Harborview Rome: CNA Knelt on Resident's Chest - GA
The incident occurred on July 11, 2025, at approximately 7:15 in the morning. The resident, identified in inspection records only as R1, was on the floor when the aide, referred to as CNA1, knelt on his chest and flicked him in the face. A licensed practical nurse arrived minutes later after being summoned by one of the aides in the room, walked in, and saw CNA1 preparing to flick the resident again. She told her to stop.
R1 appeared very upset, the nurse said.
CNA1 finished her shift at 2:00 that afternoon. She left the building. Only then was she placed on administrative leave.
The facility's own investigation, completed by July 16, substantiated the abuse. CNA1 was terminated. The incident was reported to local police. On August 20, more than five weeks after the morning it happened, a warrant was issued for CNA1's arrest. She was arrested that same day.
Federal inspectors arrived at Harborview Rome on August 26 and completed their survey on August 28. By then, R1 was no longer living at the facility. Inspectors could not interview him. CNA1 could not be reached.
What inspectors could do was interview the three people who had been standing in that room.
CNA2 confirmed she was present on July 11 when the incident occurred. She told inspectors she watched CNA1 flick R1 in the face and hold him down on the floor by putting her knee in his chest. CNA3, interviewed separately the same day, gave the same account. She too had been in the room. She too watched CNA1 flick the resident in the face and press her knee into his chest to hold him down.
LPN1 was not in the room when it started. CNA3 summoned her. The nurse said she arrived at about 7:30 in the morning and found CNA1 preparing to flick the resident again. She intervened. She told inspectors R1 was visibly distressed.
Three witnesses. One nurse who walked in mid-incident and told the aide to stop. A resident on the floor, pinned down, upset.
And then six hours of CNA1 continuing to work.
The facility's administrator, interviewed on August 26, confirmed the investigation had been substantiated. She told inspectors her expectation was that residents would remain free of abuse at the facility. She also acknowledged directly that CNA1 should have been placed on administrative leave immediately after the incident on July 11, not at the end of her shift, in order to protect R1 and every other resident in the building from potential further abuse.
That acknowledgment is notable for what it concedes. The facility's own investigation was thorough, inspectors noted. Staff came forward. The abuse was substantiated quickly. CNA1 was fired. Police were called. A warrant was eventually issued and served. By the standards of how these cases sometimes go, the institutional response was not nothing.
But CNA1 spent the hours between 7:15 in the morning and 2:00 in the afternoon walking the halls of Harborview Rome with access to residents. The man she had just knelt on, whose face she had flicked, who inspectors described as very upset, remained in that building too. Whatever the facility's eventual response, that six-hour window existed because someone made a decision, or failed to make one, in the immediate aftermath of a witnessed assault.
The inspection report does not identify who made that decision, or whether anyone on staff with authority to act was told what had happened before CNA1's shift ended. It does not say whether R1 received any assessment or support in the hours after the incident. It does not explain why the arrest warrant took until August 20 to materialize, 40 days after the assault.
What it says is that three people saw what happened, a fourth walked in while it was still happening, and the person responsible spent the rest of her workday in the building.
The deficiency cited is F0600, rated at a level of actual harm, affecting a few residents. It is a finding that the facility failed to protect residents from abuse, specifically the requirement that residents be free from abuse, which includes physical abuse. The citation does not represent a finding that the facility covered up what happened or failed to investigate. It represents a finding that even after abuse was witnessed by multiple staff members, the person who committed it continued to have access to vulnerable residents for hours.
Harborview Rome is located at 1345 Redmond Circle in Rome, Georgia. The complaint inspection was completed August 28, 2025.
R1 was gone by the time inspectors arrived. The inspection report does not say where he went, whether he left voluntarily, whether his family was told what happened to him that morning, or whether he was told anyone had been arrested.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harborview Rome from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
HARBORVIEW ROME in ROME, GA was cited for violations during a health inspection on August 28, 2025.
The incident occurred on July 11, 2025, at approximately 7:15 in the morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.