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Legacy Health And Rehabilitation Of Pleasant Grove

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About Legacy Health And Rehabilitation Of Pleasant Grove

General Information

Legal Business NameLegacy Health And Rehabilitation Of Pleasant Grove, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJanuary 15, 2008 (9 years)
Capacity198
Residents121
Percent Occupied61%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Legacy Health And Rehabilitation Of Pleasant Grove

Legacy Health And Rehabilitation Of Pleasant Grove
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Alabama Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

April 1, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
ESomePotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
ESomePotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CManyPotential for Minimal HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
DFewPotential for HarmFire Safety InspectionPortable fire extinguishers.

March 26, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$4,550 fine
DFewPotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
DFewPotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

April 16, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionPortable fire extinguishers.
ESomePotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
DFewPotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
DFewPotential for HarmFire Safety InspectionProper medical gas storage and administration areas.
DFewPotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
DFewPotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
DFewPotential for HarmFire Safety InspectionFire resistant room wall surfaces.

April 10, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaint+InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaint+InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmComplaint+InspectionReview or revise the resident's care plan after any major change in physical or mental health.
DFewPotential for HarmComplaint+InspectionProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
DFewPotential for HarmComplaint+InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmHealth InspectionGive or get specialized rehabilitative services per the patient's assessment or plan of care.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Legacy Health And Rehabilitation Of Pleasant Grove require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 40min
2hr 35min
ReportedExpected
CNA
1hr
45min
ReportedExpected
LPN
35min
1hr 10min
ReportedExpected
RN
4hr 15min
4hr 25min
ReportedExpected
Total Nursing

This facility also provides approximately 20min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

100.0%
100.0%
100.0%
93.5%
Q1 2015Q2 2015Q3 2015AL
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
99.0%
92.9%
92.9%
Q1 2015Q2 2015Q3 2015AL
Assessed and Appropriately Given the Pneumococcal Vaccine
35.1%
35.7%
37.8%
39.6%
Q1 2015Q2 2015Q3 2015AL
Low Risk Residents Who Lose Control of Their Bowel or Bladder
22.9%
18.9%
22.1%
20.9%
Q1 2015Q2 2015Q3 2015AL
Received an Antipsychotic Medication
21.1%
15.3%
1.3%
13.7%
Q1 2015Q2 2015Q3 2015AL
Need for Help with ADLs has Increased
0.0%
5.0%
2.4%
7.4%
Q1 2015Q2 2015Q3 2015AL
Self Report Moderate to Severe Pain
8.2%
14.0%
14.3%
8.6%
Q1 2015Q2 2015Q3 2015AL
Lose Too Much Weight
11.3%
11.4%
9.1%
5.7%
Q1 2015Q2 2015Q3 2015AL
High Risk Residents With Pressure Ulcers
0.0%
0.0%
0.0%
1.6%
Q1 2015Q2 2015Q3 2015AL
Have Depressive Symptoms
3.1%
2.0%
5.1%
4.9%
Q1 2015Q2 2015Q3 2015AL
With a Urinary Tract Infection
0.0%
2.0%
2.0%
3.3%
Q1 2015Q2 2015Q3 2015AL
Experiencing One or More Falls with Major Injury
3.1%
4.2%
5.1%
2.8%
Q1 2015Q2 2015Q3 2015AL
With a Catheter Inserted and Left in Their Bladder
4.1%
2.9%
2.0%
1.1%
Q1 2015Q2 2015Q3 2015AL
Were Physically Restrained

Quality Measures for Short Stay Residents

47.6%
39.3%
26.9%
82.1%
Q1 2015Q2 2015Q3 2015AL
Assessed and Appropriately Given the Pneumococcal Vaccine
35.5%
33.1%
33.1%
81.3%
Q1 2015Q2 2015Q3 2015AL
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
6.5%
4.7%
1.7%
14.8%
Q1 2015Q2 2015Q3 2015AL
Self Report Moderate to Severe Pain
3.6%
0.0%
3.4%
2.5%
Q1 2015Q2 2015Q3 2015AL
Newly Received an Antipsychotic Medication
0.0%
0.0%
0.0%
0.7%
Q1 2015Q2 2015Q3 2015AL
With Pressure Ulcers That Are New or Worsened