Legacy Health And Rehabilitation Of Pleasant Grove

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 189 beds and averages 133.6 residents a day — about 71% occupied, or roughly 55 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.85 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.16 hrs/resident/day on weekends vs 4.60 on weekdays — 31% thinner on weekends — a notable drop. RN hours go from 0.57 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 4 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.

• Potential for harm · F2022-02-11 · tag F0814 — failed to dispose of garbage properly — widespread
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and review of the facility policies titled, Sanitation Principles and Garbage and Refuse, the facility failed to dispose of garbage and refuse in a sanitary method and in accordance with their policy. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: A review of the dietary policy titled, Sanitation Principles, dated 08/10/2018, revealed: .Refuse containers and dumpsters outside the nursing facility should have tight fitting lids and should be kept covered when not actually being loaded. The areas around the dumpster should be kept free of debris . A review of the dietary policy titled, Garbage and Refuse, dated 02/01/2002, revealed: .Dumpsters should be emptied according to the facility contract; garbage should not accumulate or be left outside the dumpster . Per the policy, The schedule for garbage pick-up should be revised, as needed, based on the volume of refuse. During the initial tour of the kitchen, on 02/08/2022 at 9:23 AM, the surveyor observed the single dumpster on the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-02-11 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and observations, the facility failed to ensure: 1. Resident Identifier (RI) #107's electrical outlet was repaired, which had detached from the wall and was hanging by electrical wire approximately one to two feet from the resident while in bed; and 2. a handrail between a resident room and the linen room was securely affixed to the wall. This deficient practice affected one of 42 sampled residents and was observed with handrails located on one of four units in the facility. Findings include: 1. Resident Identifier (RI) #107 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], revealed the Staff Assessment for Mental Status indicated the resident had severely impaired decision-making skills. On 02/08/2022 at 11:08 AM, observation revealed RI #107's electrical outlet close to the bed was sticking out of the wall. On 02/10/2022 at 10:56 AM, EI #27, Maintenance and Environmental Services Director, observed RI #107's room. At that time, EI…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-02-11 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of a facility policy titled, Medication Administration - General Guidelines, the facility failed to maintain a medication error rate less than 5%. There were 3 errors in 26 opportunities, which resulted in a 11.54% medication error rate involving Resident Identifier (RI) #59 and RI #93 during medication pass. Specifically, the facility failed to ensure: 1. RI #59 received a multivitamin and chewable aspirin as ordered by the physician; and 2. RI #93 received the correct dilution of an intravenous medication. This deficient practice affected RI #59 and RI #93, two of seven residents observed during medication pass. Findings included: A review of a facility policy titled, Medication Administration - General Guidelines, dated 03/2011, revealed, .Procedures . 2. Medications are administered in accordance with written orders of the attending physician . 1. RI #59 was admitted to the facility on [DATE] with diagnoses to include Essential Hypertension. RI…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-02-11 · tag F0886 — failed to test for COVID-19 as required — pattern
  Perform COVID19 testing on residents and staff.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and review of an Abbott BinaxNOW COVID-19 Ag procedure card, the facility failed to ensure proper administration of the COVID-19 test for Employee Identifier (EI) # 27, the Maintenance and Environmental Services Director, on 02/08/2022, when the result of his COVID-19 testing card was interpreted as negative before completion of the 15 minute required testing time-frame. This was observed during one of three observations of staff performing COVID-19 testing. Findings include: A review of an Abbott BinaxNOW COVID-19 Ag procedure card directed the user, in part, to Peel off adhesive liner from the right edge of the test card. Close and securely seal the card. Read result in the window 15 minutes after closing the card. In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. Results should not be read after 30 minutes. On 02/08/2022 at 8:47 AM., the surveyor observed EI #27, Maintenance and Environmental Services Director, walk up to a table and retrieve testing packages out of a box…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-02-11 · tag F0553 — failed to let residents help plan their care — isolated
