Harborview Post Acute: Staff Competency Harm - TN
The incident at Harborview Post Acute exposed a cascade of delayed care that federal inspectors found violated basic medical standards. LPN A conducted neurological checks on the injured resident without adequate lighting, later telling investigators he was "unsure of what the patient looked like during his assessment as it was dark."
When confronted with his own documentation during an October interview, LPN A stated, "No, that does not make sense."
The resident's condition demanded urgent attention. Both eyes were swollen completely shut. A knot protruded from the back of his head. Yet after the facility's nurse practitioner ordered emergency room evaluation, the patient remained at Harborview for seven additional hours before transport.
LPN D, who was on duty during the delay, couldn't explain the holdup. When inspectors asked whether 911 should have been called based on the resident's condition, LPN D responded, "That depends on what the provider says."
The nurse practitioner disagreed. During a telephone interview, she acknowledged that non-emergency transfers sometimes take three to four hours but said she wasn't aware this patient had waited seven hours. When asked whether 911 should have been called for emergency transport, she answered simply: "Yes."
She also confirmed what other nursing staff told investigators about conducting neurological assessments in darkness. "No, that's not a good assessment," the nurse practitioner said.
Multiple nurses at Harborview acknowledged the obvious problems with evaluating head injuries without proper lighting. RN E told inspectors she "would not be able to see well" if she completed neurological checks in the dark.
LPN F was more specific about what darkness prevents nurses from observing: "You can't see the patient or if they are making a facial expression, not all patients can talk."
LPN G simply answered "No" when asked whether neurological assessments should be completed in darkness.
The facility's Quality Service Consultant agreed that seven hours was too long to wait for emergency transport, telling inspectors, "No, it should not have taken 7 hours."
Yet the Director of Nursing claimed ignorance about the assessment conducted in darkness until federal investigators arrived. "I was not aware of that until you came in on the complaint," she told inspectors.
When asked about her expectations for neurological assessments, the Director of Nursing stated, "I do not expect them to do that at all... it should be completed with good lighting."
The protocol for head injuries from falls was clear to nursing staff. RN E explained the standard process: "notify the provider, and the provider will say whether to send the patient out."
But LPN F revealed confusion about who determines the method of transport. "The provider will tell the nurse or you may have to ask," she said, suggesting uncertainty about emergency versus non-emergency transfers.
The resident's injuries demanded immediate evaluation that never came promptly. With both eyes swollen shut, he couldn't communicate his condition clearly. The knot on his head indicated potential serious trauma. Yet he waited in darkness while a nurse attempted to assess neurological function without being able to see his face.
Federal inspectors found the facility failed to ensure residents received proper medical evaluation after injuries. The seven-hour delay in emergency transport, combined with inadequate assessment conditions, represented actual harm to the resident requiring urgent neurological evaluation.
The case highlighted systemic problems at Harborview Post Acute, where nursing staff conducted critical medical assessments under conditions their own colleagues called inadequate, while administrators remained unaware of practices that violated basic medical standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harborview Post Acute from 2025-10-27 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: June 20, 2026 · Our methodology
Harborview Post Acute in MEMPHIS, TN was cited for violations during a health inspection on October 27, 2025.
The incident at Harborview Post Acute exposed a cascade of delayed care that federal inspectors found violated basic medical standards.
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.