Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Legacy Health And Rehab during CMS and state inspections, most recent first.
The facility failed to provide the required 8 hours of RN coverage per day on multiple occasions, particularly on weekends, due to a recent resignation. Staff confirmed the inconsistency in RN coverage, and the administration acknowledged the deficiency.
The facility did not update the daily nurse staffing information as required by their policy. The posted staffing information was outdated, showing the schedule for a previous date rather than the current staff. The DON stated that the Unit 1 Charge Nurse was responsible for updating the staffing sheet.
The facility failed to provide hot water at a kitchen handwashing sink and did not maintain kitchen equipment and floors in a sanitary condition. Observations showed food debris on kitchen equipment and the floor, and the Dietary Manager confirmed the lack of cleanliness and hot water availability.
A resident with multiple diagnoses, including Multiple Sclerosis and moderate cognitive impairment, was found to have their call light out of reach on multiple occasions. Despite the facility's policy requiring call lights to be within easy reach, observations and staff interviews confirmed the call light was inaccessible, leading to a deficiency in accommodating the resident's needs.
A facility failed to provide a resident with information about their right to formulate an advance directive upon admission. The resident, with severe cognitive impairment and multiple diagnoses, did not receive the necessary information, and the Advanced Directive Acknowledgement form was not signed. The Admissions Director confirmed the oversight.
The facility failed to maintain a safe, clean, and homelike environment for several residents, as observed in multiple rooms with chipped paint, rust-like substances, and dirty residues. These deficiencies were confirmed by the Assistant Administrator, Housekeeping Director, and Maintenance Director, who acknowledged the lack of compliance with the facility's policy.
The facility failed to accurately complete MDS assessments for three residents regarding anticoagulant use and active diagnoses. A resident with Pulmonary Embolism and Depression was prescribed Eliquis, but it was not recorded in the MDS. Another resident with severe cognitive impairment and Atrial Fibrillation also had Eliquis omitted from their MDS. Additionally, a resident with Bipolar Disorder and Venous Thrombosis had both their anticoagulant medication and active diagnoses inaccurately captured. These deficiencies were confirmed by the MDS Coordinators.
A facility failed to develop a comprehensive care plan for a resident with a colostomy. Despite the resident being cognitively intact and requiring moderate assistance for ADLs, the care plan did not include specific measures for colostomy care, even though physician orders were in place. This oversight was confirmed by the Unit Manager.
A facility failed to update a resident's care plan to reflect a new fall intervention after the resident, who was moderately cognitively impaired and dependent on staff for transfers, fell from the bed. The intervention involved replacing an air mattress with a regular mattress, but the care plan still indicated the use of an air mattress. The oversight was confirmed by the Unit Manager/LPN MDS Coordinator, contrary to the facility's policy.
An LPN failed to secure medications in a locked location, leaving a bottle of Valproic Acid unsecured on a medication cart. This action was against the facility's policy, which requires medications to be stored in locked compartments. The incident involved a resident with Type 2 Diabetes, Schizophrenia, and Anxiety Disorder.
A resident with dementia and a high fall risk experienced an unwitnessed fall, but the facility failed to notify the resident's family, physician, and DON as required by policy. The DON confirmed that staff are expected to make these notifications immediately, but acknowledged that some staff delay until morning if no injury is present.
Failure to Provide Minimum RN Coverage
Penalty
Summary
The facility failed to provide the required minimum of 8 hours per day of Registered Nurse (RN) coverage on multiple occasions. A review of the facility's Payroll Based Journal (PBJ) report from 10/1/2023 to 12/31/2023 revealed that there was no RN coverage on several weekends, including specific Saturdays and Sundays. Additionally, the facility's daily staffing posting sheets and time clock punches indicated insufficient RN coverage on various other days, with some days having as little as 1.13 hours of RN coverage. Interviews with facility staff, including the Staff Development Coordinator/Infection Control Nurse, confirmed the lack of consistent RN coverage, particularly on weekends. The RN who was scheduled to work on Saturdays and Sundays had recently quit, and the facility was in the process of hiring a replacement. The Administrator, Assistant Administrator, Director of Nursing, and the Controller acknowledged the facility's failure to meet the minimum RN coverage requirement.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate daily nurse staffing information, as required by their policy. The policy, revised in July 2016, mandates that the facility must post the number of nursing personnel responsible for providing direct care to residents for each shift on a daily basis. However, during an observation on April 8, 2024, at 7:40 AM, it was noted that the staffing information displayed was outdated, showing the staff scheduled for April 5, 2024, rather than the current staff present on April 8, 2024. In an interview conducted on April 10, 2024, at 2:35 PM, the Director of Nursing indicated that the responsibility for posting the daily staffing sheet lay with the Unit 1 Charge Nurse. This oversight in updating the staffing information led to the deficiency noted by the surveyors.
