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 Tifton during CMS and state inspections, most recent first.
Food temperatures were not properly monitored or maintained during meal service. Dietary staff documented only a few main items on hot/cold logs, did not record all altered-texture foods, and used broken thermometers that could not be calibrated correctly. During kitchen and tray observations, multiple items on the steam table and on a test tray were below the facility’s hot-holding standard, and staff reported the steam table did not hold heat well and cool air blew across it.
Food items were found improperly dated, labeled, covered, and stored, and the facility ice machine contained a soda can embedded in the ice. A dietary aide removed the can with bare hands without washing, and the DM confirmed thawed items should have been dated and that scoops should not rest directly on sugar. The Administrator stated nothing should ever be stored inside the ice machine.
Resident-to-resident abuse was not prevented when one cognitively intact resident slapped his roommate after being scratched, and another cognitively impaired resident was verbally threatened by his roommate with statements that he would be beaten and killed. Staff heard both incidents, separated the residents, and the DON confirmed the abuse was substantiated based on the reported threats and physical altercation.
Inadequate AMA Discharge Planning: A resident with CHF, COPD, acute respiratory failure, and substance use history was discharged after leaving the facility overnight, but staff did not arrange needed post-discharge care or follow-up. The DON, RCC, and SSD believed the resident had to be discharged because she was outside the facility after midnight, and staff documented that the facility could not provide meds or home health and did not give the resident an opportunity to return.
Residents were not invited to their initial care plan meetings after admission. Two cognitively intact residents, both their own medical decision-makers, had comprehensive care plans completed, but the record showed no evidence of an interdisciplinary care planning meeting or resident invitation. The SSD could not locate documentation of invitations or meetings, and the DON confirmed residents were expected to be invited to an initial care planning meeting within 72 hours of admission.
The facility failed to keep two residents free from smoking-related hazards and did not adequately supervise smoking behavior. One resident with moderate cognitive impairment had repeated smoking violations, including smoking inside the facility and on facility grounds, with no documented tobacco cessation education or smoking safety assessment. Another cognitively intact resident with paraplegia was documented smoking in his room on multiple occasions, yet no incident reports or follow-up were found. Staff confirmed residents were expected to smoke off property, but the records showed repeated noncompliance and incomplete oversight.
A resident with type 2 DM, urinary retention, and moderate cognitive impairment had an indwelling urinary catheter documented in the MDS and care plan, including monitoring for I&O and signs of UTI and discomfort. However, the resident’s record did not contain a physician order for the catheter’s use or care, and the DON confirmed that such orders were expected to be current in the chart.
Failure to Assess Alternatives Before Bed Rail Use The facility did not properly assess or document alternatives before using bed rails for three residents. Records showed mobility bars or side rails were used per resident or family request, but the initial assessments did not show that alternatives were tried first. Observations found the rails positioned in the middle of the bed or otherwise not optimally placed, and staff confirmed the rails were being used because of resident or family preference. The DON stated the rails had been applied on admission and that the facility expected bed rail policy to be followed.
Medication Supply Room Left Unsecured: The facility failed to keep an overflow medication room locked on the south hall. The door was propped open behind the nurses' station while staff walked past, and the room contained 30 residents' overflow medications plus two packages of expired meds on the floor. The DON stated the room should always be closed and locked, and the facility policy required drugs and biologicals to be stored in locked compartments with access limited to authorized personnel.
Infection control was not followed for two residents. One resident with an indwelling urinary catheter had the catheter bag and tubing observed touching the floor multiple times, and the UM and DON confirmed it should have been kept off the floor. Another resident was on contact isolation for an infected hip prosthesis, but a housekeeper cleaned the room without a gown and reused the same gloves while moving in and out of the room, and a PTA also provided therapy without a gown or gloves and did not sanitize the equipment afterward.
A resident with a UTI history and Foley catheter was ordered Erythromycin for UTI prophylaxis even though the most recent urine culture was negative. The IP stated the antibiotic was started because of lower abdominal pain and the resident’s history, and confirmed there was no positive culture and that she did not raise concerns with the Medical Director about the order being outside the facility’s antibiotic use parameters.
A facility applied to become the representative payee for a cognitively intact resident without obtaining the resident's consent, despite the resident being alert and oriented and having signed a payment agreement. Staff interviews and record review confirmed that consent was obtained for other residents in similar situations, but not for this resident.
