Harborview Post Acute
Harborview Post Acute in MEMPHIS, TN — inspection on October 27, 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.
Inspection Findings
During interview on 10/23/2025 at 2:56 PM, the Quality Service Consultant (QSC) was asked should it have taken 7 hours to transport Resident #1 to the ER after the FNP gave the order.
The QSC stated, No, it should not have taken 7 hours.
During a telephone interview on 10/24/2025 at 12:14 PM, the FNP acknowledged it sometimes can take 3 to 4 hours for non-emergency transfers but was not aware that it had taken 7 hours for Resident #1 to be transported to the ER.
The FNP was asked based on your assessment of Resident #1, should 911 been called for transport to the ER for evaluation.
The FNP stated, Yes .
The FNP was asked should a neurological (neuro) checks and assessments be completed in the dark.
FNP stated, No, that's not a good assessment.
During an interview on 10/27/2025 at 10:47 AM, LPN A acknowledged he did not recall Resident #1. LPN A was read the FNP note dated 3/31/2023, which indicated LPN A was unsure of what the patient looked like during his assessment as it was dark. LPN A stated, No, that does not make sense .
During an interview on 10/27/2025 at 12:24 PM, RN E stated she would not be able to see well if she completed neuro checks/assessment in the dark. RN E was asked the protocol for a resident with head injuries from a fall. RN E stated, .notify the provider, and the provider will say whether to send the patient out .
During an interview on 10/27/2025 at 12:49 PM, LPN F was asked if neuro checks/assessments should be completed in the dark. LPN F stated, No ma'am, you can't see the patient or if they are making a facial expression, not all patients can talk. LPN F was asked who determines when a patient is sent out 911 or by non-emergency services. LPN F stated The provider will tell the nurse or you may have to ask.
During an interview on 10/27/2025 at 1:10 PM, when LPN G was asked should neuro checks/assessment be completed in the dark. LPN G stated, No
During an interview on 10/27/2025 at 2:22 PM, the Director of Nursing (DON) was asked did the facility identify an issue with the nurse [LPN A] completing neuro checks/assessment in the dark.
The DON stated, I was not aware of that until you came in on the complaint.
The DON was asked is it her expectation for neuro checks/assessments not to be completed in the dark.
The DON stated, I do not expect them to do that at all .it should be completed with good lighting.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.