Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LEGACY HEALTH AND REHABILITATION OF PLEASANT GROVE
PLEASANT GROVE, AL · 189 certified beds · Last Life Safety survey February 11, 2022
CMS Certification Number 015461 · first certified January 2008
Ownership
Operated by NHS MANAGEMENT · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within AL
12 citations — more than 66% of the 224 certified nursing homes in AL. Compared within AL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2023 to July 2023), and past the point by which nine in ten US facilities have been surveyed. This facility’s last Life Safety survey was February 2022. Nursing homes nationally are typically surveyed 12–17 months after the last one (median 14), measured over 19,385 consecutive surveys in the last two years of CMS records. AL has too few recent surveys to measure on its own, so the national interval is used.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 12 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in AL, and nationally. Surveyors differ markedly between states, so the AL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 12 |
| Median facility in AL | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 27, 2018 | 6 |
| July 1, 2019 | 2 |
| February 11, 2022 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2018-06-27 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1 | 2022-02-11 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2022-02-11 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 1 | 2018-06-27 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2018-06-27 |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 1 | 2022-02-11 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2018-06-27 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2018-06-27 |
What the citations cover
- Smoke Deficiencies 7
- Services Deficiencies 1
- Miscellaneous Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Services Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Construction Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 11, 2022 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (March 22, 2022) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (March 22, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 22, 2022) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (March 22, 2022) |
July 1, 2019 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 23, 2019) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (July 23, 2019) |
June 27, 2018 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 6, 2018) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (August 6, 2018) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (August 6, 2018) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 6, 2018) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 6, 2018) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 6, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.