Cycle 1
Health 2022-05-17 · Fire 2022-05-17
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Huntsville, AL
Willowbrooke Ct Skilled Care Ctr At Magnolia Trace
5-star overall rating with 3-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
One Crown Circle, Huntsville, AL
(256) 261-1602
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
16
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
2003-03-18
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
26 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.35
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.91
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.55
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.43
CMS adjusted RN staffing hours
Adjusted total hours
4.50
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
924
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0170
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.65
Baseline 21.57% · Performance 18.35% · Measure score 6.65 · Achievement 6.65 · Improvement 6.60
Healthcare-associated infections
1.97
Baseline 6.67% · Performance 7.25% · Measure score 1.97 · Achievement 1.97 · Improvement 0
Total nurse turnover
10
Baseline 24.24% · Performance 10.53% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 177 · Observed rate 7.91% · Lower 95% interval 7.69% |
| Discharge to community | 66.52% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 169 · Observed rate 66.86% · Lower 95% interval 59.58% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 108 · Denominator 108 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 108 |
| Discharge self-care score | 38.3% |
53.69%
15.4 pts worse
|
Numerator 36 · Denominator 94 |
| Discharge mobility score | 18.09% |
50.94%
32.8 pts worse
|
Numerator 17 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 3 · Denominator 108 · Adjusted rate 3.16% |
| Healthcare-associated infections requiring hospitalization | 7.25% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 110 · Observed rate 5.45% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 95 |
| Staff flu vaccination coverage | 84.96% |
42%
43 pts better
|
Numerator 113 · Denominator 133 |
| Discharge function score | 34.04% |
56.45%
22.4 pts worse
|
Numerator 32 · Denominator 94 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 94.29% |
96.28%
2 pts worse
|
Numerator 66 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 23.64% |
25.2%
1.6 pts worse
|
Numerator 13 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.3%
15.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
11.5%
5.5 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.1% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.1%
0.5 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
80.3%
18.4 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
24.5%
5.1 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 14.3% · Expected 17.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-17 · Fire 2019-10-17
1 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-10-11 · Fire 2018-10-11
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-05-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-26
D · Potential for more than minimal harm
2022-05-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-05-26
F · Potential for more than minimal harm
2019-10-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-10-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-10-17
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-10-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-25
D · Potential for more than minimal harm
2018-10-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-11-07
D · Potential for more than minimal harm
2018-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-07
D · Potential for more than minimal harm
2018-10-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-11-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-05-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-20
E · Potential for more than minimal harm
2019-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-20
Penalties and ownership
What sits behind the stars
Ownership
Acts Retirement Services, Inc
5% Or Greater Direct Ownership Interest · Organization
Acts Management Services, Inc.
Operational/Managerial Control · Organization
Acts Retirement Services, Inc
Operational/Managerial Control · Organization
Ahern, Susan
Corporate Officer · Individual
Ahern, Susan
W-2 Managing Employee · Individual
Allmond, Susan
Corporate Director · Individual
Christiansen, Karen
Corporate Officer · Individual
Christiansen, Karen
W-2 Managing Employee · Individual
Clemens, Thomas
Corporate Director · Individual
Detweiler, Harold
Corporate Director · Individual
Dunn, Thomas
Corporate Director · Individual
Esterhai, John
Corporate Director · Individual
Esterhai, John
Corporate Officer · Individual
Evans, Robert
Corporate Director · Individual
Fox, Glenn
Corporate Officer · Individual
Fox, Glenn
W-2 Managing Employee · Individual
Gerner, Elric
Corporate Director · Individual
Gerner, Elric
Corporate Officer · Individual
Grant, Gerald
Corporate Director · Individual
Grant, Gerald
Corporate Officer · Individual
Grant, Gerald
W-2 Managing Employee · Individual
Kelly, Michael
Corporate Director · Individual
Kelly, Michael
Corporate Officer · Individual
Kulathum, Dilip
Corporate Director · Individual
Kulathum, Dilip
Corporate Officer · Individual
Lammers, John
Corporate Director · Individual
Lawson, Daniel
Corporate Director · Individual
Marr, Larry
Corporate Director · Individual
Mashner, Marvin
Corporate Director · Individual
Valdivia, Peggy
Corporate Officer · Individual
Valdivia, Peggy
W-2 Managing Employee · Individual
Worth, James
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Huntsville Health & Rehabilitation, LLC
Huntsville, AL
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Rocket City Rehabilitation And Healthcare Center
Huntsville, AL
1-star overall rating with 1-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Diversicare Of Big Springs
Huntsville, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
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