Above 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 Manchester Center For Rehabilitation And Healing L during CMS and state inspections, most recent first.
Failure to Assess Lap Belt Use for Two Residents: Two cognitively intact residents were observed in power wheelchairs with lap belts secured in place, but the facility had not completed assessments for the belts. One resident had COPD, morbid obesity, and DM2 with a care plan for impaired mobility and PT/OT needs, while the other had hemiplegia, abnormal posture, and a right hand contracture with OT services noted. The DOR and DON confirmed the residents had not been assessed for lap belt use.
Care plans were not implemented accurately for two residents with lap belts and one resident with a fall-related wheelchair intervention. Two cognitively intact residents were observed in power wheelchairs with lap belts in use, but their care plans did not reflect the restraint use; the DON confirmed the plans were inaccurate. A third resident with severe cognitive impairment had a wheelchair intervention for Dycem, but it was not present when observed, and the DON confirmed it was missing.
A resident with vascular dementia, age-related physical disability, and repeated falls had a comprehensive care plan that did not reflect the bed in lowest position, a floor mat on the right side of the bed, or a nightlight, even though these measures were observed in the room. The DON and Administrator confirmed the care plan had not been revised to include them.
Improper Infection Control During Medication Administration: An LPN handled a resident’s oral medications with her hands before placing them into a medication cup and administering them. The resident had multiple chronic conditions, including COPD, HF, DM, and chronic pain syndrome, and the DON confirmed staff were expected to follow infection control practices and not touch medications with hands.
A resident with severe cognitive impairment and multiple medical conditions was left unattended and locked inside a facility van for several hours after returning from a medical appointment. The Transportation Coordinator, distracted by multiple phone calls and severe weather, failed to unload the resident, who was later found by an LPN during shift change. Emergency services were called to access the van, and the resident was assessed to be at her baseline with no observed harm.
Failure to Assess Lap Belt Use for Two Residents
Penalty
Summary
The facility failed to perform an assessment for the use of a lap belt for 2 residents reviewed for physical restraints. Facility policy dated 4/2017 stated individuals shall be reviewed regularly, at least quarterly. Resident #34 was admitted with diagnoses including COPD, morbid obesity, and type II diabetes, and an admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact. Her care plan identified fall risk related to impaired mobility and noted the need for PT/OT for impaired ROM and wheelchair management and mobility training. During observations on 6/2/2026 and 6/3/2026, Resident #34 was seen seated in her power wheelchair with a lap belt secured around her waist, and the DON confirmed the resident had not been assessed for use of the lap belt. The DOR also stated the resident was not assessed for the lap belt and said the resident does not utilize it on her power wheelchair. Resident #67 was admitted with diagnoses including hemiplegia, abnormal posture, and depression, and an MDS assessment showed a BIMS score of 13, indicating the resident was cognitively intact. Her care plan noted OT services related to abnormal posturing of the hemiplegic limb in the current power chair and right hand contracture. During observations on 6/1/2026 and 6/3/2026, Resident #67 was seen sitting in her power wheelchair with a lap belt secured across her right arm and waist. A CNA stated the belt was on the power wheelchair to keep the resident from falling out, and the DON later stated the lap belt was used for positioning the resident's right arm. The DOR stated the resident was not assessed by therapy for the use of a lap belt, and the DON confirmed the resident had not been assessed for use of the lap belt since obtaining the wheelchair in 12/2024.
