation.
A resident with a history of dysphagia and recent aspiration was not given timely assistance during a respiratory distress episode while being assisted with feeding by an OT. The OT left the resident to seek help, and when an LPN arrived, the resident was unresponsive and pulseless. Staff did not follow protocols to remain with unresponsive residents and failed to document the incident. The resident died from hypoxic respiratory failure and aspiration.
A resident with COPD and a malignant neoplasm was inaccurately assessed in the MDS, as it failed to document the oxygen therapy they were receiving. The MDS Resident Assessment Coordinator confirmed the error, noting that the section related to oxygen therapy was marked incorrectly.
The facility failed to provide resident-centered activities for two residents with moderate cognitive deficits and multiple medical conditions. Despite their preferences for independent and social activities, the residents were not engaged in meaningful activities due to a lack of structured one-on-one interactions and inadequate accommodation of their needs. The Activities Director acknowledged the absence of a schedule for one-on-one activities, resulting in minimal engagement for these residents.
Two residents receiving oxygen therapy in a facility were found to have their oxygen concentrators set at three liters per minute (LPM) instead of the physician-ordered two LPM. Both residents had intact cognition and specific medical conditions requiring precise oxygen administration. An LPN confirmed the discrepancies by checking the electronic medical records.
An LPN in an LTC facility failed to follow infection control practices by picking up a dropped medication cup from the floor and placing it back with clean cups, and by handling medication with bare hands. The DON confirmed these actions were against the facility's infection control protocols.
Failure to Implement Communication Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for one resident, R71, who was admitted with diagnoses including unspecified hypothyroidism, essential primary hypertension, residual deficits from a prior cerebral infarction with left-sided hemiplegia and hemiparesis, and generalized muscle weakness. Her quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment, and documented that she used a wheelchair and required two-or-more-person assistance for ADLs. The care plan dated 06/20/2025 identified a communication problem related to language and included interventions to anticipate and meet needs, observe and document nonverbal indicators of discomfort or distress, and provide a translator such as family, a tablet, or a phone language application as needed. During observation and interviews, R71 was found to not speak English, and her family was present but also did not speak English. A CNA stated that R71 requires total care and two-person assistance for Hoyer transfers and that staff communicate with her using family translate application. The ADON stated staff communicate daily with the family, rely on gestures and family to communicate with R71, and that no staff members speak R71's primary language. The DON and MDS Coordinator confirmed that staff believed they were using the language app, that the facility was creating laminated communication sheets in English and R71's primary language, and that care-plan interventions should be implemented as written.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to provide proper hand hygiene during wound care for R5, a resident admitted with diagnoses including hyperlipidemia, essential primary hypertension, type 2 diabetes mellitus with hyperglycemia, chronic systolic congestive heart failure, presence of a cardiac pacemaker, seasonal allergic rhinitis, generalized muscle weakness, dizziness and giddiness, unsteadiness on feet, and unspecified low back pain. R5’s MDS showed a BIMS score of 12, indicating moderate cognitive impairment, and section GG reflected use of a wheelchair with independent to partial/moderate assistance. R5 also had urinary incontinence and a care plan identifying risk for or actual pressure ulcer due to assistance required in bed mobility. During observed wound care to R5’s buttocks wound, RN GG donned PPE including gown and gloves without performing hand hygiene, then removed the resident’s brief, cleansed the wound, removed gloves without hand hygiene, and handled the resident-specific Thera-Honey tube and dressing materials while repeatedly changing gloves without hand hygiene between steps. RN GG also placed her hands in her pockets to retrieve a marker before applying the dressing and only washed her hands with soap and water after completing the care. The facility’s hand hygiene policy stated that gloves do not replace hand hygiene and that hand hygiene is required before and after handling dressings and when moving from a contaminated body site to a clean body site. RN GG confirmed she had alcohol hand sanitizer available but did not use it or soap and water between glove changes or before donning PPE, and the DON stated hand hygiene was expected before entering and after exiting resident rooms and before and after donning gloves and other PPE.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all individuals in their care. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
Staff failed to maintain or enhance the dignity, respect, and individuality of residents, as required by facility policy. Specifically, a certified nursing assistant was observed standing while feeding a resident who was slouched in bed, rather than sitting at eye level, which did not promote dignified care. The resident in question had a history of dyskinesia of the esophagus and was assessed as moderately cognitively impaired, with a care plan indicating the need for assistance with meals. Additionally, staff members, including an LPN and a staffing coordinator, were observed entering residents' rooms without knocking or identifying themselves, despite facility policy and staff awareness that this was required to respect residents' living space and privacy. Further observations revealed that during repositioning of a resident, staff did not pull the curtain or shut the door to provide privacy from visitors or others in the hallway. Interviews with staff confirmed that some routinely entered rooms without knocking or announcing themselves, and one CNA stated she always stood while feeding residents. A resident also reported that staff would enter the room without knocking or announcing themselves. These actions and inactions were inconsistent with the facility's policy on promoting and maintaining resident dignity and privacy.
