Harborview Post Acute
Inspection Findings
F-Tag F0726
F 0726 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident #1 had both eyes swollen shut, and one eye swollen shut, and a knot was on the back of his head. LPN D was not aware of an order to transfer Resident #1 to the ER for evaluation. LPN D was asked from his assessment of Resident #1, should 911 had been called. LPN D stated, That depends on what the provider says. 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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If continuation sheet
Harborview Post Acute in MEMPHIS, TN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 MEMPHIS, TN, (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 Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.