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)
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
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
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing
LPN hours / resident day
0.61
Licensed practical nurse staffing
Aide hours / resident day
1.86
Nurse aide staffing
Weekend hours
2.75
Weekend nurse staffing
RN turnover
42%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
Brown, Natalie
Operational/Managerial Control · Individual
Gallagher, James
Operational/Managerial Control · Individual
Hoch, Robert
Operational/Managerial Control · Individual
Lagana, Kristin
Operational/Managerial Control · Individual
Pc Gen Ct Opco Topco LLC
5% Or Greater Indirect Ownership Interest · Organization
Pc Gen Ct Topco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Tetreault, Marnie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Complete Care At Kimberly Hall-South
Windsor, CT
4-star overall rating with 3-star inspections with $14,728 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Seabury
Bloomfield, CT
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Touchpoints At Bloomfield
Bloomfield, CT
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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