Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

LEGACY HEALTH AND REHAB

MANCHESTER, TN · 72 certified beds · Last Life Safety survey June 25, 2025

CMS Certification Number 445383 · first certified August 1996

Ownership

Independently operated (no chain recorded by CMS) · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

16
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
4
Inspection & testing records
Of the citations on file

Position within TN

16 citations — more than 83% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 9 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: September 2026 to March 2029. This facility’s last Life Safety survey was June 2025. Facilities in TN are typically surveyed 15–44 months after the last one (median 33), measured over 279 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Emergency preparedness

2 of the 16 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 16 Life Safety citations above. The Physical Environment Index

  • F-0584 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.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.

This facility16TN median8National median11
Citations on file over three years, compared
MeasureCitations
This facility16
Median facility in TN8
Median facility nationally11

Survey history

Citations at each Life Safety survey
22021-1052024-0492025-06
Citations at each Life Safety survey
Survey dateCitations
October 27, 20212
April 10, 20245
June 25, 20259

Most-cited tags

Most-cited tags at this facility
K-02112K-09202K-09231E-00041K-09211E-00311K-07811K-07541
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.22024-04-10
K-0920Ensure proper usage of power strips and extension cords.22025-06-25
K-0923Have proper medical gas storage and administration areas.12025-06-25
E-0004Develop and maintain an Emergency Preparedness Program (EP).12025-06-25
K-0921Ensure that testing and maintenance of electrical equipment is performed.12025-06-25
E-0031Provide emergency officials' contact information.12024-04-10
K-0781Have restrictions on the use of portable space heaters.12025-06-25
K-0754Provide properly sized and located linen or trash receptacles.12025-06-25

What the citations cover

Citations by CMS category
  • Gas, Vacuum, and Electrical Systems Deficiencies 6
  • Miscellaneous Deficiencies 3
  • Emergency Preparedness Deficiencies 2
  • Egress Deficiencies 2
  • Other 3
Citations by CMS category
CategoryCitations
Gas, Vacuum, and Electrical Systems Deficiencies6
Miscellaneous Deficiencies3
Emergency Preparedness Deficiencies2
Egress Deficiencies2
Smoke Deficiencies2
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

June 25, 2025 — 9 citations

Citations issued on June 25, 2025
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (August 1, 2025)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (July 15, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (August 9, 2025)
K-0754Provide properly sized and located linen or trash receptacles.Deficient, Provider has date of correction (August 9, 2025)
K-0781Have restrictions on the use of portable space heaters.Deficient, Provider has date of correction (August 1, 2025)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (August 8, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (August 1, 2025)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (August 8, 2025)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (August 1, 2025)

April 10, 2024 — 5 citations

Citations issued on April 10, 2024
TagWhat the surveyor checksStatus
E-0031Provide emergency officials' contact information.Deficient, Provider has date of correction (May 25, 2024)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (May 25, 2024)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (May 25, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (May 25, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 25, 2024)

October 27, 2021 — 2 citations

Citations issued on October 27, 2021
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (December 3, 2021)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (December 3, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.