  Allow resident to participate in the development and implementation of his or her person-centered plan of care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of a facility policy titled, Person Centered Care Plans, the facility failed to ensure Resident Identifier (RI) #83 was invited to participate in care plan meetings. The deficient practice affected RI #83, one of one resident sampled for care plan meetings. Findings include: A review of facility policy titled, Person Centered Care Plans, with an effective date of 08/15/2018, revealed: . b. When the resident/guest is unable to participate in the care plan meeting (due to illness or cognitive impairments) the resident/guest(s) family members should be encouraged to attend, in behalf of the resident/guest, as permitted by the resident/guest. Family participation should be recorded in the EMR [electronic medical record] . II. Preparation for Care Plan Committee Meetings . c. The Social Service, or other designee, should inform the resident/guest and families of the scheduled meeting . A quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-02-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, observations, and review of a facility policy titled, Hygiene and Grooming, the facility failed to ensure Resident Identifier (RI) #52 received assistance with personal grooming. This deficient practice affected RI #52, one of two residents sampled for activities of daily living. Findings include: A review of a facility policy titled, Hygiene and Grooming, with an effective date of 10/01/2010, revealed, Guidelines for the provision of hygiene and grooming services are . Shaving daily or as needed. RI #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Adjustment Disorder with Depressed Mood, Unspecified Dementia Without Behavioral Disturbance, Gastrostomy Status, and Unspecified Anxiety Disorder. RI #52's significant change Minimum Data Set (MDS) assessment, dated 12/01/2021, revealed RI #52 had severely impaired decision-making skills and was totally dependent on one staff member for personal hygiene tasks. A review of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-02-11 · tag F0693 — failed to provide proper feeding-tube care — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, observations, and review of a facility policy titled, Enteral Tube Administration, the facility failed to ensure Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN), did not manually use the plunger of a syringe to force medications into Resident Identifier (RI) #34's percutaneous endoscopic gastrostomy tube during medication administration on 02/10/2022. This deficient practice affected RI #34, one of one resident observed receiving medications via percutaneous endoscopic gastrostomy tube during medication pass observations Findings include: A review of a facility policy titled, Enteral Tube Administration, dated 03/2011, revealed, .Medications are administered via feeding tube in a safe and accurate manner when the resident is unable to take medication by mouth. The policy did not indicate to manually push medication or water flushes with the plunger of the syringe. RI #34 was admitted to the facility on [DATE] with diagnoses to include Dysphagia,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-02-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of a policy titled, Medication Monitoring Antipsychotics, the facility failed to monitor behaviors for Resident Identifier (RI) #45 who was receiving the psychotropic medication Seroquel (antipsychotic). This deficient practice affected RI #45, one of seven residents reviewed for psychotropic medication use and behavior monitoring. Findings include: A review of the facility policy, Medication Monitoring Antipsychotics, dated 03/2011, revealed, .Policy Antipsychotic medications are monitored and dosages evaluated in an effort to ensure the resident receives the lowest effective dose with minimal side effects. Procedures: 1. Antipsychotics are given only if the resident has been diagnosed with one of the following indications .and the diagnosis is documented in the medical record . l. Dementing illness with associated behaviors . 2. In addition, the use of an antipsychotic must meet at least one of the following criteria: A. The symptoms are deemed as…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2019-07-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of the Food and Drug Administration (FDA) 2017 Food Code, the facility failed to: 1) prevent the potential for cross contamination by ensuring there were air gaps between the floor drain and the drain pipes from the dishwasher and the pot and pan sinks, 2) ensure the drain pipe of the only handwashing sink in the dishroom was connected to the sink so that it could be functional for staff use, and 3) ensure three of ten air vents in the kitchen were clean and free of a black substance, identified by facility staff as mold. This had the potential to affect all residents receiving meals from the facility, 119 of 125 residents. Findings include: 1) The 2017 FDA Food Code included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. An initial tour of the kitchen was conducted on 6/11/19 at 9:56 a.m. with Employee Identifier (EI) #1, the Food and Nutrition Supervisor (FNS). At 10:49 a.m.,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2019-07-01 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and a document titled RAI (Resident Assessment Instrument) Version 3.0 Manual the facility failed to ensure Resident Identifier (RI) # 168's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/11/19 accurately reflected the residents level of assistance needed with transfers. This affected RI # 168, one of 31 sampled residents for whom MDS assessments were reviewed. Findings Include: RI #168 was admitted to the facility on [DATE]. A review of a document titled RAI Version 3.0 Manual documented the following: .G0110:Activities of Daily Living (ADL) Assistance .Code 4, total dependence: if there was full staff performance of an activity with no participation by resident for any aspect of the ADL activity and the activity occurred three or more times. The resident must be unwilling or unable to perform any part of the activity over the entire 7-day look-back period . RI # 168's Annual MDS with an ARD of 3/11/19 documented the following: .Section G…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to NHS MANAGEMENT — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 21 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $7.7M paid to related parties — landlords or management companies under common ownership — equal to about 58% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AL