Inspection Reports for Manchester Center for Rehabilitation and Healing, LLC
395 Interstate Drive, Manchester, TN, 37355-3108
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation after a resident was found locked inside a facility van for an extended period following transportation to a medical appointment.
Complaint Details
The complaint involved an allegation of deprivation of goods and services by staff when Resident #1 was left unattended in a locked transport van for several hours on 5/8/2024. The allegation was substantiated as past non-compliance with no physical or mental harm to the resident. The incident was reported to multiple agencies including police, EMS, APS, and the Ombudsman, all of whom were satisfied with the facility's response and corrective actions.
Findings
The facility failed to ensure that Resident #1 was unloaded from the transport van and returned to her room after a medical appointment, resulting in the resident being locked inside the van for an estimated 3 to 4 hours during severe weather conditions. Multiple assessments found no physical or mental harm to the resident, and corrective actions including policy updates and staff reeducation were implemented.
Deficiencies (1)
Failed to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Facility census: 108
Duration resident locked in van: 3
Distance to orthopedic surgeon: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Discovered Resident #1 locked in the van and called 911 |
| Transportation Coordinator | Failed to unload Resident #1 from the van after medical appointment | |
| NP | Nurse Practitioner | Assessed Resident #1 after incident and was present during discovery of the resident in the van |
| Director of Nursing | Director of Nursing | Assessed Resident #1 post-incident and involved in investigation |
| Director of Maintenance | Director of Maintenance | Assisted in gaining access to the van and moving the vehicle |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 7, 2022
Visit Reason
The inspection was conducted to investigate allegations of abuse involving two residents and to review compliance with pre-admission screening and resident review (PASARR) referrals, food safety, and infection control practices.
Complaint Details
The complaint investigation focused on allegations of abuse involving Residents #40 and #96. The facility failed to thoroughly investigate the abuse allegations, lacking witness statements from involved staff and residents. The investigation was triggered by an incident on 10/5/2022 where Resident #40 reported being slapped and scratched by Resident #96.
Findings
The facility failed to thoroughly investigate allegations of abuse for two residents, failed to submit new PASARR referrals for five residents with newly identified mental health disorders, had expired food products in storage, and did not maintain appropriate infection control practices for a resident on contact isolation for C. difficile.
Deficiencies (4)
Failed to provide evidence that allegations of abuse were thoroughly investigated for 2 residents.
Failed to make a referral to the state-designated authority for Level II PASARR after new mental health diagnoses for 5 residents.
Procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards; found expired flour tortillas 9 days past expiration.
Failed to ensure appropriate infection control practices for 1 resident on contact isolation for C. difficile; no signage indicating isolation precautions and PPE requirements, and phlebotomist was unaware of isolation status.
Report Facts
Residents reviewed for abuse: 4
Residents reviewed for PASARR: 23
Expired food product days: 9
Residents affected by infection control deficiency: 1
Residents potentially affected by infection control deficiency: 11
Residents on transmission-based precautions reviewed: 5
Laboratory specimens obtained by phlebotomist: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Documented the abuse incident and investigation on 10/5/2022. |
| CNA #1 | Certified Nursing Assistant | Cared for Residents #40 and #96 on the night of the altercation and provided interview statements. |
| DON | Director of Nursing | Confirmed lack of witness statements and infection control deficiencies. |
| [NAME] O'Keefe | Dietary Manager | Interviewed regarding food safety and kitchen operations. |
| [NAME] | Registered Dietician | Interviewed regarding dietary policies and resident diets. |
| Phlebotomist #1 | Phlebotomist | Obtained laboratory specimens and was unaware of resident isolation status. |
| LPN #1 | Licensed Practical Nurse | Informed Phlebotomist #1 about isolation status and confirmed lack of signage. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 7, 2019
Visit Reason
The inspection was conducted due to a complaint alleging failure to timely report and investigate an allegation of abuse involving Resident #33.
Complaint Details
The complaint involved Resident #33 whose daughter reported that a Certified Nurse Assistant (CNA #2) was verbally abusive and caused fear in the resident. The facility failed to report this allegation within the required 2-hour timeframe and delayed the investigation by one day.
Findings
The facility failed to immediately report an allegation of abuse to the Administrator and State Survey Agency within 2 hours and failed to initiate an immediate investigation of the abuse allegation. Additionally, the facility failed to perform proper hand hygiene after providing direct resident care for Resident #32.
Deficiencies (3)
Failed to timely report suspected abuse to proper authorities within 2 hours.
Failed to initiate an immediate investigation of an allegation of abuse.
Failed to perform proper hand hygiene after providing direct resident care.
Report Facts
Residents reviewed for abuse: 24
Residents sampled for hand hygiene observation: 17
Residents observed for hand hygiene compliance: 3
Brief Interview for Mental Status score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Named in verbal abuse allegation against Resident #33 |
| Certified Nurse Assistant #3 | Certified Nurse Assistant | Failed to perform proper hand hygiene after resident care |
| Social Service Director | Received grievance report and reported it to Director of Nursing one day later | |
| Director of Nursing | Director of Nursing | Was informed of grievance one day after report and delayed investigation |
| Administrator | Administrator | Confirmed failure to timely report abuse allegation to proper authorities |
| Infection Prevention Nurse | Infection Prevention Nurse | Confirmed staff expectations for hand hygiene and facility policy failure |
Inspection Report
Deficiencies: 3
Date: Jun 20, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to treatment and care according to physician orders and food safety and sanitation in the facility.
Findings
The facility failed to perform ordered lab tests for one resident and failed to ensure expired or unlabeled food items were not available for resident use. Additionally, kitchen equipment and floors were not maintained in a clean and sanitary manner, potentially affecting all residents.
Deficiencies (3)
Failed to perform lab tests ordered by the Physician for 1 resident (#24) related to HA1C testing.
Failed to ensure expired foods were not available for resident use in refrigerators, stock rooms, and nourishment refrigerators.
Failed to maintain kitchen equipment and floors in a clean and sanitary manner, including greasy ovens and dirty floors.
Report Facts
Residents affected: 1
Residents affected: 66
Expired food items: 31
Expired food items: 26
Expired food items: 9
Expired food items: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Confirmed HA1C not done in February 2018 | |
| Director of Nursing | Confirmed failure to follow Physician orders for HA1C and confirmed expired food in nourishment refrigerator | |
| Interim Dietary Manager | Confirmed expired food items in refrigerators and stock room and need for kitchen cleaning | |
| Administrator | Acknowledged need for improvements and expectation for new Dietary Manager to deep clean | |
| Certified Dietary Manager | Confirmed ovens and floor needed deep cleaning |
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