Legacy Health and Rehab
811 Keylon Street, Manchester, TN 37355 · Coffee County · (931) 450-5150
72 certified beds, about 51 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1996
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
3 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 445383 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on June 25, 2025, inspectors cited 8 health deficiencies (the Tennessee average is 4.4, the national average 9.2).
None of its 24 health citations since October 2021 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.51 hours per resident per day, against 3.80 across Tennessee and 3.86 nationally. Registered nurses accounted for 0.43 of those hours.
35.4% of nursing staff left within the year CMS measured (Tennessee average 48.9%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
410/21
109/23
1104/24
806/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 24 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
19D
1E
4F
Potential for minimal harm
0A
0B
0C
June 25, 2025Standard inspection · 8 citations
- D 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.
Inspectors wroteBased on facility policy review, observation and interview the facility failed to maintain a safe, clean, homelike environment for 4 residents (Residents #4, #6, #32, and #36) of 24 residents observed.
- D Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on medical record review and interview, the facility failed to refer 2 residents (Residents #4 and #25), after the residents were diagnosed with a serious mental disorder, to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) evaluation and determination of 10 residents reviewed for PASARR.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to develop a person-centered care plan related to smoking for 1 resident (Resident #39) of 14 residents reviewed for care plans.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to revise a comprehensive care plan for 1 Resident (Resident #34) of 14 residents reviewed for care plans.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure a Physician's Order was obtained for oxygen therapy for 2 residents (Residents #4 and #255) of 6 residents reviewed for oxygen therapy.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of the facility policy, review of kitchen equipment cleaning documentation, observation, and interview, the facility failed to ensure kitchen equipment was maintained in a clean and sanitary condition and failed to ensure dietary staff wore protective hair coverings during food preparation in the kitchen, which had the potential to affect 53 of 53 residents residing in the facility.
- D Dispose of garbage and refuse properly.
Inspectors wroteBased on facility policy review, observation, and interviews the facility failed to ensure the outside dumpster area was maintained in a sanitary and orderly condition.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to provide a sanitary environment by failing to clean and store soiled items in a multi-resident bathroom for 1 Resident (Resident #4) of 10 residents observed.
April 10, 2024Standard inspection, Complaint inspection · 11 citations
- F 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.
Inspectors wroteBased 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).
- F Post nurse staffing information every day.
Inspectors wroteBased on facility policy review, observation and interview the facility failed to post accurate staffing information to reflect daily staffing levels.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased 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.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure the call light was in reach for 1 resident (Resident #7) of 52 residents observed for call light accessibility.
- D 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.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to provide a resident with information regarding a resident's right to formulate an advanced directive upon admission to the facility for 1 resident (Resident #3) of 18 residents reviewed for advanced directives.
- D 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.
Inspectors wroteBased on facility policy review, review of a daily room cleaning check off sheet, observations, and interviews the facility failed to maintain a safe, clean, homelike environment for 6 residents (Residents #30, #25, #50, #3, #35, and #17) on 1 of 4 hallways observed.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 Residents (Resident #31, #20, and #14) of 10 Residents reviewed for anticoagulant use, and failed to accurately capture active diagnoses for 1 resident (Resident #14) of 18 resident reviewed for accurate MDS assessments.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan to include a colostomy (a surgical procedure which places a hole in the abdominal wall which allows waste to leave the body) for 1 resident (Resident #31) of 18 residents reviewed for care planning.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to revise a comprehensive care plan to reflect a new fall intervention for 1 resident (Resident #14) of 18 residents reviewed for care plans.
- D 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.
Inspectors wroteBased on facility policy review, observation, and interviews, the facility failed to ensure resident medications were secured in a locked location for 1 resident (Resident #30) of 2 residents reviewed for medication administration.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to ensure appropriate notifications were conducted following a resident fall for 1 resident (Resident #454) of 4 residents reviewed for falls.
September 19, 2023Complaint inspection · 1 citation
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of a facility policy, facility investigation, medical record review, and interview, the facility failed to protect the resident's rights to be free from physical and mental abuse of 1 resident (Resident #2) of 5 reviewed for abuse and neglect.
October 27, 2021Standard inspection · 4 citations
- F 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.
Inspectors wroteBased 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.
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on facility policy review, medical record review, observation, and interview the facility failed to administer medications timely to 3 residents (Residents #46, #30, and #36) observed for medication administration and maintain a medication error rate less than 5 percent as evidenced by 14 medication errors out of 29 medication administration opportunities resulting in a medication error rate of 44.8 percent.
- D 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.
Inspectors wroteBased on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#17) of 24 residents reviewed for medical records.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on professional standards review, facility policy review, record review, observation, and interview, the facility failed to maintain infection control practices to ensure signage was posted on 1 resident's door (Resident #251) of 2 residents sampled for transmission-based precautions of 6 residents reviewed for infection control.
