Manchester Center: Resident Left in Van During Storms - TN
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
MANCHESTER CENTER FOR REHABILITATION AND HEALING L in MANCHESTER, TN was cited for violations during a health inspection on September 24, 2025.
The incident occurred after the coordinator drove Resident #1 to an orthopedic appointment that ended around 2:30 or 3:00 in the afternoon.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.