Manchester Center For Rehabilitation And Healing L
MANCHESTER CENTER FOR REHABILITATION AND HEALING L in MANCHESTER, TN — inspection on September 24, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
orthopedic appointment on the day of the incident. Resident #1's appointment was around .2:30 or 3:00 in the afternoon .the best that I remember .
The Transportation Coordinator stated she was unable to state the exact time they returned to the facility, but it was .probably around 4:00 .
The Transportation Coordinator parked the van in the back of the facility.
This surveyor asked the Transportation Coordinator to describe the weather conditions and temperature at the time of the incident and the Transportation Coordinator stated .it's been a long time .I wish I could .there were tornado warnings and severe storms .
The Transportation Coordinator stated she received a phone call when she returned to the facility from an ambulance company about another resident's appointment and exited the van to go inside to check the calendar.
The Transportation Coordinator stated she had not unloaded Resident #1 from the van when she went inside to check the calendar.
While inside the facility, The Transportation Coordinator received multiple other phone calls about other resident appointments the next day.
The transportation process at the time of was to load the resident into van, take them to the appointment, and unload them and return them to their room.
There was no sign out sheet at the time or checklists to ensure residents were unloaded after transport.
The Transportation Coordinator confirmed she was aware residents were not to be left alone in the van at any time.
The NP received a call from someone (unable to recall who the staff member was or what time it was) at the facility while she and the Transportation Coordinator were together asking if she knew where Resident #1 was and at that time the Transportation Coordinator knew she had forgotten to remove Resident #1 from the van after the appointment.
The Transportation Coordinator was suspended from transportation duties until she had been educated on the new processes.
The new processes included a sign in and out sheet for every transport, safety checklists to be completed before and after every trip, a 2nd attendant in the van during transport for residents depending on their BIMS score, no cell phones in the van except the business cell phone.
The transport coordinator stated there was no one in the van with her at the time of the transport.
The Transportation Coordinator stated she had seen Resident #1 on multiple occasions after the incident and she had no change in her behaviors.
The Transportation Coordinator no longer works at the facility.During a telephone interview on 9/23/2025 at 5:42 PM, the former DON stated she re[TRUNCATED]
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