Failure to Involve Resident and Family in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and her family representative were invited to and participated in the development and implementation of her person-centered care plan. Despite facility policies requiring that residents and their representatives be provided with a written summary of the baseline care plan and be included in care plan meetings, documentation and interviews revealed that neither the resident nor her family were invited to the 72-hour care plan meeting following admission. The resident, who was admitted with diagnoses including dysphagia and gastro-esophageal reflux disease and had intact cognition as indicated by a BIMS score of 15, did not have evidence of participation in the care planning process. Further review of records and staff interviews confirmed that the required care plan meetings were not held as scheduled, and the family only became aware of care planning issues after inquiring about therapy discontinuation. The family reported not receiving any invitations or communications regarding care plan meetings until after they initiated contact. Staff interviews corroborated that the care plan meetings were not conducted according to policy, and there was no documentation of resident or family involvement in the initial or subsequent care plan meetings.
Failure to Provide Timely Assistance During Resident Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia and recent aspiration events was not provided timely assistance during an episode of respiratory distress. The resident had been admitted with diagnoses including dysphagia and gastro-esophageal reflux disease, and her care plan included monitoring for signs of swallowing difficulty. Despite this, the resident experienced a coughing episode and signs of respiratory distress during an occupational therapy session, where she was being assisted with self-feeding. The occupational therapist observed the resident coughing and mouth breathing, attempted to obtain a pulse oximeter reading without success, and then left the resident alone to seek help from the LPN. Upon the LPN's arrival, the resident was found unresponsive and pulseless. The LPN left the room again to find the Unit Manager, and when they returned, resuscitation efforts were initiated. There was no documentation of the incident in the resident's medical record by the LPN, and the nurse failed to write an order for hospital transfer after speaking with the nurse practitioner. Interviews revealed that staff had been educated to never leave an unresponsive resident and to call out for help, but this protocol was not followed. The Director of Nursing was unaware that therapy was being provided at the time of the incident. The resident was ultimately pronounced dead, with the cause of death listed as hypoxic respiratory failure and aspiration of food.
Inaccurate MDS Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to accurately assess a resident, identified as R34, during the quarterly Minimum Data Set (MDS) assessment. The assessment, with a reference date of 7/10/2024, incorrectly indicated that the resident did not receive oxygen therapy within the last 14 days, despite the resident's care plan and medical orders indicating the use of oxygen therapy. R34 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and malignant neoplasm of the upper lobe, left bronchus or lung, and had an order for oxygen at 2 liters via nasal cannula as needed. An interview with the MDS Resident Assessment Coordinator confirmed the error, acknowledging that the section of the MDS related to oxygen therapy was marked incorrectly.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities that met the individual needs of two residents, R49 and R36, who were bed-bound and dependent on care. The facility's policy on activities emphasized the importance of supporting residents' choices based on comprehensive assessments and care plans. However, observations and interviews revealed that these residents were not engaged in activities that aligned with their preferences or needs. Resident R49, who has multiple medical conditions and a moderate cognitive deficit, expressed a preference for independent activities and spending time with family. Despite this, the Activities Director (AD) confirmed that R49 had not participated in any group activities in the last three months and had no documented one-on-one activities. The AD attributed this to R49's dialysis schedule and family visits but acknowledged the lack of a structured schedule for one-on-one activities. Resident R36, also with a moderate cognitive deficit and various medical conditions, was dependent on staff for emotional, intellectual, physical, and social needs. The resident expressed a desire to participate in activities but was unable to attend group activities due to mobility issues. The AD's log showed minimal one-on-one interactions, primarily consisting of conversations, with no activities offered that matched R36's preferences. This lack of engagement highlights the facility's failure to accommodate the residents' needs and preferences as outlined in their care plans.
Oxygen Therapy Not Administered as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders for two residents, R34 and R14, who were receiving oxygen therapy. R34 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and malignant neoplasm of the upper lobe, left bronchus or lung. The physician's order for R34 specified oxygen therapy via nasal cannula at a rate of two liters per minute (LPM). However, observations on multiple occasions revealed that R34's oxygen concentrator was set at three LPM, contrary to the physician's order. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who checked the medical orders in the facility's electronic medical record (EMR). Similarly, R14, who was admitted with acute and chronic respiratory failure with hypoxia and a post-COVID-19 condition, had a physician's order for oxygen therapy at two LPM via nasal cannula. Observations showed that R14's oxygen concentrator was also set at three LPM, not in accordance with the physician's order. This was again confirmed by the same LPN who verified the orders in the EMR. The failure to adhere to the prescribed oxygen therapy settings for both residents had the potential to place them at risk for medical complications and a diminished quality of life.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration, as observed with one of the five nurses. The facility's policy on Medication Administration, dated 6/1/2024, specifies that medications should be administered by licensed nurses in a manner that prevents contamination or infection, including not touching medication with bare hands. On 7/31/2024, an LPN was observed dropping a medication cup on the floor, picking it up, and placing it back on a stack of clean, unused medication cups. The LPN then used her bare hands to take medication from a medication card and place it into a medication cup for administration to a resident. During an interview, the LPN confirmed the actions, acknowledging that she should have discarded the dropped cup and should not have touched the medication with her bare hands. The Director of Nursing also confirmed that these actions were not in line with appropriate infection control procedures and that she expected the LPN to be aware of the correct protocols.
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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.
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Nursing homes near Rome
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Place Nursing And Rehabilitation | 0.3 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Rome | 1.8 mi | ★★★★★ | 7 | 0 |
| Fifth Avenue Health Care | 2.4 mi | ★★★★★ | 9 | 0 |
| Etowah Landing | 3.3 mi | ★★★★★ | 7 | 0 |
| Winthrop Health And Rehabilitation | 5.2 mi | ★★★★★ | 4 | 0 |
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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.