Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harborview Post Acute during CMS and state inspections, most recent first.
Failure to assess and monitor surgical incision sites. A resident admitted with bilateral ankle ORIF had care plan interventions for monitoring surgical incisions for infection and changes in appearance, but the record showed the wounds were documented as unable to assess on initial skin checks. The resident was observed wearing walking boots and stated staff had not removed the dressings to assess the incisions, while an LPN said she had only checked circulation and had not visually seen the wounds. Interviews showed the treatment nurse knew of the surgical wounds but did not assess them, did not document the resident’s refusal, and did not notify the MD.
Nursing staff did not demonstrate the required competencies to assess and respond to a resident's unwitnessed fall with head injuries, resulting in delayed recognition of injuries and a seven-hour delay in transferring the resident to the ER. Assessments were performed inadequately, including in poor lighting, and staff interviews revealed confusion about protocols for post-fall care and emergency transfers.
Failure to Assess and Monitor Surgical Incisions
Penalty
Summary
The facility failed to assess and monitor surgical incision sites for a resident admitted with a displaced bimalleolar fracture of the right lower leg and bilateral ORIF procedures. The resident’s care plan included monitoring the surgical incisions for signs and symptoms of infection, changes in appearance, treatment effectiveness, and notifying the MD as needed. Admission and skin assessment policies required a physical assessment of the skin and communication of findings, but the record showed the surgical incisions were documented as "unable to assess" on the initial skin assessment and again on a subsequent skin assessment, with no visual assessment of the incisions recorded at those times. The resident’s record later showed surgical wounds with staples intact at the right outer ankle, left outer ankle, and left inner ankle. During observation, the resident was sitting up in bed wearing walking boots to both feet and stated staff had not removed the boots and dressings to assess the skin and incisions. The resident also reported difficulty sleeping at night with the boots and increased burning to the ankles, likely from the incisions. An LPN stated she had only assessed circulation and had not visually seen the surgical incisions. Interviews further revealed that the treatment nurse knew of the surgical wounds but did not assess the incisions because the resident refused removal of the dressings, and she did not document the refusal or notify the physician. The treatment nurse also stated she had not assessed the surgical incisions prior to the day of the interview and had realized there were no follow-up orders but failed to follow up. The ADON stated that if there was no order to leave the dressing in place, a complete skin assessment should have been completed, and staff should document and notify the physician of refusal of care.
Failure to Ensure Competent Nursing Assessment and Timely Response After Resident Fall
Penalty
Summary
Nursing staff failed to demonstrate the necessary competencies and skills to provide safe and appropriate care for a resident who experienced an unwitnessed fall resulting in head injuries. The facility's own assessment and policies required staff to possess and apply appropriate skills and competencies, including conducting thorough assessments and timely interventions following resident falls. However, after the resident's fall, staff did not recognize or document the extent of the injuries, and assessments were performed inadequately, including conducting neurological checks in poor lighting conditions, which staff later acknowledged was not appropriate. The medical record and facility investigation revealed that the resident, who had multiple diagnoses including cerebral infarction, seizures, and poor mobility, was not properly assessed after the fall. Despite visible injuries such as swelling and hematomas to the face and head, there was a significant delay in transferring the resident to the emergency room for evaluation. The Family Nurse Practitioner (FNP) identified the injuries and gave an order for transfer, but the resident was not sent to the hospital until approximately seven hours later. Documentation was lacking regarding the timing of EMS notification and the specific assessments performed after the fall. Interviews with facility staff, including LPNs, RNs, the ADON, DON, and the FNP, revealed confusion and inconsistency regarding protocols for post-fall assessment, documentation, and emergency transfer procedures. Staff admitted to performing assessments in the dark, being unsure of the resident's baseline appearance, and not following established protocols for head injuries. The delay in recognizing the severity of the resident's injuries and the failure to promptly transfer the resident for medical evaluation resulted in actual harm.
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What surveyors actually found near you
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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 Memphis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regional One Health Subacute Care | 2 mi | — | 0 | 0 |
| Midtown Center For Health And Rehabilitation | 2.9 mi | ★★★★★ | 0 | 0 |
| Majestic Gardens At Memphis Rehab & Snc | 2.9 mi | ★★★★★ | 0 | 0 |
| Allen Morgan Health And Rehabilitation Center | 6 mi | ★★★★★ | 2 | 0 |
| Highlands Health And Rehabilitation Center | 6 mi | ★★★★★ | 2 | 1 |
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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.