A resident with significant medical needs reported being struck by another resident and subsequently experienced emotional distress and fear for personal safety. Although nursing staff assessed for physical injuries, the facility did not provide required emotional support, psychosocial assessment, or follow-up by the social worker, and key information about the resident's ongoing fear was not communicated among staff, resulting in a failure to fully implement the abuse prevention and response policy.
A resident with significant medical conditions reported being struck multiple times by another resident who entered his room at night. Although the incident was documented and reported internally, the facility did not notify law enforcement as required by policy. The resident experienced emotional distress and did not receive follow-up regarding the incident.
A resident who was cognitively intact reported being physically assaulted by another resident, resulting in emotional distress and fear for personal safety. Despite expressing ongoing psychological distress and keeping scissors for self-protection, the care plan was not updated to address these psychosocial needs, and no evidence was found that staff assessed or supported the resident's mental well-being after the incident.
A resident with multiple medical conditions reported being physically assaulted by another resident and subsequently expressed emotional distress and fear for his safety. Despite these concerns, there was no follow-up assessment or provision of medically related social services by the Social Worker, and the resident was not referred for psychological evaluation after the incident.
Two residents with stage IV wounds experienced unaddressed pain during wound care procedures. Despite care plans requiring pain assessment and management, LPNs continued wound treatments while the residents showed clear signs of pain, and pain medication was not administered as required by the care plans.
Two residents with complex medical histories experienced unaddressed pain during wound care procedures. Despite one having an active PRN Tylenol order and the other lacking any current pain medication order, neither received pain relief before or during treatment. Nursing staff did not assess for pain or follow pain management protocols, and both residents were observed expressing discomfort throughout the procedures.
Staff did not consistently wear required PPE, specifically gowns, during high-contact care activities such as wound and perineal care for residents on Enhanced Barrier Precautions. Despite clear signage and facility policy, CNAs and LPNs provided care without gowns, and glove supplies were handled improperly without hand hygiene. Interviews confirmed staff were either unaware of requirements or failed to follow them, even though PPE supplies were available.
A resident with severe cognitive impairment and multiple diagnoses, including morbid obesity, was injured during a transfer due to the facility's failure to specify the use of a mechanical swing lift in the care plan. The resident slid in the sling of a stand lift, resulting in a chest wall hematoma and anemia. Despite prior training, CNAs used the incorrect lift, leading to the incident.
A resident with severe cognitive impairment and morbid obesity was injured during a transfer when CNAs used a stand lift instead of a mechanical swing lift, despite the resident's inability to bear weight. The sling slipped, causing bruising and a chest wall hematoma. The CNAs continued the transfer improperly and failed to report the incident immediately, leading to the resident's hospitalization.
Food Temperatures Not Monitored or Maintained During Meal Service
Penalty
Summary
The facility failed to ensure food was monitored and served at appropriate temperatures during meal service. Record review showed that the October, November, and December 2025 Hot/Cold Temperature Logs documented only about four temperatures per meal service on average, and only the main items at regular texture were recorded. The log procedure required staff to check all food items, calibrate thermometers before use, document temperatures and times, and take corrective action when needed, but the dietary staff did not document all food items and did not have functioning thermometers available. During a kitchen observation, the Dietary Manager attempted to calibrate a manual probe thermometer in ice water, but the needle was stuck and the thermometer was not functioning correctly. A Dietary Aide stated the thermometer should read 32 F and confirmed the manual probe was not working; she then produced a digital thermometer from her pocket that read LL and was also broken. The DM left to look for another thermometer, and a maintenance department radar thermometer was later brought in and calibrated to 36 F. Staff also stated the steam table did not hold temperatures well and that an air conditioning vent blew cool air across the top of the steam table. Food temperatures taken during meal service showed multiple items below the facility’s hot holding standard of 135 F. On the steam table, several items including rice, barbeque chicken, black eyed peas, mashed potatoes, beef patty, and altered-texture items were recorded at temperatures as low as 82 F and 84 F before being returned to the oven. During breakfast service, grits, scrambled eggs, sausage links, and pureed items were also found below the expected temperature range and were placed back in the oven. A test tray taken from the kitchen to the resident hallway on an unheated covered meal cart showed further temperature loss by the time it reached the nurses’ station, with items recorded between 104 F and 117 F. The DON, RCC, and Administrator all stated they expected residents to be served food at the proper temperature.
Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
Food was not dated, labeled, stored properly, or kept in a sanitary manner in the kitchen. During observation of the ice machine, a full-sized can of lemon-lime soda was found placed inside the machine, half deep into the ice. A dietary aide confirmed the can should not have been there and removed it with bare hands without washing her hands, while touching the ice in the machine during the process. In the walk-in refrigerator, surveyors observed two thawed vanilla Magic Cups without thaw dates recorded, a bag of sliced turkey marked with a prep date but no use-by date, a large stack of sliced ham that was not properly covered or dated, and a container of chicken noodle soup labeled with a use-by date that had already passed. In dry storage, sugar was kept in a large plastic container with the scoop resting directly on the sugar, including the handle. The dietary manager confirmed the scoop placement was incorrect and stated the thawed Magic Cups should have been dated when thawed; the administrator also stated there should never be any items stored inside the ice machine.
Resident-to-Resident Abuse Not Prevented
Penalty
Summary
The facility failed to ensure residents were free from verbal and physical abuse in two resident-to-resident altercations. One resident was admitted with diagnoses including CHF, confusional arousals, and CKD, and his quarterly MDS showed a BIMS score of 14/15, indicating he was cognitively intact. On 11/03/25, staff documented that the resident and his roommate were involved in an altercation in their shared room, after which the roommate was scratched on the leg and the resident slapped the roommate on the face. The incident report stated the abuse was substantiated after CNA 1 heard the slap, entered the room, observed scratches on one resident and redness on the other resident’s face, and separated them. A second resident was admitted with diagnoses including encephalopathy, heart failure, and CKD stage 3, and his admission MDS showed a BIMS score of 5/15, indicating cognitive impairment. On 10/08/25, staff heard his roommate yelling threats, including that he was going to beat the resident’s ass, while the two were in their shared room. The resident was removed from the room after staff entered and found the roommate yelling at him, and the incident report substantiated verbal abuse based on the roommate’s threats to physically hurt him. The resident stated he did not want to continue sharing a room with the roommate because of the roommate’s behavior and nighttime disruption. Facility records and staff interviews confirmed both incidents involved resident-to-resident abuse. In the first event, the DON stated the residents were separated after the slap and scratches, police were called, and the incident was reported to the state survey agency. In the second event, the DON stated the verbal abuse was reported to the state survey agency and substantiated, and staff interviews confirmed the roommate was yelling threats while leaning over the resident in bed. The facility policy defined abuse to include physical abuse such as hitting and slapping, and verbal abuse as oral communication that includes disparaging or derogatory terms.
Inadequate AMA Discharge Planning
Penalty
Summary
The facility failed to ensure an appropriate discharge plan for one resident who was discharged against medical advice after leaving the facility overnight. The resident had been admitted following a hospitalization for cardiac arrest and had diagnoses including congestive heart failure, COPD, acute respiratory failure, and alcohol and cocaine use. A progress note documented that staff told the resident's significant other that the resident needed to return by midnight per insurance regulations or the discharge would be against medical advice without medications. Another note documented that the Social Services Director told the resident's representative that because the resident was outside the facility after midnight, she would have to be discharged and that the facility could not give medications, arrange home health, or provide follow-up services. During interviews, the DON, Regional Clinical Consultant, and Social Services Director stated they believed the resident had to be discharged because she was outside the facility after midnight and acknowledged they were not aware the resident had to be given the chance to return. The Social Services Director confirmed the resident was not given an opportunity to return, and the resident never came back to retrieve belongings. The facility's Transfer and Discharge policy stated that for an AMA discharge, the resident and family/legal representative should be informed of the risks, benefits of staying, and alternatives, and that the facility should not force, pressure, or intimidate a resident into leaving AMA.
