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Complaint Investigation

Harborview Tifton

March 12, 2025 · Tifton, GA · 1451 Newton Drive
Citations 1
CMS Rating 1/5
Beds 100
Provider ID 115412
Healthcare Facility
Harborview Tifton
Tifton, GA  ·  View full profile →
Inspection Summary

HARBORVIEW TIFTON in TIFTON, GA — inspection on March 12, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF697
Actual harm 34318 Few Based on observations, record review, staff interviews, and a review of the facility policy titled Administering affected

Findings included:

A review of the undated policy titled Administering Pain Management, it was documented that the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. It was noted that Pain Management was defined as the process of alleviating the resident's pain based on his/her clinical condition and established treatment goals and that Pain Management was a multidisciplinary care process that included the following: assessing the potential for pain; recognizing the presence of pain; identifying the characteristics of pain; and addressing the underlying causes of the pain.

1. A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility with diagnoses of type 2 diabetes mellitus, chronic gout, metabolic encephalopathy, pressure ulcer, hypertensive heart disease, dementia, pain, and glaucoma.

During an observation on 3/5/2025 at 10:39 am, R1 was lying in bed on an airflow mattress with bilateral assistive rails in the upper position and had a wedge and a pillow for positioning.

Wound Nurse/Licensed Practical Nurse (LPN) CC was being assisted by LPN DD and Certified Nurse Certified (CNA) SS to provide the resident with wound care treatment. LPN CC washed her hands, and CNA SS removed the resident brief and provided perineal care.

The wound bed was 80% yellowish slough and 20% reddish granulation. LPN CC cleaned the wound with wound cleanser, and while cleaning the wound, R1 was observed voicing, Ouch, ouch, ouch.

That hurts. LPN CC continued to obtain wound measurements of 8.5L x 3.1W x 4.7D. LPN CC began checking for undermining using her finger and again the resident began saying, Oh, oh and tried moving away from LPN CC's hand. LPN DD told R1 to take a deep breath and that it was almost over. LPN CC continued applying the Dakin solution on a kerlix and packing the Dakin-moistened kerlix into the wound bed. LPN CC then placed an adhesive border dressing over the moistened kerlix. R1 continued squirming on the bed throughout the dressing change (moving away from the nurse's hands).

Further observation revealed a sign on R1's door documenting that enhanced barrier precautions were in place. LPN CC, LPN DD, and CNA SS were not wearing a gown as they performed wound care and/or perineal care.

A review of the Order Summary Report dated 3/5/2025 revealed R1 had an order for Tylenol 325 milligrams (mg) tablet, to administer two tablets orally every six hours as needed for pain related to pressure ulcer of the sacral region with an order and start date of 3/4/2025.

A review of the Medication Administration Record (MAR) dated 3/1/2025 through 3/31/2025 revealed no evidence that Tylenol was administered.

115412

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115412 B.

Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harborview Tifton 1451 Newton Drive Tifton, GA 31794

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TIFTON, GA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HARBORVIEW TIFTON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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