WINDSOR HOUSE (HUNTSVILLE, AL) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	8.3%
Alabama:	13.9%

Percent of long-stay residents who self-report moderate to severe pain

Here:	24.9%
State:	9.6%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	7.4%
State:	5.9%

Percent of long-stay residents who lose too much weight

This Nursing Home:	3.1%
Alabama:	8.1%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Nursing Home:	29.0%
State:	38.9%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

This Nursing Home:	4.9%
Alabama:	3.4%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	1.1%
Alabama:	2.9%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	99.0%
State:	95.1%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	99.0%
State:	91.7%

Percent of short-stay residents who self-report moderate to severe pain

Here:	26.7%
Alabama:	19.6%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	98.2%
Alabama:	87.4%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	93.8%
State:	83.6%

Percent of long-stay residents who received an antipsychotic medication

Here:	41.1%
State:	27.0%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.520
State:	0.613

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.880
State:	1.059

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.410
State:	1.672

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.120
State:	0.045

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.120
Alabama:	0.048

Complaint Deficiency

An approved installation, maintenance and testing program for fire alarm systems
- Harm: Actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Actual harm
- Scope: Some
Provide proof that all residents' personal money which is deposited with the nursing home, is secure
- Harm: Actual harm
- Scope: Many
Properly constructed piped-in oxygen systems
- Harm: Actual harm
- Scope: Many
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Restrictions on the use of flammable curtains
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Send and promptly deliver unopened mail to residents
- Harm: Potential for minimal harm
- Scope: Many
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Try to resolve each resident's complaints quickly
- Harm: Potential for minimal harm
- Scope: Many
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Ensure the activities program is directed by a qualified professional
- Harm: Potential for minimal harm
- Scope: Many
Provide housekeeping and maintenance services
- Harm: Potential for minimal harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Some
No-smoking signs where oxygen is used
- Harm: Minimal harm or potential for actual harm
- Scope: Few

WINDSOR HOUSE - HUNTSVILLE, AL

Quality Measures

Staff Information

Complaint Deficiency

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