Residents Not Invited to Initial Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two residents, R16 and R40, were invited to their initial interdisciplinary care plan meetings after admission. R16 was admitted with diagnoses including infection and inflammation reaction due to other internal joint prosthesis and idiopathic necrosis of the right femur. Her record showed she was her own medical decision-maker and had a BIMS score of 15 out of 15, indicating she was cognitively intact. A comprehensive care plan was issued, but the record contained nothing showing an interdisciplinary care planning meeting had been held since admission or that she had been invited to one. During interview, R16 stated she knew what a care planning meeting was but had not been invited to or attended one since admission. R40 was admitted with diagnoses including heart failure and a recent fracture of the left fibula. Her record also showed she was her own medical decision-maker and had a BIMS score of 15 out of 15. A comprehensive care plan was issued, but the record contained nothing showing an interdisciplinary care planning meeting had been held since admission or that she had been invited to one. During interview, R40 stated she was aware of what a care planning meeting was but had not been invited to or attended one since admission. The SSD stated she was responsible for scheduling care planning meetings and inviting residents, but could not locate documentation that either resident had been invited or that an initial meeting had been held. The DON confirmed the expectation that an initial care planning meeting should be held within 72 hours of admission and that each resident should be invited.
Smoking policy violations and lack of smoking safety oversight
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and provided adequate supervision related to smoking for two sampled residents, R45 and R11. R45 was admitted with diagnoses including encephalopathy, heart failure, and atherosclerotic heart disease, and his MDS showed a BIMS score of 9, indicating moderate cognitive impairment. The record showed he was a regular tobacco user before admission, with documentation that he smoked about three cigarettes a day. His care plan identified repeated smoking-related behaviors, including smoking inside the facility, smoking in his bathroom, and smoking on facility grounds, and noted that a lighter was found and removed from his room. The record also showed he was admitted to a non-smoking facility despite documentation identifying him as a smoker, and there was no documentation that he was provided tobacco cessation education or that a smoking safety assessment was completed after repeated smoking behavior was observed. Surveyors observed R45 standing outside the facility with a door ajar while smoking a cigarette. During interviews, R45 stated he signed out and went to the side of the building to smoke, while facility staff stated residents were supposed to sign out and smoke off the property at a dirt road south of the building. Staff also confirmed that R45 had not always signed in and out and that he had received repeated warnings and a 30-day discharge notice for smoking policy violations. The DON stated the facility could offer nicotine patches and behavioral support, but also confirmed she was not aware of who would complete a smoking assessment for residents who were non-compliant with smoking rules. R11 was admitted with diagnoses including paraplegia and a history of spinal cord injury, and his MDS showed a BIMS score of 15, indicating he was cognitively intact. His smoking care plan identified him as a daily smoker and documented that he had smoked marijuana in his room and cigarettes in front of the facility despite repeated reminders that the facility was smoke free. The care plan directed staff to notify the charge nurse if he was suspected of violating smoking rules and to observe his clothing and skin for cigarette burns, but the record contained no smoking assessment to determine whether he could smoke safely or follow the facility’s smoking rules. Progress notes documented that staff found him smoking in his room on two occasions and educated him not to smoke in the room, but the accident and incident logs contained no incident reports or investigations related to those events, and the EMR showed no follow-up related to the smoking infractions.
Missing Physician Order for Indwelling Urinary Catheter
Penalty
Summary
Failure to provide appropriate catheter care occurred for one resident with an indwelling urinary catheter. R69’s record showed diagnoses of type 2 diabetes and urinary retention, and the Quarterly MDS indicated the resident had an indwelling urinary catheter in the bladder and a BIMS score of 12 out of 15, reflecting moderate cognitive impairment. The resident’s care plan addressed catheter monitoring, including intake and output, and monitoring for signs and symptoms of UTI and pain or discomfort related to catheter use. Review of the physician order set revealed no physician’s order related to the use or care of the resident’s urinary catheter. During interview, the DON confirmed the expectation that all physician orders related to the use and care of a resident’s urinary catheter were to be in place and up to date in the resident’s record. The facility requested policies and procedures related to indwelling urinary catheters, but they were not received prior to survey exit.
