Legacy Health and Rehab
Manchester, Tennessee · CCN 445383
18 surveys since 2010, 1 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 83
- Surveys
- 18
- Harm or worse
- 1
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 72
- Ownership
- For profit - Limited Liability company
- Chain
- Independent
- County
- Coffee · rural
- Medicare-certified since
- 1996
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 3
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 63 for-profit facilities of 66–99 beds in Tennessee.
Last survey on record
Jun 25, 2025
502 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.51 | 3.49 |
| Registered-nurse hours per resident day | 0.43 | — |
| Annual nurse turnover | 35.4% | 52.6% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1979.2% | E14.2% | F416.7% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5782×
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.
- F5842×
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.
- F6562×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F7612×
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.
In the surveyor’s words
From the most serious findings on record at Legacy Health and Rehab, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF812Jun 24, 2026
Based on facility policy review, observation, and interview, the facility failed to maintain sanitary kitchen equipment in 1 of 1 kitchen observed. The facility's failure had the potential to affect 49 of 49 residents.The findings include: Review of the facility policy titled, Dietary Cleaning and Sanitation Policy, undated, revealed, .The Dietary Department shall maintain all kitchen, food storage, food preparation, service, and dishwashing areas in a clean and sanitary condition at all times. Cleaning and sanitizing activities shall be performed according to established schedules and procedures. All dietary staff are responsible for maintaining sanitation standards .equipment shall be cleaned and sanitized after each use . […]
- No harm, potential for more than minimal, widespreadF727Apr 10, 2024
Based on review of the facility's Payroll Based Journal (PBJ) report dated 10/1/2023-12/31/2023, daily nursing staff posting sheets, time clock punches, and interviews, the facility failed to provide the minimum requirement of 8 hours per day of Registered Nurse (RN) coverage on 20 days reviewed on the PBJ report and 12 days reviewed on 1/1/2024-4/10/2024 (not a PBJ report). The findings include: Review of the facility's PBJ dated 10/1/2023-12/31/2023 showed the following dates with no RN coverage: 10/7/2023 (Saturday), 10/14/2023 (Saturday), 10/15/2023 (Sunday), 10/29/2023 (Sunday), 11/4/2023 (Saturday), 11/5/2023 (Sunday), 11/12/2023 (Sunday), 11/18/2023 (Saturday), 11/26/2023 (Sunday), 12/2/2023 Saturday), 12/10/2023 (Sunday), 12/24/2023 (Sunday), and 12/31/2023 (Sunday). […]
- No harm, potential for more than minimal, widespreadF732Apr 10, 2024
Based on facility policy review, observation and interview the facility failed to post accurate staffing information to reflect daily staffing levels. The findings include: Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 7/2016, showed .Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents During an observation on 4/8/2024 at 7:40 AM, of the daily nurse staffing showed the staffing information posted was the staff scheduled for 4/5/2024 and had not been updated to reflect the current staff in the facility on 4/8/2024. […]
- No harm, potential for more than minimal, widespreadF812Apr 10, 2024
Based on facility policy review, observations, and interviews, the failed to ensure there was hot water was available for staff to wash/sanitize their hands in 1 of 2 kitchen hand washing sinks. The facility failed to maintain kitchen equipment in a sanitary manner and failed to ensure the kitchen floor was maintained in a sanitary manner, which had the potential to affect 52 of 52 residents. The findings include: Review of the facility policy titled, Sanitization, revised 10/2008, showed .All .kitchen areas .shall be kept clean .free from litter and rubbish .all equipment shall be kept clean .washed to remove soils .using mechanical means necessary . […]
- No harm, potential for more than minimal, widespreadF761Oct 27, 2021
Based on facility policy review, observation, and interview, the facility failed to monitor and document daily temperature checks for 2 medication refrigerators (400 hall and 600 hall) of 2 medication refrigerators sampled. The findings include: Review of the facility policy titled Refrigerators and Freezers dated December 2014, showed .Monthly tracking sheets for all refrigerators and freezers will be posted .Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily . […]
Read 21 findings in full →The most serious and the most recent: 21 of 83 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 24, 2026Standard3 findings
- Jun 25, 2025Standard8 findings
- Apr 10, 2024Standard and complaint11 findings
- Sep 19, 2023Complaint1 finding
- Nov 29, 2021Complaint1 finding
- Oct 27, 2021Standard4 findings
- Aug 29, 2019Complaint1 finding
- Apr 3, 2019Standard6 findings
Show the 10 earlier surveys
- Feb 20, 2019Complaint2 findings
- Apr 4, 2018Standard and complaint2 findings
- Mar 8, 2017Standard6 findings
- Mar 9, 2016Standard3 findings
- Jan 28, 2015Standard2 findings
- Jan 30, 2014—1 finding
- Dec 4, 2013—11 findings
- Nov 7, 2012—5 findings
- May 12, 2011—15 findings · 1 harm
- Jun 9, 2010—1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction