LEGACY HEALTH AND REHABILITATION OF PLEASANT GROVE (PLEASANT GROVE, AL) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	14.3%
State:	13.9%

Percent of long-stay residents who self-report moderate to severe pain

This Nursing Home:	12.1%
Alabama:	9.6%

Percent of long-stay high-risk residents with pressure ulcers

Here:	15.0%
State:	5.9%

Percent of long-stay residents who lose too much weight

This Nursing Home:	3.3%
State:	8.1%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

This Nursing Home:	3.2%
State:	3.4%

Percent of long-stay residents with a urinary tract infection

Here:	5.4%
State:	5.7%

Percent of long-stay residents who were physically restrained

Here:	2.0%
State:	1.6%

Percent of long-stay residents experiencing one or more falls with major injury

Here:	2.0%
State:	3.0%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	100.0%
Alabama:	95.1%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	100.0%
State:	91.7%

Percent of short-stay residents who self-report moderate to severe pain

This Nursing Home:	14.5%
State:	19.6%

Percent of short-stay residents with Pressure ulcers that are new or worsened

Here:	0.8%
State:	0.9%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	98.4%
State:	87.4%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	100.0%
Alabama:	83.6%

Percent of short-stay residents who newly received an antipsychotic medication

This Nursing Home:	1.7%
State:	3.2%

Percent of long-stay residents who received an antipsychotic medication

Here:	44.0%
Alabama:	27.0%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.670
State:	0.613

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	1.210
State:	1.059

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.880
State:	1.672

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.050
State:	0.045

Number Therapy Hours Per Resident Per Day

Here:	0.050
State:	0.048

Complaint Deficiency

Restrictions on the use of flammable curtains
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide special eating equipment and utensils for each resident who needs them
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridors that are separated from common areas by walls constructed to limit the passage of smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Signs that state that exit doors are to be kept closed
- Harm: Potential for minimal harm
- Scope: Many
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
- Harm: Potential for minimal harm
- Scope: Many

LEGACY HEALTH AND REHABILITATION OF PLEASANT GROVE - PLEASANT GROVE, AL

Quality Measures

Staff Information

Complaint Deficiency

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