Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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 | — | 0 | 0 |
| Pruitthealth - Sylvester | 20.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.