Failure to Assess Alternatives Before Using Bed Rails
Penalty
Summary
The facility failed to properly assess and initiate side rails before alternatives were attempted for three residents reviewed for accidents and hazards. The report states that for each of the three residents, side rails or mobility bars were used or ordered for repositioning and increased mobility, but the documentation did not show that appropriate alternatives were tried first as required by facility policy. The deficiency was identified through record review, observations, interviews, and review of the facility’s bed rail policy. For one resident with end stage renal failure, major depressive disorder, and generalized anxiety disorder, the record showed an order for mobility bars for repositioning and increased mobility per family request. The initial side rail evaluation documented that the resident was using side rails for support or positioning, wanted the bed rails raised, and that no alternatives were attempted before the side rails were initiated. Observations showed bilateral half side rails raised, and staff confirmed the resident preferred the rails positioned lower near the waist and legs rather than toward the head of the bed. The DON stated the bed rails were applied on admission and that consent had been signed by the family. For a second resident with cerebral infarction, Alzheimer’s disease, gastrostomy status, and seizures, the record showed an order for mobility bars for repositioning and increased mobility per family request. The initial side rail evaluation documented that the resident was using side rails for support or positioning, wanted the bed rails raised, and that no alternatives were attempted before the side rails were initiated. Observations showed bilateral rails raised in the middle of the bed with blue bed bolsters inside the rails, while staff stated the resident could not reach the rails because of contracted arms and a brace on the right arm. Staff and the DON stated the rails were placed on admission per family request, and the DON acknowledged the position was not optimal. For a third resident with hemiplegia and hemiparesis following a stroke, the MDS showed moderate cognitive impairment and did not code bed rail use, yet the admission/readmission nursing evaluation documented quarter rails for mobility bilaterally per the patient and family’s request. The comprehensive record did not show evidence that alternatives to bed rail use were assessed or that the reason alternatives failed was documented. The resident was repeatedly observed with 1/3 rails raised bilaterally in the middle of the bed, and staff confirmed the rails were generally kept in that position because that was how the resident wanted them. The DON confirmed that each resident was expected to have a thorough assessment before bed rails were applied and that the facility expected its bed rail policy to be followed.
Medication Supply Room Left Unsecured
Penalty
Summary
The facility failed to ensure overflow medications were secured in one of two medication supply rooms on the south hall. During an observation, the medication supply room door behind the nurses' station was held open with a cardboard box, and three staff members walked past while the area was unattended. When the room was later observed with the Unit Manager, it contained 30 residents' overflow medications stacked on the shelves and two packages of expired medications lying on the floor. The Unit Manager stated there were no scheduled medications in the room and that two nurses had a key to the room in their medication carts. The Director of Nursing stated the medication supply room door should be closed and always locked so residents and staff would not have access to residents' medications and supplies. The Maintenance Director stated he was installing a keypad on the medication supply room door because a nurse reported she did not have a key to the room. The Unit Manager later stated an LPN had propped the door open because she needed to return to the room for supplies and did not realize she had a key to the room in the medication cart. The facility policy required all drugs and biologicals to be stored in locked compartments and only authorized personnel to have access to the keys.
Infection Control and Contact Isolation Failures
Penalty
Summary
The facility failed to follow its infection prevention and control program for two residents. One resident had an indwelling urinary catheter and diagnoses including type 2 diabetes and urinary retention. Review of the resident’s record showed the catheter was in place, but no catheter-related orders were found. The care plan directed monitoring of intake and output and monitoring for signs and symptoms of UTI and pain or discomfort related to the catheter. During multiple observations, the resident’s catheter bag and/or tubing was seen lying or dragging in direct contact with the floor. During an observation in the dining room, the Unit Manager confirmed the catheter drainage bag was touching the floor and stated it should not be in contact with the floor to prevent potential infection. The DON also stated catheter drainage bags and tubing were expected to be kept off the floor at all times. A second resident was on Contact Isolation Precautions for an active infection of the total hip prosthesis and was receiving IV Meropenem and IV Micafungin for that infection. The resident’s infection care plan directed that the resident be maintained in contact isolation. A sign on the resident’s door indicated gloves and a gown were required for entry. During observation, a housekeeper cleaned the resident’s room, including the floor, bathroom surfaces, bed frame, and overbed table, without wearing a gown and while wearing the same pair of gloves throughout the process, including when leaving the room to obtain supplies and when exiting to clean another resident’s room. In therapy, a Physical Therapy Aide provided services to the resident without wearing a gown or gloves and did not appropriately sanitize the equipment used after the session. During interview, the aide confirmed the PPE was not worn and the equipment was not sanitized, and stated he was not aware the resident was on contact isolation precautions. The Therapy Director and DON stated their expectation was that staff entering the resident’s room or working directly with the resident would wear a gown and gloves, and that equipment used for treatment should be sanitized after use. The facility’s infection prevention and control policy stated the program was designed to prevent transmission of communicable diseases and infections, and that residents with infection or communicable disease were to be placed on transmission-based precautions per CDC guidelines.
