Cycle 1
Health 2021-05-29 · Fire 2021-05-29
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Huntsville, AL
Windsor House
1-star overall rating with 1-star inspections with $266,231 in total fines with 11 recent health deficiencies
4411 Mcallister Drive, Huntsville, AL
(256) 837-8585
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Diversicare Healthcare
Operator or chain grouping
Approved since
1987-10-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
0.45
Registered nurse staffing · state 0.64 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.50 · national 2.35
Total nurse hours
2.71
All reported nurse hours · state 3.91 · national 3.89
Licensed hours
1.03
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.30
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.36 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
68%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,615
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.31
Baseline 19.31% · Performance 19.44% · Measure score 4.31 · Achievement 4.31 · Improvement 0
Healthcare-associated infections
6.17
Baseline 6.08% · Performance 5.99% · Measure score 6.17 · Achievement 6.17 · Improvement 0.36
Total nurse turnover
0
Baseline 58.62% · Performance 68.75% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 3.19 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.58% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 13.79% · Lower 95% interval 7.93% |
| Discharge to community | 47.36% |
50.57%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 37.74% · Lower 95% interval 34.51% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.59% |
95.27%
0.7 pts worse
|
Numerator 35 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 19.23% |
53.69%
34.5 pts worse
|
Numerator 5 · Denominator 26 |
| Discharge mobility score | 30.77% |
50.94%
20.2 pts worse
|
Numerator 8 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 5.99% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 0% · Lower 95% interval 2.9% |
| Staff COVID-19 vaccination coverage | 7.23% |
8.2%
1 pts worse
|
Numerator 6 · Denominator 83 |
| Staff flu vaccination coverage | 33.98% |
42%
8 pts worse
|
Numerator 35 · Denominator 103 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 10 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.73% |
25.2%
2.5 pts worse
|
Numerator 5 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
91.3%
About the same
|
93.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 91.0% · Q3 87.9% · Q4 91.5% · 4Q avg 91.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.8%
5.2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.4%
0.9 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 4.5% · Q3 3.3% · Q4 1.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
1.3%
1 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.3%
0.8 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.3% · Q3 2.9% · Q4 4.2% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
24.9%
13.1 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 12.9% · Q3 9.9% · Q4 8.3% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
22.8%
0.8 pts better
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 19.6% · Q3 27.5% · Q4 21.1% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.6%
0.6 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.5% |
14.8%
6.3 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 9.6% · Q3 0.0% · Q4 6.5% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
13.4%
8.4 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 6.3% · Q3 1.6% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.6%
0.1 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 3.3% · Q4 5.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
13.5%
8.6 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 24.0% · Q3 14.6% · Q4 14.0% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
5.7%
0.1 pts better
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.7% · Q3 9.1% · Q4 7.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.7% |
84.3%
19.6 pts worse
|
81.7%
17 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 73.7% · Q3 70.6% · Q4 25.7% · 4Q avg 64.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
11.5%
2.4 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 16.1% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
2.1%
2.6 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 8.3% · Q4 4.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.1% |
80.3%
7.2 pts worse
|
79.7%
6.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
24.5%
2.6 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 29.0% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-03-07 · Fire 2019-03-07
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2018-04-05 · Fire 2018-04-05
12 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2019-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-17
E · Potential for more than minimal harm
2018-04-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2018-05-10
D · Potential for more than minimal harm
2018-04-05
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2018-05-10
D · Potential for more than minimal harm
2018-04-05
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 2018-05-10
Inspection history
Recent health citations
J · Immediate jeopardy
2023-09-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-19
J · Immediate jeopardy
2023-09-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-09-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-09-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-09-20
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-10-19
E · Potential for more than minimal harm
2023-08-24
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-28
D · Potential for more than minimal harm
2023-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-28
G · Actual harm
2021-05-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-07-02
G · Actual harm
2021-05-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-07-02
F · Potential for more than minimal harm
2021-05-29
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-07-02
E · Potential for more than minimal harm
2021-05-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-29
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-29
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-02
D · Potential for more than minimal harm
2019-03-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-04-11
D · Potential for more than minimal harm
2018-04-05
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2018-05-10
D · Potential for more than minimal harm
2018-04-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-05-10
D · Potential for more than minimal harm
2018-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-05-10
Penalties and ownership
What sits behind the stars
$266,231
2023-08-24
Fine
Fine · fine $266,231
Fine
Ownership
Diversicare Leasing LP
5% Or Greater Direct Ownership Interest · Organization
Advocat Finance, LLC
5% Or Greater Indirect Ownership Interest · Organization
Beasley, Ted
W-2 Managing Employee · Individual
Bodie, Rebecca
Corporate Officer · Individual
Dac Acquisition LLC
5% Or Greater Indirect Ownership Interest · Organization
Dac Newcorp Inc
5% Or Greater Indirect Ownership Interest · Organization
Diversicare Healthcare Services LLC
5% Or Greater Indirect Ownership Interest · Organization
Diversicare Management Services LP.
5% Or Greater Indirect Ownership Interest · Organization
Diversicare Management Services LP.
Operational/Managerial Control · Organization
Ford, Ashley
Contracted Managing Employee · Individual
Kellman, Franklin
Corporate Director · Individual
Kohn, Brian
Corporate Director · Individual
Nee, Stephen
Corporate Officer · Individual
Ratner, Eran
Corporate Director · Individual
Ratner, Eran
Corporate Officer · Individual
Weishaar, Matthew
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Brookshire Healthcare Center
Huntsville, AL
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Diversicare Of Big Springs
Huntsville, AL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
The Health Center At Research Park
Huntsville, AL
1-star overall rating with 1-star inspections with abuse icon flag with $69,011 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out