Deficiencies in Kitchen Sanitation and Handwashing Facilities
Penalty
Summary
The facility failed to ensure hot water was available for staff to wash and sanitize their hands at one of the two kitchen handwashing sinks. During an observation and interview with the Dietary Manager (DM), it was noted that the sink, which had been converted from an eye wash station, did not have hot water connected. The DM confirmed that it was expected for hot water to be available for kitchen staff use, but it was not. Additionally, the facility did not maintain kitchen equipment and floors in a sanitary manner. Observations in the food preparation area revealed thick layers of sticky, black food debris on the outer door, bottom edge, and temperature dials of the food warmer. In the dishwashing area, food debris, a plastic cup, and a plastic fork were found scattered on the floor beneath the dishwasher on consecutive days. The DM acknowledged that the kitchen equipment and floors were not cleaned as expected, which was supposed to be done daily and deep cleaned weekly.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure the call light was within reach for a resident, leading to a deficiency in accommodating the needs and preferences of the resident. The facility's policy, dated March 2021, requires that the call light be within easy reach when a resident is in bed or confined to a chair. However, during observations and interviews, it was found that the call light for a resident with multiple diagnoses, including Multiple Sclerosis and moderate cognitive impairment, was not accessible. The resident, who required substantial assistance with personal hygiene, was observed seated in a reclining chair with the call light clipped to the privacy curtain and later draped over the side of the bed, both times out of reach. Interviews with staff, including an LPN and a CNA, confirmed that the call light was not within the resident's reach and was not accessible for use. The Director of Nursing also acknowledged that the facility's expectation was for call lights to be within reach when residents are in bed or sitting in chairs. Despite this expectation, the facility did not ensure the call light was accessible for the resident's use, resulting in a failure to meet the resident's needs and preferences as outlined in the care plan.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide a resident with information regarding their right to formulate an advance directive upon admission. The facility's policy, revised in December 2016, mandates that residents be given written information about formulating an advance directive upon admission. However, for one resident, who was admitted with severe cognitive impairment and multiple diagnoses including Schizoaffective Disorder, Bipolar Type, Dementia, Psychotic Disorder with Hallucinations, Anxiety Disorder, and Hypertension, this information was not provided. The resident's admission Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 7, reflecting severe cognitive impairment. The Advanced Directive Acknowledgement form for this resident was not signed by either the resident or their representative upon admission. During an interview, the Admissions Director confirmed that neither the resident nor their representative received the necessary information about formulating an advance directive at the time of admission.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for six residents across one of the four hallways observed. The facility's policy, revised in February 2021, mandates that residents are provided with a safe, clean, and homelike environment. However, observations revealed that the rooms of several residents had chipped paint, rust-like substances, and dirty residues, which were not in compliance with the facility's policy. Resident #30's room was observed on multiple occasions to have a bathroom door frame with missing, chipped paint and a rust-like substance where the paint was missing. The floor around the toilet had a brownish/black dirty residue, and the closet and entry door frames also had chipped paint. Similar conditions were noted in the shared bathroom of Residents #25 and #50, where the bathroom and closet door frames had chipped paint and rust-like substances, and the floor around the toilet was dirty. Additionally, Resident #25's bedside table had chipped wood, and a dresser had a missing handle. Other residents, including Residents #3, #35, and #17, also experienced similar deficiencies. Resident #3's room had a bathroom door frame with chipped paint and rust, a dresser with missing handles, and a broken nightstand. Resident #35's room had a stained toilet seat, chipped paint, and a dresser with missing paint and a knob. Resident #17's room had a bathroom door frame with chipped paint and rust, and a dresser with missing paint. These observations were confirmed by the Assistant Administrator, Housekeeping Director, and Maintenance Director, who acknowledged that the rooms were not maintained in a safe, clean, and homelike environment.
