Cycle 1
Health 2025-06-25 · Fire 2025-06-25
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Manchester, TN
Legacy Health And Rehab
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
811 Keylon Street, Manchester, TN
(931) 450-5150
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.58
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
7,372
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.25
Baseline 19.24% · Performance 18.54% · Measure score 6.25 · Achievement 6.25 · Improvement 2.69
Healthcare-associated infections
1.17
Baseline 7.19% · Performance 7.49% · Measure score 1.17 · Achievement 1.17 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.56
Baseline 3.33 hours · Performance 3.52 hours · Measure score 1.56 · Achievement 1.56 · Improvement 0.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.63% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 13.51% · Lower 95% interval 8.47% |
| Discharge to community | 37.65% |
50.57%
12.9 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 24.32% · Lower 95% interval 23.65% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 41 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 31.03% |
53.69%
22.7 pts worse
|
Numerator 9 · Denominator 29 |
| Discharge mobility score | 13.79% |
50.94%
37.1 pts worse
|
Numerator 4 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 9.76% |
2.29%
7.5 pts worse
|
Numerator 4 · Denominator 41 · Adjusted rate 6.95% |
| Healthcare-associated infections requiring hospitalization | 7.48% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 8.82% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 2.41% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 83 |
| Staff flu vaccination coverage | 11.76% |
42%
30.2 pts worse
|
Numerator 12 · Denominator 102 |
| Discharge function score | 20.69% |
56.45%
35.8 pts worse
|
Numerator 6 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45.83% |
25.2%
20.6 pts better
|
Numerator 11 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
89.9%
5.9 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 97.9% · Q3 97.9% · Q4 100.0% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
94.5%
1.6 pts better
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.1% |
11.8%
9.3 pts worse
|
11.4%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 18.2% · Q3 14.3% · Q4 28.9% · 4Q avg 21.1% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
6.2%
2.7 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.3% · Q3 4.8% · Q4 11.9% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 49.4% |
32.2%
17.2 pts worse
|
19.6%
29.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.8% · Q2 47.7% · Q3 47.6% · Q4 46.5% · 4Q avg 49.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.7% |
18.1%
11.6 pts worse
|
16.7%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.0% · Q2 44.0% · Q3 12.0% · Q4 15.4% · 4Q avg 29.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.0% |
19.9%
8.1 pts worse
|
16.3%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
15.3%
1.2 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 18.9% · Q3 6.1% · Q4 11.1% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.5% |
0.9%
1.6 pts worse
|
1.0%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 1.9% · Q4 4.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.9%
1.4 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.0% |
20.2%
6.2 pts better
|
19.8%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 10.0% · Q3 16.5% · Q4 7.3% · 4Q avg 14.0% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.4%
1 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.2% · Q3 3.6% · Q4 1.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 51.3% |
79.6%
28.3 pts worse
|
81.7%
30.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 39.3% · Q2 57.1% · Q3 58.1% · Q4 50.0% · 4Q avg 51.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
11.2%
0.4 pts worse
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 13.5% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.0% |
1.6%
5.4 pts worse
|
1.6%
5.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.9% |
79.8%
3.9 pts worse
|
79.7%
3.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
22.2%
2.5 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 21.6% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-10 · Fire 2024-04-10
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-10-27 · Fire 2021-10-27
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-25
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-06-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-06-25
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-08-09
D · Potential for more than minimal harm
2025-06-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-09
D · Potential for more than minimal harm
2025-06-25
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-01
D · Potential for more than minimal harm
2024-04-10
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-25
D · Potential for more than minimal harm
2024-04-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-25
D · Potential for more than minimal harm
2021-10-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-12-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-25
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-25
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-08-09
D · Potential for more than minimal harm
2025-06-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-06-25
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-08-04
D · Potential for more than minimal harm
2025-06-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-01
F · Potential for more than minimal harm
2024-04-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-10
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-10
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-09-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-25
F · Potential for more than minimal harm
2021-10-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-27
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2021-12-10
D · Potential for more than minimal harm
2021-10-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-03
Penalties and ownership
What sits behind the stars
Ownership
Legacy Health And Rehab LLC
5% Or Greater Direct Ownership Interest · Organization
Dodge, Rose
Corporate Officer · Individual
Hopkins, Holly
W-2 Managing Employee · Individual
Legacy Health And Rehab LLC
Operational/Managerial Control · Organization
Nearby options
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4-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Tullahoma
Tullahoma, TN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Nhc Healthcare, Tullahoma
Tullahoma, TN
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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