Inspection Reports for
Legacy Health and Rehab
811 Keylon St, Manchester, TN 37355, Manchester, TN, 37355
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jun 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for nursing home care, including environment safety, care planning, infection control, and other facility operations.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper care planning, oxygen therapy orders, kitchen sanitation, hair covering compliance among dietary staff, dumpster area sanitation, and infection prevention practices.
Deficiencies (8)
F 0584: The facility failed to maintain a safe, clean, homelike environment for 4 residents, including damaged flooring, closet doors with holes, broken furniture, and damaged footboard.
F 0644: The facility failed to refer 2 residents diagnosed with serious mental disorders to the state-designated authority for Level II PASARR evaluation.
F 0656: The facility failed to develop a person-centered care plan related to smoking for 1 resident.
F 0657: The facility failed to revise a comprehensive care plan to reflect discontinued dialysis shunt site assessments for 1 resident.
F 0695: The facility failed to ensure physician orders were obtained for oxygen therapy for 2 residents receiving oxygen.
F 0812: The facility failed to maintain kitchen equipment in a clean and sanitary condition and failed to ensure dietary staff wore protective hair coverings during food preparation.
F 0814: The facility failed to maintain the outside dumpster area in a sanitary and orderly condition.
F 0880: The facility failed to provide a sanitary environment by failing to clean and properly store soiled urinals in a multi-resident bathroom.
Report Facts
Residents observed: 24
Residents reviewed for PASARR: 10
Residents reviewed for care plans: 14
Residents reviewed for oxygen therapy: 6
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 53
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Confirmed oxygen therapy without physician order and unclean urinals in Resident #4's bathroom |
| Registered Nurse C | Registered Nurse | Confirmed oxygen therapy without physician order for Residents #4 and #255 and confirmed footboard damage |
| Licensed Practical Nurse Unit Manager G | Licensed Practical Nurse Unit Manager | Confirmed Resident #4 and #255 lacked physician orders for oxygen therapy |
| Dietary Manager | Dietary Manager | Confirmed kitchen equipment sanitation issues and dietary staff hair covering violations |
| Administrator | Administrator | Confirmed environmental deficiencies including damaged furniture and flooring, and dietary staff hair covering violations |
| Director of Nursing | Director of Nursing | Confirmed smoking care plan deficiency and oxygen therapy order requirements |
| Licensed Practical Nurse B | Licensed Practical Nurse | Confirmed PASARR submission deficiency for Resident #4 |
| 600 Hall Unit Manager | Unit Manager | Confirmed PASARR submission deficiency for Resident #32 and care plan revision deficiency for Resident #34 |
Inspection Report
Enforcement
Deficiencies: 4
Date: Aug 26, 2024
Visit Reason
Commission surveyors conducted a survey at Asbury Place at Steadman Hill Assisted Care Living Facility from August 26, 2024 through August 29, 2024 to investigate compliance with applicable regulations.
Findings
The facility was found to have multiple violations including failure to provide protective care, safety, and awareness of resident whereabouts, as well as allowing a portable space heater in the kitchen. These violations led to disciplinary action and civil monetary penalties.
Deficiencies (4)
Tenn. Comp. R. and Regs. 0720-26-.07 (7)(a)(1) [Services Provided] - The facility failed to provide protective care to Resident #8.
Tenn. Comp. R. and Regs. 0720-26-.07 (7)(a)(2) [Services Provided] - The facility failed to provide safety while in the ACLF.
Tenn. Comp. R. and Regs. 0720-26-.07 (7)(a)(3) [Services Provided] - The facility failed to maintain awareness of the whereabouts of Resident #6.
Tenn. Comp. R. and Regs. 0720-26-.10 (2)(h) [Life Safety] - The facility allowed a portable space heater in the kitchen, violating fire safety rules.
Report Facts
Civil Monetary Penalty: 2000
Civil Monetary Penalty: 3000
Civil Monetary Penalty: 1000
Civil Monetary Penalty: 2000
Total Civil Monetary Penalty: 8000
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 10, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure appropriate notifications were made following a resident fall.
Complaint Details
The complaint investigation found that notifications were not made to the resident's physician, nurse practitioner, Director of Nursing, or family representative after Resident #454's fall on 1/30/2024. The Director of Nursing confirmed this failure during an interview on 4/10/2024.
Findings
The facility failed to notify the resident's physician, nurse practitioner, Director of Nursing, and family representative following an unwitnessed fall of Resident #454 on 1/30/2024. The Director of Nursing confirmed that notifications were not made as required by facility policy.
Deficiencies (1)
F 0580: The facility failed to notify the resident's physician, nurse practitioner, Director of Nursing, and family representative following Resident #454's fall on 1/30/2024. This failure occurred despite facility policy requiring such notifications for all falls.
Report Facts
Fall Risk Score: 24
Residents reviewed for falls: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding notification failures following Resident #454's fall |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 10, 2024
Visit Reason
Routine inspection of Legacy Health and Rehab to assess compliance with regulatory requirements including resident care, environment, staffing, medication management, and kitchen sanitation.
Findings
The facility was found deficient in multiple areas including call light accessibility, advanced directive information provision, maintenance of a safe and homelike environment, accurate resident assessments, care planning, RN staffing coverage, nurse staffing posting, medication security, and kitchen sanitation.
Deficiencies (10)
F 0558: The facility failed to ensure the call light was within reach for Resident #7, limiting the resident's ability to summon staff assistance.
F 0578: The facility failed to provide Resident #3 with information regarding the right to formulate an advance directive upon admission.
F 0584: The facility failed to maintain a safe, clean, and homelike environment for six residents, with issues including chipped paint, rust-like substances, dirty residues, and broken furniture.
F 0641: The facility failed to accurately complete Minimum Data Set assessments for anticoagulant use and active diagnoses for several residents.
F 0656: The facility failed to develop a comprehensive care plan addressing the colostomy needs of Resident #31.
F 0657: The facility failed to revise Resident #14's care plan to reflect a new fall intervention after a fall incident.
F 0727: The facility failed to provide the minimum requirement of 8 hours per day of Registered Nurse coverage on multiple days.
F 0732: The facility failed to post accurate daily nurse staffing information reflecting actual staffing levels.
F 0761: The facility failed to ensure medications were secured in a locked location, leaving a bottle of Valproic Acid unsecured on a medication cart.
F 0812: The facility failed to provide hot water at one kitchen handwashing sink and failed to maintain kitchen equipment and floors in a sanitary condition.
Report Facts
Residents observed for call light accessibility: 52
Residents reviewed for advanced directives: 18
Residents reviewed for homelike environment: 6
Residents reviewed for anticoagulant use: 10
Residents reviewed for accurate MDS assessments: 18
Residents reviewed for care planning: 18
Days with insufficient RN coverage: 32
Hours of RN coverage on specific days: 1.25
Hours of RN coverage on specific days: 3.02
Hours of RN coverage on specific days: 5.25
Hours of RN coverage on specific days: 2.83
Hours of RN coverage on specific days: 1.48
Hours of RN coverage on specific days: 2.5
Hours of RN coverage on specific days: 1.13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed call light was not within Resident #7's reach |
| Certified Nursing Assistant #1 | CNA | Confirmed call light was not accessible to Resident #7 |
| Director of Nursing | DON | Confirmed call light accessibility failure for Resident #7 and responsible for staffing postings |
| Admissions Director | Confirmed Resident #3 was not provided advance directive information upon admission | |
| Licensed Practical Nurse MDS Coordinator | LPN MDS Coordinator | Confirmed inaccurate MDS assessments for anticoagulant medication |
| Registered Nurse MDS Coordinator | RN MDS Coordinator | Confirmed inaccurate MDS assessments for anticoagulant medication and active diagnoses |
| Unit Manager | UM/LPN MDS Coordinator | Confirmed care plan deficiencies for Residents #31 and #14 |
| Staff Development Coordinator/Infection Control Nurse | SDC/Infection Control Nurse | Confirmed lack of consistent RN coverage on weekends |
| Administrator | Confirmed failure to meet minimum RN coverage requirements | |
| Assistant Administrator | Confirmed failure to meet minimum RN coverage requirements and staffing posting issues | |
| Controller | Confirmed failure to meet minimum RN coverage requirements | |
| Licensed Practical Nurse #2 | LPN | Left medication unsecured on medication cart |
| Dietary Manager | DM | Confirmed kitchen sanitation deficiencies and lack of hot water at handwashing sink |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2023
Visit Reason
The inspection was conducted following a complaint investigation into an incident of alleged physical and mental abuse between two residents at the facility.