Antibiotic Use Not Supported by Positive Culture
Penalty
Summary
The facility failed to ensure antibiotics were used in accordance with current evidence-based antibiotic use indications for one resident who was reviewed for antibiotic stewardship. The resident had a diagnosis of UTI documented in the EMR and was also noted to have a Foley catheter due to bladder-neck obstruction, with a history of UTIs. The physician ordered Erythromycin 250 mg every 6 hours for 28 days for UTI, starting 11/14/25, even though the last urine culture collected on 10/14/25 was negative. During interview, the Infection Preventionist stated the resident had complained of lower abdominal pain and that, because of the resident’s history and Foley catheter, the provider decided to place the resident on the antibiotic as prophylaxis. When asked whether there was a positive culture confirming infection, she confirmed there was no positive culture. In a later interview, she confirmed she was aware the resident had not had a positive culture and that after receiving the antibiotic order, she did not address the Medical Director with concerns about the antibiotic being outside the facility’s antibiotic use parameters.
Failure to Obtain Consent for Representative Payee Application
Penalty
Summary
The facility failed to obtain consent before applying to become the representative payee for a resident who was cognitively intact, as evidenced by a BIMS score of 15 on multiple MDS assessments. The resident, who had diagnoses including paraplegia, chronic pain syndrome, opioid dependence, osteoarthritis, insomnia, and urine retention, was admitted to the facility and had an outstanding balance for care. Despite being alert and oriented, the facility applied to manage the resident's Social Security benefits without documented consent from the resident. The facility's policy defines misappropriation of resident property as the use of a resident's money without consent, and the application for representative payee was completed based on a physician's assessment that the resident could not manage finances, though the resident had previously signed a payment agreement. Interviews with facility staff confirmed that the resident was alert and oriented, and that consent was obtained for other residents in similar situations but not for this particular resident. The facility received one Social Security payment as representative payee before the resident was discharged, and the subsequent payment was rejected. The administrator and business office manager both acknowledged the lack of consent and the resident's cognitive intactness at the time the application was made.
Failure to Implement Abuse Policy Following Resident-on-Resident Incident
Penalty
Summary
A resident with multiple medical conditions, including morbid obesity, intracerebral hemorrhage, and an above-knee amputation, reported being struck multiple times by another resident while in bed. The incident was documented by nursing staff, who assessed the resident and found no visible injuries. Despite the resident expressing emotional distress, flashbacks, and a lack of safety following the event, there was no evidence that facility staff provided emotional support, counseling, or a psychosocial assessment as outlined in the facility's abuse policy. The resident also reported to a nurse practitioner that he was afraid to sleep and later was found to have kept scissors under his pillow for self-protection, but this information was not communicated to the social worker or acted upon for further psychological evaluation. The facility's policy required protection of the resident and specific reporting and response actions following allegations of abuse, including examination for injury, emotional support, care plan revision, and timely reporting to appropriate authorities. However, the social worker confirmed that she did not follow up with the resident after the allegation, and there was no documentation of a psychological evaluation or referral. Additionally, the nurse practitioner did not report the resident's ongoing fear or the presence of scissors to the rest of the care team. These failures indicate that the facility did not fully implement its abuse prevention and response procedures after the resident's allegation.
Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to law enforcement as required by its own policy and regulatory standards. A cognitively intact resident with multiple medical conditions, including morbid obesity, nontraumatic intracerebral hemorrhage, above-knee amputation, congestive heart failure, and gout, reported that another resident entered his room during the night, sat on his bed, and struck him multiple times in the chest. The resident expressed emotional distress, including feeling unsafe and experiencing flashbacks, and stated that no one followed up with him after the incident to discuss what happened or how he felt. Facility documentation, including nurses' notes and an incident report, confirmed that the event was reported internally to the Administrator and the responsible party, but there was no documentation that law enforcement was notified. The facility's policy requires reporting all alleged violations to law enforcement when applicable, but this step was omitted. The Administrator interviewed after the incident acknowledged that law enforcement should have been contacted in this case.
