01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2022-02-11 | 8 | 2022-02-11 | 4 |
| Cycle 2 | 2019-07-01 | 5 | 2019-07-01 | 2 |
| Cycle 3 | 2018-06-27 | 5 | 2018-06-27 | 6 |
CMS CCN 0154612026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Legacy Health And Rehabilitation Of Pleasant Grove
30 7Th Street · Pleasant Grove, AL 35127 · Jefferson County
Certified beds189CMS provider file
Recent citation rows30current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
30 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2022-02-11 · HEALTHF0553Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Correction field: Deficient, Provider has date of correction · 2022-03-182022-02-11 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-03-182022-02-11 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2022-03-182022-02-11 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-03-182022-02-11 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-03-182022-02-11 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2022-03-182022-02-11 · HEALTHF0814Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Correction field: Deficient, Provider has date of correction · 2022-03-182022-02-11 · HEALTHF0886Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Perform COVID19 testing on residents and staff.
Correction field: Deficient, Provider has date of correction · 2022-03-182022-02-11 · FIREK0131Severity D · isolated; potential for more than minimal harm
Construction Deficiencies
Meet requirements for sections of health care facilities separated by fire resistive construction.
Correction field: Deficient, Provider has date of correction · 2022-03-222022-02-11 · FIREK0225Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2022-03-222022-02-11 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2022-03-222022-02-11 · FIREK0781Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Correction field: Deficient, Provider has date of correction · 2022-03-222019-07-01 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2019-08-302019-07-01 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2019-08-302019-07-01 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2019-08-302019-07-01 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2019-08-302019-07-01 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2019-08-302019-07-01 · FIREK0351Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2019-07-232019-07-01 · FIREK0531Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have elevators that firefighters can control in the event of a fire.
Correction field: Deficient, Provider has date of correction · 2019-07-232018-06-27 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2018-07-312018-06-27 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2018-07-312018-06-27 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2018-07-312018-06-27 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2018-07-312018-06-27 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2018-07-3103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- NORTHPORT HOLDING OPERATIONS, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 05/29/2007
- JAMES N ESTES JR FAMILY DYNASTY TR NO 2Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST18% · since 01/01/2013
- JAMES NORMAN ESTES JR TROrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST6% · since 07/01/2013
- JENNIFER E AGEE FAMILY DYNASTY TR NO 2Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST18% · since 01/01/2013
- JENNIFER LEE ESTES TR 031093Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST6% · since 07/01/2013
- ESTES, JAMESIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST51% · since 05/29/2007
- CAPITAL FUNDING LLCOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 06/01/2012
- CAPITAL FUNDING LLCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 06/01/2012
- HOLDING FACILITIES GROUP LLCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 06/01/2012
- PLEASANT GROVE HEALTH REALTY LLCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 06/01/2012
- SERVISFIRST BANKOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 08/29/2018
- COBB, LEIGHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/24/2023
- MORRIS, HILARYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2023
- RASCO, LYNNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/29/2013
- ESTES, JAMESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/29/2007
- LONG, PHILLIPIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/01/2019
- COBB, LEIGHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/24/2023
- DARBY, MAEGANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/14/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.18per resident day
RN hours0.46per resident day
Weekend nurse hours3.16per resident day
Staff turnover53.2%CMS reported field
06 / LOCAL RECORDS
Open the Pleasant Grove ledger →