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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