Harborview Rome

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

calm/console him.Review of the facility's investigation into the above allegation of abuse revealed a thorough investigation. Staff interviews conducted during the investigation revealed three staff members (Licensed Practical Nurse (LPN1), CNA2 and CNA3 were in Resident R1's room and directly observed the incident

during which CNA1 flicked Resident R1 in the face and held Resident R1 down by placing her knee on his chest. The investigation revealed the incident occurred on 7/11/2025 at approximately 7:15 am and that CNA1 remained in the facility and worked providing direct care to residents until the end of her shift on 7/11/2025 at 2:00 pm. The documentation revealed CNA1 was placed on administrative leave on 7/11/2025 after she worked for her remaining shift and left the facility for the day. The Final Investigation Report related to the incident, dated 7/16/2025 revealed the facility substantiated physical abuse by CNA1 toward Resident R1 and indicated CNA1's employment with the facility had been terminated related to the event. The documentation indicated the incident had been reported to the local police department. Documentation in the investigation file revealed a warrant had been placed for the arrest of CNA1 related to the incident on 8/20/2025 and that CNA1 had been arrested related to the incident on that date.Resident R1 was no longer residing in the facility at the time of the survey conducted 8/26/2025 through 8/28/2025 and could not be interviewed.CNA1 could not be reached for interview.During an interview with CNA2 on 8/26/2025 at 10:05 am, she confirmed she was present on 7/11/2025 when the allegation of abuse of Resident R1 by CNA1 occurred and confirmed she witnessed CNA1 flick Resident R1 in the face and hold Resident R1 down on the floor by putting her knee in his chest.During an

interview with CNA3 on 8/26/2025 at 5:02 pm, she confirmed she was present on 7/11/2025 when the allegation of abuse of Resident R1 by CNA1 occurred and confirmed she witnessed CNA1 flick Resident R1 in the face and hold Resident R1 down on the floor by putting her knee in his chest.During an interview with LPN1 on 8/26/2025 at 1:55 pm, she confirmed she was summoned to Resident R1's room on 7/11/2025 at about 7:30 am by CNA3 and when she arrived in the resident's room, she observed CNA1 preparing to flick Resident R1 in the face. LPN1 stated

she told CNA1 to stop flicking the resident and she confirmed Resident R1 appeared to be very upset by the incident.During an interview with the Administrator on 8/26/2025 at 3:00 pm, she confirmed the facility's investigation of the allegation of abuse of Resident R1 by CNA1 had been substantiated. She stated her expectation was residents were to remain free of abuse in the facility and stated CNA1 should have been placed on administrative leave immediately after the alleged incident on 7/11/2025 to ensure protection of Resident R1 and all residents residing in the facility from potential further abuse.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Harborview Rome

1345 Redmond Circle Rome, GA 30165

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on 8/26/2025 at 1:55 pm, LPN1 confirmed she was summoned to Resident R1's room on 7/11/2025 at 7:30 am by CNA3. When she arrived in the resident's room, she observed CNA1 preparing to flick Resident R1 in the face. LPN1 confirmed she did not report the abuse to facility's Administration and stated she should have reported the abuse immediately to the Administrator or the nurse in charge on the day of the incident.During an

interview on 8/26/2025 at 1:30 pm, Registered Nurse (RN1) confirmed she was the charge nurse in the building on the day of the alleged abuse of Resident R1 by CNA1. RN1 confirmed the abuse had not been reported to her until Resident R1's family member reported the incident on the afternoon of 7/11/2025. RN1 confirmed CNA2, CNA3, and LPN1 had not reported the incident of abuse to her after the event occurred and stated the incident should have been reported to her, or someone in Administration, immediately after the event occurred. During an interview on 8/26/2025 at 3:00 pm, the Administrator confirmed the abuse of Resident R1 by CNA1 on 7/11/2025 had not been reported to her timely. She stated she did not become aware of the allegation of abuse until 7/11/2025 at about 4:30 pm or 5:00 pm when the allegation was reported to her by RN1. The Administrator confirmed CNA2, CNA3 and LPN1 had not reported the allegation abuse to anyone

in administration and confirmed she learned of the abuse after it was reported by Resident R1's F1 several hours

after the incident occurred. The Administrator confirmed the alleged abuse was, in turn, not reported to the SA, local police department, or the ombudsman within the required two-hour time frame. She stated her expectation was all allegations of potential abuse were to be reported to Administration immediately and allegations of abuse were expected to be reported to the SA, local police department, and the ombudsman within the required two-hour time frame.

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