The incident occurred after the coordinator drove Resident #1 to an orthopedic appointment that ended around 2:30 or 3:00 in the afternoon. The coordinator parked the van behind Manchester Center for Rehabilitation and Healing around 4:00 PM but never unloaded the resident.
"There were tornado warnings and severe storms," the coordinator told inspectors, though she couldn't recall exact weather details because "it's been a long time."
After parking, the coordinator received a phone call from an ambulance company about another resident's appointment. She left Resident #1 in the van and went inside to check the calendar. While inside, she fielded multiple phone calls about resident appointments scheduled for the next day.
The facility had no sign-out sheet or checklist system to ensure residents were unloaded after transport. The coordinator confirmed she knew residents were never supposed to be left alone in the van.
A nurse practitioner was with the transportation coordinator when someone from the facility called asking if she knew where Resident #1 was. That's when the coordinator realized she had forgotten to remove the resident from the van.
The coordinator was immediately suspended from transportation duties pending education on new safety processes. Those changes included mandatory sign-in and sign-out sheets for every transport, safety checklists before and after every trip, a second attendant in vans for certain residents based on cognitive scores, and restrictions on personal cell phone use during transport.
The coordinator said she had seen Resident #1 multiple times after the incident and noticed no changes in behavior. She no longer works at the facility.
Federal inspectors found the facility violated regulations requiring adequate supervision and assistance to prevent accidents. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The former director of nursing, reached by phone during the inspection, confirmed details of the incident but the inspection report was cut off before recording her complete statement.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manchester Center For Rehabilitation and Healing L from 2025-09-24 including all violations, facility responses, and corrective action plans.
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