SNF

WINDSOR HOUSE

CCN: 015397 · HUNTSVILLE, AL 35805 · Madison County

⚠ Inspection > 2 years ago

Overview

Address
4411 MCALLISTER DRIVE, HUNTSVILLE, AL 35805
Phone
2568378585
Certified beds
117
Avg daily residents
101 (87% of beds filled)
Ownership
For-profit corporation
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1987-10-16
Setting
Urban
1 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 1/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 1/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 2/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 4/5
Short-Stay Quality Measures ★★★★★ 1/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 2.71 3.32 3.15 ≥ 3.48 Below floor
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 0.45 0.58 0.52 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 0.59 0.74 0.68 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 1.68 2.00 1.95 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 1.03 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.03 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
2.30
hrs / resident / day
RN (weekend)
0.27
hrs / resident / day
Total nurse (adjusted, weekend)
2.68
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
57.9%
annual
RN turnover
68.4%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.18
higher acuity than avg
Case-Mix Index Ratio
0.85
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2021-05-29 11 11 0 92 1 92
Cycle 2/3 (prior) 2019-03-07 10 1 9 186 1 186
Total weighted health score
115.5
lower is better
Infection-control citations
4
last cycle

Deficiencies (24)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

20 D/E/F Actual harm — potential for minor
2 G/H/I Actual harm
2 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D 2023-09-20 2023-10-19
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. J 2023-09-20 2023-10-19
0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. J 2023-09-20 2023-10-19
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2023-09-20 2023-10-19
0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. D 2023-09-20 2023-10-19
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. E 2023-08-24 2023-09-28
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2023-08-24 2023-09-28
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2023-08-24 2023-09-28
0880 Provide and implement an infection prevention and control program. D 2023-08-24 2023-09-28
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. G 2021-05-29 2021-07-02
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. D 2021-05-29 2021-07-02
0625 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. F 2021-05-29 2021-07-02
0641 Ensure each resident receives an accurate assessment. D 2021-05-29 2021-07-02
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2021-05-29 2021-07-02
0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. D 2021-05-29 2021-07-02
0692 Provide enough food/fluids to maintain a resident's health. G 2021-05-29 2021-07-02
0761 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. D 2021-05-29 2021-07-02
0790 Provide routine and 24-hour emergency dental care for each resident. D 2021-05-29 2021-07-02
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. E 2021-05-29 2021-07-02
0880 Provide and implement an infection prevention and control program. D 2021-05-29 2021-07-02
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2019-03-07 2019-04-11
0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care. D 2018-04-05 2018-05-10
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2018-04-05 2018-05-10
0880 Provide and implement an infection prevention and control program. D 2018-04-05 2018-05-10

Penalties (1)

Fines issued
1
last 3 years
Total fines
$266,231
Date Type Fine amount
2023-08-24 Fine $266,231

Source: CMS Nursing Home Penalties.

Financial Health (FY 2024)

Payer mix (share of resident days)

Medicare 3.6% Medicaid 65.7% Other 30.7%

Operating performance

Operating Margin
1.6%
Total Margin
1.7%
Occupancy Rate
82.7%
Cost per Resident Day
$23

Revenue & costs

Net Patient Revenue
$10.3M
Total Costs
$812K
Net Income
$173K

Balance sheet

Total Assets
$12.6M
Total Liabilities
$11.7M
Fund Balance
$881K
Current Ratio
2.90

Source: CMS SNF Cost Report (FY 2024). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: DIVERSICARE HEALTHCARE

Chain ID
185
Facilities in chain
44
Legal business name
DIVERSICARE WINDSOR HOUSE, LLC
Chain-average star ratings (for peer context)
Overall
2.5
Health
2.5
Staffing
2.9
QM
3.4

Owner / manager organizations (7)

Organization Role Association
DIVERSICARE LEASING LP 5% OR GREATER DIRECT OWNERSHIP INTEREST since 07/26/2000
ADVOCAT FINANCE, LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 12/18/1996
DAC ACQUISITION LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 11/19/2021
DAC NEWCORP INC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 04/04/2022
DIVERSICARE HEALTHCARE SERVICES LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 05/10/1994
DIVERSICARE MANAGEMENT SERVICES LP. 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 10/10/1996
DIVERSICARE MANAGEMENT SERVICES LP. OPERATIONAL/MANAGERIAL CONTROL since 11/18/2024

Owner / manager individuals (9)

Name Role Association
KELLMAN, FRANKLIN CORPORATE DIRECTOR since 09/13/2024
KOHN, BRIAN CORPORATE DIRECTOR since 11/19/2021
RATNER, ERAN CORPORATE DIRECTOR since 11/19/2021
BODIE, REBECCA CORPORATE OFFICER since 03/02/2020
NEE, STEPHEN CORPORATE OFFICER since 02/20/2023
RATNER, ERAN CORPORATE OFFICER since 09/13/2024
WEISHAAR, MATTHEW CORPORATE OFFICER since 12/01/2003
FORD, ASHLEY CONTRACTED MANAGING EMPLOYEE since 07/15/2023
BEASLEY, TED W-2 MANAGING EMPLOYEE since 04/01/2024

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $23 metrics.cost_per_resident_day
Cost Report Current Ratio 2.90 metrics.current_ratio
Cost Report fiscal_year 2,024 fiscal_year
Cost Report Medicaid Day Share (%) 65.7% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 3.6% metrics.medicare_day_share
Cost Report Net Income ($) $173,119 metrics.net_income
Cost Report Net Patient Revenue ($) $10,270,133 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 82.7% metrics.occupancy_rate
Cost Report Operating Margin (%) 1.6% metrics.operating_margin
Cost Report Total Assets ($) $12,561,846 metrics.total_assets
Cost Report Total Costs ($) $811,939 metrics.total_costs
Cost Report Total Fund Balances ($) $881,017 metrics.fund_balance
Cost Report Total Liabilities ($) $11,680,829 metrics.total_liabilities
Cost Report Total Margin (%) 1.7% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.68183 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.94821 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.52096 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.15099 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 2.67748 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 101.3 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.73676 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.00235 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.58073 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.31984 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 2.92608 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.5 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.5 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 3.4 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.9 Chain Average Staffing Rating
Provider Information Chain ID 185 Chain ID
Provider Information Chain Name DIVERSICARE HEALTHCARE Chain Name
Provider Information City/Town HUNTSVILLE City/Town
Provider Information CMS Certification Number (CCN) 015397 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Madison County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1987-10-16 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 34.7174 Latitude
Provider Information Legal Business Name DIVERSICARE WINDSOR HOUSE, LLC Legal Business Name
Provider Information Location 4411 MCALLISTER DRIVE,HUNTSVILLE,AL,35805 Location
Provider Information Long-Stay QM Rating 4 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -86.629 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago Y Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 117 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections 4 Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 44 Number of Facilities in Chain
Provider Information Number of Fines 1 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.17607 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.85368 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 1 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type For profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 4411 MCALLISTER DRIVE Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name WINDSOR HOUSE Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 440 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 2 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 92 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 0 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 11 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2021-05-29 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 92 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 11 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 1 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2019-03-07 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 186 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 9 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 186 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 10 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.26521 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 68.4 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.03422 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.58627 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 1.67518 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.03137 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.44795 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 2.70940 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 1 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 1 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State AL State
Provider Information Telephone Number 2568378585 Telephone Number
Provider Information Total Amount of Fines in Dollars 266231.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 2.30224 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 1 Total Number of Penalties
Provider Information Total nursing staff turnover 57.9 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 115.500 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 35805 ZIP Code