Windsor, CT

Complete Care At Kimberly Hall North

3-star overall rating with 2-star inspections with abuse icon flag with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1 Emerson Dr, Windsor, CT

(860) 688-6443

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

150

Certified beds

Average residents

146

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

1977-01-11

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

85 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 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

0.50

Registered nurse staffing · state 0.70 · national 0.68

LPN hours / resident day

0.61

Licensed practical nurse staffing · state 0.84 · national 0.87

Aide hours / resident day

1.86

Nurse aide staffing · state 2.28 · national 2.35

Total nurse hours

2.97

All reported nurse hours · state 3.83 · national 3.89

Licensed hours

1.11

RN + LPN hours · state 1.54 · national 1.54

Weekend hours

2.75

Weekend nurse staffing · state 3.41 · national 3.43

Weekend RN hours

0.33

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.08 · national 0.07

Adjusted RN hours

0.51

CMS adjusted RN staffing hours

Adjusted total hours

3.03

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

42%

Annual RN turnover · state 39% · national 45%

Total nurse turnover

37%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,574

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

39.40

Composite VBP score used to determine payment impact.

Payment multiplier

0.9924

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

4.08

Baseline 7.42% · Performance 6.62% · Measure score 4.08 · Achievement 4.08 · Improvement 2.83

Total nurse turnover

7.06

Baseline 31.58% · Performance 34.82% · Measure score 7.06 · Achievement 7.06 · Improvement 0

Adjusted total nurse staffing

0.68

Baseline 3.42 hours · Performance 3.27 hours · Measure score 0.68 · Achievement 0.68 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.83%
10.72%
0.9 pts better
No Different than the National Rate · Eligible stays 51 · Observed rate 5.88% · Lower 95% interval 5.76%
Discharge to community 44.13%
50.57%
6.4 pts worse
No Different than the National Rate · Eligible stays 34 · Observed rate 35.29% · Lower 95% interval 33.35%
Medicare spending per beneficiary 1.14
1.02
0.1 pts worse
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 29 · Denominator 29
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 29
Discharge self-care score 66.67%
53.69%
13 pts better
Numerator 14 · Denominator 21
Discharge mobility score 61.9%
50.94%
11 pts better
Numerator 13 · Denominator 21
Pressure ulcers or injuries, new or worsened 6.9%
2.29%
4.6 pts worse
Numerator 2 · Denominator 29 · Adjusted rate 4.68%
Healthcare-associated infections requiring hospitalization 6.62%
7.12%
0.5 pts better
No Different than the National Rate · Eligible stays 26 · Observed rate 3.85% · Lower 95% interval 3.83%
Staff COVID-19 vaccination coverage 98.7%
8.2%
90.5 pts better
Numerator 152 · Denominator 154
Staff flu vaccination coverage 9.03%
42%
33 pts worse
Numerator 14 · Denominator 155
Discharge function score 76.19%
56.45%
19.7 pts better
Numerator 16 · Denominator 21
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 10%
25.2%
15.2 pts worse
Numerator 2 · Denominator 20

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.6
2.1
1.5 pts better
1.9
1.3 pts better
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0
1.5
1.5 pts better
1.8
1.8 pts better
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.3%
87.5%
10.8 pts better
93.4%
4.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 96.9% · Q3 98.4% · Q4 98.6% · 4Q avg 98.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
93.5%
6.5 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 5.0%
3.4%
1.6 pts worse
3.3%
1.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.3% · Q3 5.5% · Q4 5.7% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 9.9%
17.1%
7.2 pts better
11.4%
1.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 9.3% · Q3 12.0% · Q4 13.3% · 4Q avg 9.9%
Percentage of long-stay residents who lose too much weight 4.6%
6.4%
1.8 pts better
5.4%
0.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.5% · Q3 3.4% · Q4 3.1% · 4Q avg 4.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 14.4%
17.3%
2.9 pts better
19.6%
5.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 12.1% · Q3 17.5% · Q4 15.9% · 4Q avg 14.4%
Percentage of long-stay residents who received an antipsychotic medication 19.3%
19.4%
0.1 pts better
16.7%
2.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 18.3% · Q3 21.1% · Q4 20.4% · 4Q avg 19.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.0%
About the same
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 10.9%
18.1%
7.2 pts better
16.3%
5.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 5.0% · Q4 33.0% · 4Q avg 10.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 12.7%
18.4%
5.7 pts better
14.9%
2.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.9% · Q3 6.9% · Q4 35.7% · 4Q avg 12.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.9%
0.9 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 0.0%
1.7%
1.7 pts better
1.7%
1.7 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 new or worsened bowel or bladder incontinence 26.5%
24.8%
1.7 pts worse
19.8%
6.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 28.5% · Q3 31.6% · Q4 25.7% · 4Q avg 26.5%
Percentage of long-stay residents with pressure ulcers 1.8%
4.4%
2.6 pts better
5.1%
3.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.5% · Q3 1.5% · Q4 1.4% · 4Q avg 1.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 85.7%
70.5%
15.2 pts better
81.7%
4 pts better
Short Stay · 2024Q4-2025Q3 · Q1 65.2% · Q2 87.1% · Q3 91.5% · Q4 91.0% · 4Q avg 85.7%
Percentage of short-stay residents who had an outpatient emergency department visit 6.1%
11.1%
5 pts better
12.0%
5.9 pts better
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 8.0% · Expected 14.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 3.2%
1.5%
1.7 pts worse
1.6%
1.6 pts worse
Short Stay · 2024Q4-2025Q3 · Q2 6.2% · Q3 2.6% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 100.0%
69.7%
30.3 pts better
79.7%
20.3 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 29.3%
25.0%
4.3 pts worse
23.9%
5.4 pts worse
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 36.0% · Expected 29.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-19 · Fire 2024-09-19