Failure to Revise Care Plan After Resident Abuse Allegation
Penalty
Summary
The facility failed to revise and update the care plan for a resident following an allegation of physical abuse by another resident. Despite the resident reporting emotional distress, fear, and flashbacks after being physically assaulted in his room, there was no evidence in the care plan that his psychosocial needs were assessed or addressed. The resident expressed feeling unsafe and reported keeping scissors under his pillow for self-protection, but the care plan only reflected previous behavioral concerns related to medication management and did not include interventions or measurable objectives to address his psychological well-being after the incident. Interviews with the resident and review of medical records confirmed that the resident was cognitively intact and able to communicate his experiences and feelings. Documentation from a nurse practitioner indicated that the resident was emotionally upset and fearful following the incident, yet no follow-up or support was provided by staff to address his mental and emotional health. The facility's policy required comprehensive, person-centered care plans that address all identified needs, including psychological needs, but this was not implemented for the resident after the reported abuse.
Failure to Provide Psychosocial Assessment and Social Services After Abuse Allegation
Penalty
Summary
A deficiency occurred when the facility failed to assess the psychosocial status and provide medically related social services to a resident following an allegation of physical abuse. The resident, who had diagnoses including morbid obesity, nontraumatic intracerebral hemorrhage, above-knee amputation, congestive heart failure, and gout, was cognitively intact according to a recent MDS assessment. The resident reported that another resident entered his room at night, sat on his bed, and punched him in the chest. He expressed feeling emotionally upset, experiencing flashbacks, and not feeling safe in the facility. Despite these reports, there was no documentation that the resident was assessed by the Social Worker or referred for psychological evaluation after the incident. The Nurse Practitioner documented the resident's fear and his actions to protect himself, such as keeping scissors under his pillow, but did not report these findings to other staff or request a social work evaluation. The Social Worker confirmed she did not follow up with the resident after the abuse allegation and was unaware of the resident's actions to protect himself. The Administrator acknowledged that the Social Worker should have followed up with the resident after the incident. The lack of follow-up and assessment by the Social Worker after the abuse allegation led to the deficiency.
Failure to Implement Pain Management During Wound Care
Penalty
Summary
The facility failed to implement care plans related to wound treatment and pain management for two residents with stage IV wounds. One resident, admitted with multiple diagnoses including type 2 diabetes, pressure ulcer, and chronic pain, had a care plan requiring weekly skin inspections, wound treatments, and pain management interventions such as monitoring pain episodes and administering medications as ordered. During wound care, the resident exhibited clear signs of pain, including moaning and moving away from the nurses, but the LPNs performing the dressing change did not acknowledge or address the pain, continuing the procedure without pausing or offering pain relief. Another resident with diagnoses including COPD, diabetes, cirrhosis, and fibromyalgia had a care plan specifying the administration of analgesia before treatments and immediate response to pain complaints. Despite this, the resident did not have an order for pain medication until after a wound treatment, during which she was observed moaning, grimacing, and attempting to move away from the dressing removal. Staff continued the procedure without providing pain relief, and the MDS RN later confirmed that the pain management care plan was not followed.
Failure to Provide Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents during wound care treatment, as observed and documented by surveyors. One resident, with multiple diagnoses including diabetes, pressure ulcer, and dementia, was observed experiencing significant pain during wound care. Despite vocalizing discomfort and attempting to move away from the nurse's hands, the resident did not receive any pain medication prior to or during the procedure. The medical record showed an active order for Tylenol as needed for pain, but there was no evidence that it had been administered during the relevant period. Another resident, with a history of chronic illnesses such as COPD, diabetes, cirrhosis, and fibromyalgia, also experienced pain during wound care. The resident was observed moaning, grimacing, and squirming in response to the removal of dressings and wound cleaning. At the time of the observation, there was no active order for pain medication, as previous prescriptions had been discontinued and a new order was not in place until after the resident was admitted to hospice care later that day. The resident confirmed experiencing discomfort and pain during the treatment. Interviews with nursing staff revealed that pain assessments were not conducted prior to wound care, and pain management protocols were not followed. Staff acknowledged that they should have stopped the procedure to assess and address pain, but instead focused on completing the wound care. The Director of Nursing confirmed that staff should have assessed the residents for pain and determined the cause, but this was not done during the observed incidents.
