Cycle 1
Health 2022-02-11 · Fire 2022-02-11
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Pleasant Grove, AL
Legacy Health And Rehabilitation Of Pleasant Grove
1-star overall rating with 1-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
30 7th Street, Pleasant Grove, AL
(205) 744-8226
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
189
Certified beds
Average residents
131
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nhs Management
Operator or chain grouping
Approved since
2008-01-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
0.86
Licensed practical nurse staffing
Aide hours / resident day
3.23
Nurse aide staffing
Weekend hours
3.43
Weekend nurse staffing
RN turnover
61%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 59.4% |
91.3%
31.9 pts worse
|
93.4%
34 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.0% |
94.8%
12.8 pts worse
|
95.5%
13.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.4%
1 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
1.3%
1.2 pts worse
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.3%
0.2 pts worse
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
24.9%
4.4 pts better
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 28.4% |
22.8%
5.6 pts worse
|
16.7%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.9% |
14.8%
5.9 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
13.4%
0.5 pts worse
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.3%
0.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.8% |
13.5%
7.7 pts better
|
19.8%
14 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.7%
2 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.1% |
84.3%
26.2 pts worse
|
81.7%
23.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.1%
2.1 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.3% |
80.3%
19 pts worse
|
79.7%
18.4 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-01 · Fire 2019-07-01
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2018-06-27 · Fire 2018-06-27
5 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-02-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-22
D · Potential for more than minimal harm
2022-02-11
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-03-22
D · Potential for more than minimal harm
2022-02-11
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-03-22
D · Potential for more than minimal harm
2022-02-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-03-22
D · Potential for more than minimal harm
2019-07-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-07-23
D · Potential for more than minimal harm
2019-07-01
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2019-07-23
F · Potential for more than minimal harm
2018-06-27
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2018-08-06
F · Potential for more than minimal harm
2018-06-27
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2018-08-06
E · Potential for more than minimal harm
2018-06-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-08-06
E · Potential for more than minimal harm
2018-06-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2018-08-06
E · Potential for more than minimal harm
2018-06-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2018-08-06
E · Potential for more than minimal harm
2018-06-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-08-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-02-11
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-03-18
E · Potential for more than minimal harm
2022-02-11
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-03-18
E · Potential for more than minimal harm
2022-02-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-18
E · Potential for more than minimal harm
2022-02-11
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-11
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-02-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-03-18
F · Potential for more than minimal harm
2019-07-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-08-30
D · Potential for more than minimal harm
2019-07-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-30
D · Potential for more than minimal harm
2019-07-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-08-30
D · Potential for more than minimal harm
2019-07-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-08-30
D · Potential for more than minimal harm
2019-07-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-30
F · Potential for more than minimal harm
2018-06-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-07-31
D · Potential for more than minimal harm
2018-06-27
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2018-07-31
D · Potential for more than minimal harm
2018-06-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-07-31
D · Potential for more than minimal harm
2018-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-31
C · Minimal harm
2018-06-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-07-31
Penalties and ownership
What sits behind the stars
Ownership
Northport Holding Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Estes, James
5% Or Greater Indirect Ownership Interest · Individual
James N Estes Jr Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
Jennifer E Agee Family Dynasty Tr No 2
5% Or Greater Indirect Ownership Interest · Organization
James Norman Estes Jr Tr
5% Or Greater Indirect Ownership Interest · Organization
Jennifer Lee Estes Tr 031093
5% Or Greater Indirect Ownership Interest · Organization
Capital Funding LLC
5% Or Greater Security Interest · Organization
Capital Funding LLC
5% Or Greater Mortgage Interest · Organization
Cobb, Leigh
Operational/Managerial Control · Individual
Cobb, Leigh
Corporate Director · Individual
Darby, Maegan
Operational/Managerial Control · Individual
Estes, James
Corporate Officer · Individual
Holding Facilities Group LLC
5% Or Greater Security Interest · Organization
Long, Phillip
Corporate Officer · Individual
Morris, Hilary
Operational/Managerial Control · Individual
Morris, Hilary
Corporate Director · Individual
Pleasant Grove Health Realty LLC
5% Or Greater Security Interest · Organization
Rasco, Lynn
Operational/Managerial Control · Individual
Rasco, Lynn
Corporate Director · Individual
Servisfirst Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Caregivers Of Pleasant Grove, Inc
Pleasant Grove, AL
1-star overall rating with 2-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Self Skilled Nursing & Rehab
Hueytown, AL
1-star overall rating with 1-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Baron House Of Hueytown
Hueytown, AL
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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