Cycle 1
Health 2024-11-19 · Fire 2024-11-19
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Windsor, CT
Complete Care At Kimberly Hall-South
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
1 Emerson Drive, Windsor, CT
(860) 688-6443
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1975-11-01
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
0.83
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,011
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.08
Composite VBP score used to determine payment impact.
Payment multiplier
1.0162
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 18.88% · Performance 16.79% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.38
Baseline 6.16% · Performance 6.23% · Measure score 5.38 · Achievement 5.38 · Improvement 0
Total nurse turnover
9.06
Baseline 18.06% · Performance 26.67% · Measure score 9.06 · Achievement 9.06 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.53 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 10.37% · Lower 95% interval 6.34% |
| Discharge to community | 60.74% |
50.57%
10.2 pts better
|
Better than the National Rate · Eligible stays 151 · Observed rate 42.38% · Lower 95% interval 51.92% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 113 · Denominator 113 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 113 |
| Discharge self-care score | 69.33% |
53.69%
15.6 pts better
|
Numerator 52 · Denominator 75 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 45 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 0.88% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 113 · Adjusted rate 0.71% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 6.33% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 114 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 50 · Denominator 100 |
| Discharge function score | 65.33% |
56.45%
8.9 pts better
|
Numerator 49 · Denominator 75 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 61 · Denominator 61 |
| Resident COVID-19 vaccinations up to date | 7.25% |
25.2%
17.9 pts worse
|
Numerator 5 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 2.2 · Expected 4.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.5
1.3 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.3 · Expected 2.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.8% |
87.5%
3.7 pts worse
|
93.4%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.0% · Q2 88.1% · Q3 85.3% · Q4 76.5% · 4Q avg 83.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.9% |
93.5%
5.6 pts worse
|
95.5%
7.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.4%
1.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.6% · Q3 0.0% · Q4 2.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 67.7% |
17.1%
50.6 pts worse
|
11.4%
56.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 80.5% · Q3 70.0% · Q4 75.7% · 4Q avg 67.7% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
6.4%
3.8 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.3% · Q3 1.4% · Q4 3.9% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
17.3%
7.9 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 10.0% · Q3 8.1% · Q4 7.8% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
19.4%
8.7 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 10.9% · Q3 11.5% · Q4 5.6% · 4Q avg 10.7% · 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 | 26.5% |
18.1%
8.4 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 20.7% · Q4 37.9% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
18.4%
3.2 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 18.8% · Q3 24.2% · Q4 22.1% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · 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 | 31.6% |
24.8%
6.8 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 24.9% · Q3 34.8% · Q4 36.5% · 4Q avg 31.6% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.4%
0.1 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.6% · Q3 3.4% · Q4 5.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.9% |
70.5%
19.6 pts worse
|
81.7%
30.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.8% · Q2 61.2% · Q3 43.8% · Q4 45.6% · 4Q avg 50.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
11.1%
6.4 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 5.8% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.2% |
69.7%
15.5 pts worse
|
79.7%
25.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.1% |
25.0%
11.9 pts better
|
23.9%
10.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 18.6% · Expected 33.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-23 · Fire 2022-05-23
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-10-24 · Fire 2019-10-24
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-06
D · Potential for more than minimal harm
2022-05-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-05-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-15
D · Potential for more than minimal harm
2019-10-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-08
D · Potential for more than minimal harm
2019-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-04-03
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 2025-02-20
J · Immediate jeopardy
2025-02-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-02-03
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 2025-02-07
D · Potential for more than minimal harm
2025-01-14
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 2025-02-14
D · Potential for more than minimal harm
2025-01-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-11-19
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-11-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-11-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-11-19
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-11-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-26
B · Minimal harm
2024-11-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-09-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-07-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-03
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 2024-08-07
D · Potential for more than minimal harm
2023-10-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-30
E · Potential for more than minimal harm
2022-05-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-23
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-06-30
E · Potential for more than minimal harm
2022-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-23
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-23
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 2022-06-30
D · Potential for more than minimal harm
2022-05-23
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 2022-06-30
D · Potential for more than minimal harm
2022-05-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-06-30
B · Minimal harm
2022-05-23
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2022-06-30
E · Potential for more than minimal harm
2019-10-24
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 2019-12-05
D · Potential for more than minimal harm
2019-10-24
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-24
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 2019-12-05
D · Potential for more than minimal harm
2019-10-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-24
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-12-05
B · Minimal harm
2019-10-24
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2019-12-05
Penalties and ownership
What sits behind the stars
$14,728
2025-01-14
Fine
Fine · fine $14,728
Fine
Ownership
Pc Gen Ct Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
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
Russo, Thomas
Operational/Managerial Control · Individual
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 North
Windsor, CT
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
#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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