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
Chain footprint
43 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.23
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
5.49
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,673
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9962
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.80
Performance 52.23% · Measure score 2.80 · Achievement 2.80 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.84
Baseline 4.11 hours · Performance 4.74 hours · Measure score 5.84 · Achievement 5.84 · Improvement 3.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 137 |
| Staff flu vaccination coverage | 18.59% |
42%
23.4 pts worse
|
Numerator 37 · Denominator 199 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
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 · Q1 56.5% · Q2 52.3% · Q3 62.9% · Q4 65.9% · 4Q avg 59.4% |
| 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 · 4Q avg 82.0% |
| 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 · Q1 0.8% · Q2 2.3% · Q3 3.2% · Q4 3.2% · 4Q avg 2.4% · Used in QM five-star |
| 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 · Q1 1.8% · Q2 2.9% · Q3 3.8% · Q4 1.7% · 4Q avg 2.5% |
| 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 · Q1 0.9% · Q2 4.1% · Q3 9.6% · Q4 7.8% · 4Q avg 5.5% |
| 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 · Q1 19.5% · Q2 19.5% · Q3 21.7% · Q4 21.2% · 4Q avg 20.5% |
| 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 · Q1 34.5% · Q2 30.1% · Q3 26.4% · Q4 23.1% · 4Q avg 28.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 15.8% · Q2 2.6% · Q3 8.9% · Q4 8.5% · 4Q avg 8.9% · Used in QM five-star |
| 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 · Q1 17.6% · Q2 9.7% · Q3 17.1% · Q4 11.4% · 4Q avg 13.9% · Used in QM five-star |
| 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 · Q1 1.2% · Q2 1.2% · Q3 0.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| 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 · Q1 2.5% · Q2 2.3% · Q3 1.6% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| 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 · Q1 6.6% · Q2 1.7% · Q3 5.8% · Q4 9.3% · 4Q avg 5.8% |
| 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 · Q1 10.2% · Q2 12.0% · Q3 3.0% · Q4 5.5% · 4Q avg 7.7% · Used in QM five-star |
| 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 · Q1 41.5% · Q2 61.3% · Q3 62.3% · Q4 68.3% · 4Q avg 58.1% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 61.3% |
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
Jump out