Inaccurate MDS Assessments for Anticoagulant Use and Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents regarding anticoagulant medication use and active diagnoses. Resident #31, who was admitted with conditions including Pulmonary Embolism and Depression, was prescribed Eliquis, an anticoagulant, but this was not recorded in the MDS assessment. The Licensed Practical Nurse (LPN) MDS Coordinator confirmed the omission during an interview. Similarly, Resident #20, with severe cognitive impairment and conditions such as Heart Failure and Atrial Fibrillation, was also prescribed Eliquis, but the medication was not documented in the MDS assessment. The Registered Nurse (RN) MDS Coordinator acknowledged this oversight. Resident #14, who had diagnoses including Bipolar Disorder, Anxiety Disorder, and Venous Thrombosis, was also prescribed Eliquis. However, the MDS assessment failed to capture both the anticoagulant medication and the active diagnoses of Depression, Anxiety, and Bipolar Disorder. The RN MDS Coordinator confirmed these inaccuracies during an interview. These deficiencies indicate a failure in accurately completing the MDS assessments, which are crucial for ensuring appropriate care and treatment for residents.
Failure to Develop Comprehensive Care Plan for Colostomy
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a colostomy, which was identified during a review of the facility's care planning practices. The facility's policy requires a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs. However, the care plan for a resident admitted with multiple diagnoses, including a colostomy, did not include any specific plan related to the colostomy. The resident was cognitively intact and required moderate assistance for activities of daily living, as indicated by the admission Minimum Data Set. Despite having physician orders for colostomy care, the comprehensive care plan was not updated to reflect this need, as confirmed by the Unit Manager during an interview.
Failure to Update Care Plan After Fall Intervention
Penalty
Summary
The facility failed to revise a comprehensive care plan to reflect a new fall intervention for a resident who was moderately cognitively impaired and dependent on staff assistance for transfers. The resident, who had a history of falls, was admitted with diagnoses including abnormalities of gait and mobility, muscle weakness, and a need for personal care. Following a fall incident on February 16, 2024, where the resident fell from the bed while reaching for a drink, an immediate intervention was implemented to replace the air mattress with a regular mattress to prevent further falls. Despite this intervention, the resident's care plan, last revised on April 5, 2024, still indicated the use of an alternating air mattress and did not reflect the change to a regular mattress. During interviews, the Unit Manager/LPN MDS Coordinator confirmed that the care plan had not been updated to include the new fall intervention, which was against the facility's policy that care plans should be revised as residents' conditions change. This oversight was identified during an observation and interview conducted on April 9, 2024.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure that medications were secured in a locked location, as required by their policies. During an observation, an LPN prepared medications for a resident with diagnoses including Type 2 Diabetes, Schizophrenia, and Anxiety Disorder. The LPN left the medication room without locking the door and left a bottle of Valproic Acid unsecured on top of the medication cart. This action was contrary to the facility's policy, which mandates that medications be stored in locked compartments and that no medications are left on top of the cart. The LPN confirmed during an interview that the bottle of Valproic Acid was left unsecured. The Director of Nursing also stated that it was the facility's expectation for medications to be secured and locked. This incident highlights a failure to adhere to the facility's medication storage policies, which are designed to ensure the safety and security of medications within the facility.
Failure to Notify After Resident Fall
Penalty
Summary
The facility failed to ensure appropriate notifications were conducted following a fall involving a resident diagnosed with Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Depression with Psychotic Features, Anxiety, Hypotension, and Urinary Tract Infection. The resident, who was admitted with a high fall risk score, experienced an unwitnessed fall on 1/30/2024 at 1:00 AM. Despite the facility's policy requiring notification of the resident's family, attending physician, Director of Nursing Services, and the Nursing Supervisor on duty, there was no documentation indicating that these notifications were made. The Director of Nursing (DON) confirmed during an interview that staff are expected to notify the necessary parties of a resident's fall, regardless of the time of day or whether an injury occurred. However, the DON acknowledged that some staff might delay notifications until the morning if no injury is present, which was the case for this incident. The lack of notification was confirmed through a review of the resident's progress notes, history and physical note, and event report, all of which showed no evidence of the required notifications being made.
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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 Manchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manchester Center For Rehabilitation And Healing L | 2.1 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Tullahoma | 10.1 mi | ★★★★★ | 5 | 0 |
| Nhc Healthcare, Tullahoma | 10.4 mi | ★★★★★ | 0 | 0 |
| Lynchburg Nursing Center | 19.6 mi | ★★★★★ | 5 | 0 |
| Heritage Place Care & Rehabilitation Llc | 19.8 mi | ★★★★★ | 0 | 0 |
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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.