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Legacy Health And Rehab

For profit - Individual  ·  811 Keylon Street, Manchester, TN 37355  ·  See home’s Medicare page

Inspections Delayed
The most recent standard inspection occurred more than two years ago. Inspections are supposed to occur every 18 months.
3.31
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.7
56.8%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 53.4%
72
Certified beds
Qualifying beds in the certified provider or supplier facility.
53
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Legacy Health And Rehab Llc (100%)
Indirect owners
No indirect owner information
Managerial control
Legacy Health And Rehab Llc since Sep, 2020
Managing employee(s)
Holly Hopkins since Sep, 2020

Inspection Reports

14

total deficiencies

2

infection-related deficiencies

This home violated federal standards protecting residents from the spread of infections.

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Sep 19, 2023
Complaint report
1 deficiency
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Nov 29, 2021
Complaint report
1 deficiency
D

Quality of Life and Care Deficiency — F0684
Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Oct 27, 2021
Standard report
4 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

1 Payment Suspension
D

to F
F

Pharmacy Service Deficiency — F0761
Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Pharmacy Service Deficiency — F0759
Failure to: Ensure medication error rates are not 5 percent or greater.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0578
Failure to: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Apr 3, 2019
Standard report
6 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

to E
E

Resident Rights Deficiency — F0584
Failure to: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0550
Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0842
Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Administration Deficiency — F0868
Failure to: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Apr 4, 2018
Standard report
2 deficiencies
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to: Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Penalties

$1,325

total fines

1

payment suspension

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
Mar 14, 2022
No corresponding inspection report.
Oct 27, 2021
1 Payment Suspension