Fire safety inspections
16 fire safety citations on file: 9 on June 25, 2025, 5 on April 10, 2024, 2 on October 27, 2021.
Every fire safety citation16 citations
- F Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F Ensure that testing and maintenance of electrical equipment is performed.
- E Provide properly sized and located linen or trash receptacles.
- D Develop and maintain an Emergency Preparedness Program (EP).
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Inspect, test, and maintain automatic sprinkler systems.
- D Have restrictions on the use of portable space heaters.
- D Ensure proper usage of power strips and extension cords.
- D Have proper medical gas storage and administration areas.
- D Provide emergency officials' contact information.
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D Have generator or other power source capable of supplying service within 10 seconds.
- D Ensure proper usage of power strips and extension cords.
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Tennessee | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.51 | 3.80 | 3.86 |
| Registered nurses | 0.43 | 0.60 | 0.69 |
| All nursing staff on weekends | 3.06 | 3.31 | 3.42 |
| Nurse aides | 1.65 | ||
| Licensed practical nurses | 1.43 | ||
| Nursing staff turnover (share who left in a year) | 35.4% | 48.9% | 45.8% |
| Registered nurse turnover | 40.0% | 43.2% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.47 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.68 on weekdays and 3.06 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.74 in April to June 2025 to 3.51 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.51 | 0.43 | 3.68 | 3.06 | 0.0% | 0 of 90 | 51 |
| Oct to Dec 2025 | 3.79 | 0.46 | 4.07 | 3.06 | 0.0% | 0 of 92 | 47 |
| Jul to Sep 2025 | 3.78 | 0.38 | 4.00 | 3.21 | 0.0% | 0 of 92 | 51 |
| Apr to Jun 2025 | 3.74 | 0.40 | 3.97 | 3.17 | 0.0% | 0 of 91 | 50 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Tennessee, Jan to Mar 2026 | 3.75 | 0.56 | 3.95 | 3.27 | 4.0% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Tennessee | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 9.4 | 14.0 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 2.5 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 3.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.4 | 1.7 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 17.4 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.8 | 5.0 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 20.6 | 16.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 10.8 | 22.6 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 17.8 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.4 | 1.7 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.1 | 1.6 | 1.8 |
Owners and operators
Legal business name: LEGACY HEALTH AND REHAB LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Legacy Health and Rehab LLC | 5% or greater direct ownership interest | Organization | 100% | 09/18/2020 |
| Hopkins, Holly | W-2 managing employee | Individual | 09/18/2020 | |
| Dodge, Rose | Corporate officer | Individual | 09/18/2020 | |
| Legacy Health and Rehab LLC | Operational/managerial control | Organization | 09/18/2020 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 6 problems in this area, most recently on June 25, 2025: "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."
- When is the care plan meeting, and can family attend it?Inspectors cited 6 problems in this area, most recently on June 25, 2025: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 3 problems in this area, most recently on June 25, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on April 10, 2024: "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."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.06 hours per resident per day, below the Tennessee average of 3.31.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Manchester Center for Rehabilitation and Healing L Manchester, 2.1 mi · 4 of 5 stars · 12 citations
- Life Care Center of Tullahoma Tullahoma, 10.1 mi · 2 of 5 stars · 7 citations
- NHC Healthcare, Tullahoma Tullahoma, 10.4 mi · 3 of 5 stars · 13 citations
- Lynchburg Nursing Center Lynchburg, 19.6 mi · 5 of 5 stars · 6 citations
- Heritage Place Care & Rehabilitation LLC Winchester, 19.8 mi · 1 of 5 stars · 6 citations
- Elk River Health & Nursing Center of Winchester Winchester, 20.1 mi · 3 of 5 stars · 9 citations
- Southern Tenn Medical Center SNF Winchester, 20.1 mi · 1 of 5 stars · 11 citations
- Signature Healthcare of Monteagle Rehab & Wellness Monteagle, 21.3 mi · 3 of 5 stars · 20 citations
Tennessee contacts for a concern about a nursing home
These are the official offices in Tennessee. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Tennessee Health Facilities Commission, Division of Licensure and Regulation, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Tennessee Long-Term Care Ombudsman, Department of Disability and Aging, 877-236-0013. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
Common questions
- What is Legacy Health and Rehab's Medicare star rating?
- CMS rates Legacy Health and Rehab 2 out of 5 stars overall, with 2 for health inspections, 3 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Legacy Health and Rehab get at its last inspection?
- 8 health deficiencies at the standard inspection on June 25, 2025. The Tennessee average is 4.4.
- Has Legacy Health and Rehab been fined?
- CMS lists no fines in the last three years.
- Does Legacy Health and Rehab accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Legacy Health and Rehab?
- CMS lists 4 owners and managers. Legal business name: LEGACY HEALTH AND REHAB LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.