Complaint Details
The complaint investigation was substantiated based on video footage, witness statements, and staff interviews confirming that Resident #3 made physical contact with Resident #2 by striking her right cheek. The facility determined abuse occurred and Resident #3 was sent to a Geri-psych inpatient facility.
Findings
The facility substantiated that abuse occurred when Resident #3 struck Resident #2 on the right cheek during an altercation in the dining room. The incident resulted in minimal harm with a small red area on Resident #2's cheek and no acute injury was noted.
Deficiencies (1)
F 0600: Protect each resident from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect. The facility failed to protect Resident #2 from physical and mental abuse by Resident #3 during an incident in the dining room.
Report Facts
Residents Affected: 1
Date Survey Completed: Sep 19, 2023
Size of red area: 2
Inspection Report
Deficiencies: 4
Date: Oct 27, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication administration, drug storage, infection control, and other facility policies.
Findings
The facility was found deficient in maintaining complete medical records, timely medication administration with a high medication error rate, monitoring and documenting medication refrigerator temperatures, and posting required infection control signage for transmission-based precautions.
Deficiencies (4)
F 0578: The facility failed to maintain a complete and accurate medical record for 1 resident, as the Tennessee Physician Orders for Scope of Treatment form was incomplete.
F 0759: The facility failed to administer medications timely to 3 residents, resulting in a medication error rate of 44.8 percent, exceeding the allowed 5 percent.
F 0761: The facility failed to monitor and document daily temperature checks for 2 medication refrigerators as required by policy.
F 0880: The facility failed to maintain infection control practices by not posting required isolation signage on the door of 1 resident under transmission-based precautions.
Report Facts
Medication errors: 14
Medication error rate: 44.8
Undocumented daily temperature checks: 15
Undocumented daily temperature checks: 12
Residents reviewed for medical records: 24
Residents affected by medication errors: 3
Residents sampled for transmission-based precautions: 2
Residents reviewed for infection control: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration delay finding |
| LPN #3 | Licensed Practical Nurse | Named in medication administration delay finding |
| Director of Nursing | Confirmed incomplete POST form and medication administration expectations | |
| Assistant Director of Nursing | Compliance Director | Confirmed medication administration time frames and temperature monitoring policy |
| Physician for Resident #30 | Physician | Interviewed regarding medication administration timing and harm |
| Medical Director | Medical Director | Interviewed regarding medication administration timing and harm |
| Administrator | Administrator | Confirmed infection control signage deficiency |
Document
Deficiencies: 0
Date: Feb 5, 2020
Visit Reason
The document is a Consent Order addressing Horizon Health & Rehab Center's failure to pay nursing home assessment fees for the third and fourth quarters, resulting in disciplinary action by the Tennessee Board for Licensing Health Care Facilities.
Findings
The facility failed to pay four quarterly nursing home assessment fees owed to TennCare that were over ninety days past due. The Board found grounds for disciplinary action based on this violation of Tennessee Code.
Report Facts
Days delinquent: 90
Number of payments missed: 4
License number: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Beth Hopkins | Administrator | Named as Respondent signing the Consent Order. |
| Caroline R. Tippens | Senior Associate General Counsel | Signed the Consent Order on behalf of Tennessee Department of Health. |
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