Failure to Use Required PPE During High-Contact Care Activities
Penalty
Summary
Staff failed to adhere to the facility's Infection Prevention and Control Program by not wearing appropriate personal protective equipment (PPE), specifically protective gowns, during high-contact resident care activities. Multiple observations revealed that certified nurse aides (CNAs) and licensed practical nurses (LPNs) did not wear gowns while providing perineal care and wound care to residents who were on Enhanced Barrier Precautions (EBP). The facility's policy and posted signage required the use of gloves and gowns for such activities, but staff either did not read the signage, did not see PPE available, or simply forgot to don the required gowns. Three residents with significant medical conditions, including stage IV pressure ulcers, diabetes, and other chronic illnesses, were involved in these incidents. In each case, staff provided care such as perineal cleaning and wound dressing changes without the mandated protective gowns, despite clear EBP signage on the residents' doors and documented orders for EBP in the electronic medical records. Staff interviews confirmed a lack of compliance, with some staff unaware of the requirements or unable to explain their failure to use PPE. Additionally, improper handling of glove supplies was observed. A staff member responsible for distributing gloves was seen transferring gloves between boxes with bare hands and without using hand sanitizer, moving partially filled boxes from room to room. This practice was confirmed during interviews and was not in accordance with infection control protocols. The facility had supplies of gowns available in storage areas, but these were not consistently accessed or used by staff during resident care.
Failure to Implement Proper Transfer Care Plan
Penalty
Summary
The facility failed to develop a care plan intervention to address the transfer needs of a resident who required the use of a mechanical swing lift during transfers. This oversight resulted in actual harm when the resident, who was severely cognitively impaired and unable to bear weight, slid down in the sling of a stand lift, causing a chest wall hematoma and subsequent anemia that required a blood transfusion. The resident had multiple diagnoses, including intracranial injury, schizophrenia bipolar type, mood disorder, anxiety disorder, and morbid obesity, and was dependent on staff for transfers. The care plan in place did not specify the need for a mechanical swing lift, leading to the use of an inappropriate stand lift by three CNAs during a transfer. The CNAs, despite having received training, failed to act appropriately when the resident slipped in the sling, continuing the transfer and causing injury. The facility's investigation revealed that the CNAs used the stand lift instead of the mechanical swing lift, which was necessary due to the resident's inability to bear weight, contributing to the incident.
Improper Use of Stand Lift Leads to Resident Injury
Penalty
Summary
The facility failed to transfer a resident using the correct transfer lift, resulting in actual harm. The resident, who was admitted with diagnoses including intracranial injury, schizophrenia bipolar type, mood disorder, anxiety disorder, and morbid obesity, was severely cognitively impaired and dependent on staff for transfers. The resident's care plan did not specify the need for a mechanical swing lift, and during a transfer, the resident was incorrectly moved using a stand lift, which was inappropriate given the resident's inability to bear weight. The incident occurred when three CNAs attempted to transfer the resident using a stand lift, despite the resident's inability to bear 50% of her weight. During the transfer, the sling slipped, causing the resident to be in a hang glider position, which resulted in bruising and a chest wall hematoma. The CNAs continued with the transfer despite the resident slipping, which was against the proper procedure. The CNAs had received training on the stand lift but failed to act appropriately during the incident. The facility's investigation revealed that the CNAs did not report the incident immediately, and the bruising was only identified days later. The DON confirmed that the staff should have used a mechanical swing lift instead of a stand lift, as the resident could not bear the required weight. The failure to use the correct equipment and the lack of immediate reporting contributed to the resident's injury and subsequent hospitalization.
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Nursing homes near Tifton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehabilitation Center Of South Georgia | 1.3 mi | ★★★★★ | 7 | 0 |
| Pruitthealth - Ocilla | 17 mi | ★★★★★ | 7 | 0 |
| Palemon Gaskins Mem Nsg Home | 17.2 mi | ★★★★★ | 16 | 0 |
| Pruitthealth - Ashburn | 19.3 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Sylvester | 20.4 mi | ★★★★★ | 0 | 0 |
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