Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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 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.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 163 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 11 | 0 |
| Majestic Gardens At Memphis Rehab & Snc | 2.9 mi | ★★★★★ | 43 | 0 |
| Allen Morgan Health And Rehabilitation Center | 6 mi | ★★★★★ | 2 | 0 |
| Highlands Health And Rehabilitation Center | 6 mi | ★★★★★ | 2 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.