Harborview Rome: CNA Knelt on Resident's Chest - GA
The incident happened on July 11, 2025, at approximately 7:15 in the morning. Two other aides witnessed it. A nurse walked in mid-incident and told the aide to stop. The resident, identified in inspection records only as R1, appeared very upset. And still, the aide, identified as CNA1, finished her shift and left the facility at 2:00 p.m. that afternoon before being placed on administrative leave.
An arrest warrant for CNA1 was issued on August 20, 2025. She was arrested that same day. By the time federal inspectors arrived at the facility eight days later, the resident she had pinned to the floor was gone. He was no longer living at Harborview Rome and could not be interviewed.
The inspection, a complaint survey conducted August 26 through August 28, 2025, found the facility had substantiated physical abuse by CNA1 and had ultimately terminated her employment. But inspectors also found that the facility's response in the immediate aftermath of the incident failed to protect R1 and every other resident in the building.
Two certified nursing assistants were in the room when it happened. CNA2, interviewed by inspectors on August 26 at 10:05 a.m., said she was present and saw CNA1 flick R1 in the face and hold him down on the floor with her knee on his chest. CNA3, interviewed that same afternoon at 5:02 p.m., said the same thing. She had been there. She had watched it happen.
CNA3 was also the one who went to get help.
At approximately 7:30 a.m., about fifteen minutes after the incident began, CNA3 summoned LPN1 to R1's room. When the nurse arrived, CNA1 was still there, and she was preparing to flick the resident in the face again. LPN1 told her to stop. She confirmed that R1 was visibly distressed.
What happened next is the part the facility's own administrator later said should have gone differently. CNA1 was not removed from the floor. She was not placed on administrative leave. She stayed, and she worked, and she provided direct care to residents for the remainder of her shift, leaving the building at 2:00 p.m. only after her scheduled hours were done.
The facility opened a formal investigation. Its final report, dated July 16, 2025, substantiated physical abuse by CNA1 and confirmed her termination. The incident had been reported to the local police department. But none of that changed what had already happened on the morning of July 11, in the hours between 7:15 a.m. and 2:00 p.m., when a woman who had just knelt on a resident's chest continued working the halls.
The administrator, interviewed on August 26 at 3:00 p.m., did not dispute any of this. She confirmed the investigation had been substantiated. She said her expectation was that residents would remain free of abuse in the facility. And she acknowledged directly that CNA1 should have been placed on administrative leave immediately after the incident, to protect R1 and every other resident from the possibility of further abuse.
She said it plainly. The response had been wrong.
What the inspection report does not explain is why it took six hours and forty-five minutes for that conclusion to be acted on. Two aides saw what happened. A nurse saw what was still happening when she arrived fifteen minutes later and told CNA1 to stop. The information was there at 7:30 in the morning. CNA1 walked out at 2:00 in the afternoon.
The inspection report does not identify what R1's medical condition was, what brought him to Harborview Rome, or whether he sustained physical injury from being held down on the floor with a knee on his chest. He was gone by the time inspectors arrived. He could not be asked.
CNA1 could not be reached for comment.
The facility is located at 1345 Redmond Circle in Rome, Georgia. The complaint survey was completed August 28, 2025. Inspectors cited the facility for actual harm affecting a small number of residents.
The arrest warrant came thirty-nine days after the morning CNA1 put her knee on R1's chest. By then, the resident had already left. Whether he left because of what happened to him, or for some other reason, the inspection report does not say.
What it says is that two people watched a colleague hold a resident down on the floor. That a nurse walked in and told her to stop. That the aide finished her shift. That a warrant was eventually issued, and an arrest made, and a termination completed, and a final report written that used the word "substantiated."
And that the man on the floor was not there anymore when anyone came to ask him what it had been like.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
HARBORVIEW ROME in ROME, GA was cited for violations during a health inspection on August 28, 2025.
The incident happened 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.