Care plans did not reflect or match restraint and fall interventions
Penalty
Summary
The facility failed to implement the care plan for the use of a lap belt for Resident #34 and Resident #67. Resident #34 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Type II Diabetes, and had a BIMS score of 15 indicating cognitive intactness. The comprehensive care plan addressed fall risk related to impaired mobility and PT/OT needs for impaired ROM, wheelchair management, and mobility training, but no care planning was found for the lap belt restraint. During an observation, Resident #34 was seen seated in a power wheelchair in the common area with the lap belt secured around the waist. Resident #67 was admitted with diagnoses including Hemiplegia, Abnormal Posture, and Depression, and had a BIMS score of 13 indicating cognitive intactness. The comprehensive care plan addressed OT services related to abnormal posturing of the hemiplegic limb and right hand contracture, but did not reflect the use of the lap belt. During observations, Resident #67 was seen in a power wheelchair with a lap belt secured across the right arm and waist. The DON stated the lap belt was used for positioning the resident's right arm and confirmed the care plans for Resident #34 and Resident #67 were not accurate. The facility also failed to follow the care plan for Resident #107, who had diagnoses including Vascular Dementia, Age-Related Physical Disability, and Repeated Falls, with a BIMS score of 1 indicating severe cognitive impairment. The care plan included an intervention for Dycem to the wheelchair, but during observation the resident did not have Dycem in the wheelchair, and the DON confirmed it was not present.
Care Plan Not Updated to Reflect Fall-Prevention Measures
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #107 to reflect interventions that were in place for repeated falls. Resident #107 was admitted with diagnoses including vascular dementia, age-related physical disability, and repeated falls, and the admission MDS showed a BIMS score of 1, indicating severe cognitive impairment, with partial/moderate assistance needed for transfers and substantial/maximal assistance needed for toileting. Although the comprehensive care plan was revised on 6/2/2026, it did not include the bed in lowest position, a floor mat on the right side of the bed, or a nightlight. Observations on 6/1/2026 and 6/2/2026 showed the bed in lowest position, a floor mat on the right side of the bed, and a nightlight plugged in at the foot of the bed. During interview on 6/3/2026, the DON and Administrator confirmed the care plan had not been revised to reflect these measures.
Improper Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for one resident. Review of the facility policy titled, "Administering Medications," dated 4/2019, stated that staff follow established facility infection control procedures for the administration of medications. Resident #18 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, Diabetes Mellitus, and Chronic Pain Syndrome, and had current physician orders for multiple medications including Eliquis, Benzonate, Duloxetine, Farxiga, Furosemide, Gabapentin, Hydrocodone-Acetaminophen, Metoprolol, Oxybutin, Potassium, and Sertraline. During observation of medication administration, an LPN prepared Resident #18's medications by placing the pills into her hand and then into the medication cup before administering them to the resident. The medications were handled in this manner for the listed oral medications. When interviewed, the LPN stated she was able to touch the pills because they were not hazardous medications. The DON later confirmed that staff were expected to follow infection control practices, including not touching medications with hands.
Resident Left Unattended in Locked Facility Van After Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia, was not returned to her room after being transported to a medical appointment. The Transportation Coordinator, responsible for safely transporting residents, returned to the facility with the resident but failed to unload her from the facility van. The resident, who was wheelchair-bound and dependent on staff for activities of daily living, remained locked inside the van for an estimated three to four hours during a period of severe weather, while the facility was under a code black for serious weather conditions. The Transportation Coordinator became distracted by multiple phone calls regarding other residents' appointments and impending poor weather, which led her to deviate from her usual routine. She parked the van in a different location than usual and went inside the facility to check the calendar, forgetting to unload the resident. There was no sign-out sheet or checklist in place at the time to ensure residents were accounted for after transport. The resident was discovered missing when an LPN became concerned about her whereabouts during shift change and initiated a search, eventually finding her in the locked van. Upon discovery, emergency services were called to gain access to the van. The resident was found alert, in her wheelchair, and assessed by medical staff, who determined she was at her baseline with no observed injuries or distress. The incident was reported to facility leadership, law enforcement, and other relevant agencies. The deficiency was cited under F 689 for failure to ensure the environment was free from accident hazards and to provide adequate supervision to prevent accidents.
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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) |
|---|---|---|---|---|
| Legacy Health And Rehab | 2.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Tullahoma | 11.8 mi | ★★★★★ | 5 | 0 |
| Nhc Healthcare, Tullahoma | 12.1 mi | ★★★★★ | 0 | 0 |
| Lynchburg Nursing Center | 21.2 mi | ★★★★★ | 5 | 0 |
| Nhc Healthcare, Mcminnville | 21.2 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 August 2026) and official state health department websites.