14 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 2 Health 2022-05-26 · Fire 2022-05-26

12 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

14 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2019-09-26 · Fire 2019-09-26

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-09-19

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-11-26

E · Potential for more than minimal harm 2024-09-19

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-10-28

E · Potential for more than minimal harm 2024-09-19

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2024-11-26

D · Potential for more than minimal harm 2024-09-19

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-10-28

F · Potential for more than minimal harm 2022-05-26

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2022-07-15

F · Potential for more than minimal harm 2022-05-26

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2022-07-15

F · Potential for more than minimal harm 2022-05-26

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-07-15

F · Potential for more than minimal harm 2022-05-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-07-15

F · Potential for more than minimal harm 2022-05-26

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-07-15

F · Potential for more than minimal harm 2022-05-26

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-07-15

F · Potential for more than minimal harm 2022-05-26

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-07-15

E · Potential for more than minimal harm 2022-05-26

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2022-07-15

E · Potential for more than minimal harm 2022-05-26

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-07-15

E · Potential for more than minimal harm 2022-05-26

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-07-15

E · Potential for more than minimal harm 2022-05-26

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-07-15

D · Potential for more than minimal harm 2022-05-26

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-07-15

D · Potential for more than minimal harm 2022-05-26

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-07-15

D · Potential for more than minimal harm 2022-05-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-07-15

F · Potential for more than minimal harm 2019-09-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-12-12

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-29

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-09-05

D · Potential for more than minimal harm 2025-07-29

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-09-05

D · Potential for more than minimal harm 2025-06-27

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 2025-08-07

D · Potential for more than minimal harm 2025-06-27

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-08-07

D · Potential for more than minimal harm 2025-02-04

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 2025-01-30

D · Potential for more than minimal harm 2024-12-23

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-02-03

D · Potential for more than minimal harm 2024-09-19

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 2024-10-28

D · Potential for more than minimal harm 2024-09-19

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-10-28

D · Potential for more than minimal harm 2024-09-19

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-10-28

D · Potential for more than minimal harm 2024-09-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-10-28

D · Potential for more than minimal harm 2024-09-19

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 2024-10-28

D · Potential for more than minimal harm 2024-09-19

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-10-28

D · Potential for more than minimal harm 2024-09-19

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-10-28

D · Potential for more than minimal harm 2024-09-19

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2024-10-28

D · Potential for more than minimal harm 2024-09-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-28

B · Minimal harm 2024-09-19

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-10-28

D · Potential for more than minimal harm 2024-05-08

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-05-08

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 2024-06-19

J · Immediate jeopardy 2022-05-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-06-12

J · Immediate jeopardy 2022-05-26

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2022-06-12

G · Actual harm 2022-05-26

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2022-07-06

E · Potential for more than minimal harm 2022-05-26

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 2022-07-06

E · Potential for more than minimal harm 2022-05-26

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 2022-07-06

E · Potential for more than minimal harm 2022-05-26

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2022-07-06

D · Potential for more than minimal harm 2022-05-26

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-07-06

D · Potential for more than minimal harm 2022-05-26

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2022-07-06

E · Potential for more than minimal harm 2019-09-26

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 2019-11-05

D · Potential for more than minimal harm 2019-09-26

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2019-11-05

D · Potential for more than minimal harm 2019-09-26

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2019-11-05

D · Potential for more than minimal harm 2019-09-26

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2019-11-05

D · Potential for more than minimal harm 2019-09-26

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2019-11-05

D · Potential for more than minimal harm 2019-09-26

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-11-05

D · Potential for more than minimal harm 2019-09-26

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2019-11-05

B · Minimal harm 2019-09-26

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-11-05

Penalties and ownership

What sits behind the stars

Ownership

Pc Gen Ct Opco Holdco LLC

5% Or Greater Direct Ownership Interest · Organization

100% 3 facilities 2022-11-15
Brown, Natalie

Operational/Managerial Control · Individual

0% 2 facilities 2024-11-27
Gallagher, James

Operational/Managerial Control · Individual

0% 3 facilities 2022-11-15
Hoch, Robert

Operational/Managerial Control · Individual

0% 20 facilities 2022-11-15
Lagana, Kristin

Operational/Managerial Control · Individual

0% 5 facilities 2022-11-15
Pc Gen Ct Opco Topco LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 3 facilities 2022-11-15
Pc Gen Ct Topco LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 3 facilities 2022-11-15
Peace Capital Holdings LLC (De)

5% Or Greater Indirect Ownership Interest · Organization

0% 57 facilities 2022-11-15
Sms 2021 Trust

5% Or Greater Indirect Ownership Interest · Organization

0% 63 facilities 2022-11-15
Stein, Shalom

Corporate Officer · Individual

0% 83 facilities 2022-11-15
Tetreault, Marnie

Operational/Managerial Control · Individual

0% 5 facilities 2022-11-15

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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

Overall
5 / 5
Health
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Staffing
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Fines
$0

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