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Health Inspection Summary

Windsor House

4411 McAllister Drive

Huntsville, AL 35805

(256) 837-8585

Deficiency Category	Inspection Date: 5/29/21 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 3/7/19 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 4/5/18 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	3	1
Quality of Life and Care Deficiencies	4	2	0
Infection Control Deficiencies	1	1	1
Resident Assessment and Care Planning Deficiencies	2	1	3
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	3	2	3
Nutrition and Dietary Deficiencies	0	0	0
Pharmacy Service Deficiencies	1	1	0
Environmental Deficiencies	0	0	0
Administration Deficiencies	0	0	0

Detailed result for inspection on 5/29/21

Date of last standard health inspection:	5/29/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	11
Average number of Health Deficiencies in Alabama:	3.6
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Few
Provide enough food/fluids to maintain a resident's health.	5/29/21	7/2/21	3 - Actual harm	Few
Provide routine and 24-hour emergency dental care for each resident.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/29/21	7/2/21	3 - Actual harm	Few
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.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Many

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	5/29/21	7/2/21	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 3/7/19

Date of last standard health inspection:	3/7/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	9/20/23Read the full report (PDF) 8/24/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	8/24/23Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	10
Average number of Health Deficiencies in Alabama:	2.7
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	9/20/23	10/19/23	4 - Immediate jeopardy to resident health or safety	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	9/20/23	10/19/23	4 - Immediate jeopardy to resident health or safety	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	3/7/19	4/11/19	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	9/20/23	10/19/23	2 - Minimal harm or potential for actual harm	Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.	9/20/23	10/19/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	9/20/23	10/19/23	2 - Minimal harm or potential for actual harm	Few
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.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 4/5/18

Date of last standard health inspection:	4/5/18Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	8/25/22Read the full report (PDF) 5/6/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	5/6/22Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	8
Average number of Health Deficiencies in Alabama:	3.8
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	8/25/22	9/29/22	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	4/5/18	5/10/18	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	4/5/18	5/10/18	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Allow resident to participate in the development and implementation of his or her person-centered plan of care.	4/5/18	5/10/18	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	8/25/22	9/29/22	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	9/20/23	10/19/23	4 - Immediate jeopardy to resident health or safety	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	9/20/23	10/19/23	4 - Immediate jeopardy to resident health or safety	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	9/20/23	10/19/23	2 - Minimal harm or potential for actual harm	Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.	9/20/23	10/19/23	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	9/20/23	10/19/23	2 - Minimal harm or potential for actual harm	Few
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.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	8/25/22	9/29/22	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Some
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	8/25/22	9/29/22	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few
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.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	8/24/23	9/28/23	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Some
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/6/22	6/10/22	2 - Minimal harm or potential for actual harm	Few

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