COMPLETE CARE AT KIMBERLY HALL-SOUTH
1 EMERSON DRIVE, WINDSOR, CT 06095 · CCN 075237
Ratings
- Overall
- ★★★★☆ 4
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★★★★★ 5
- Staffing
- ★★★☆☆ 3
Facility
- Ownership type
- For profit - Limited Liability company
- Certified beds
- 180
- Avg residents/day
- 105.0
- Phone
- 8606886443
Inspection history vs Connecticut & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Connecticut avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-11-19 | 10 | 13.3 | 9.5 | -3.3 better |
| 2 | 2022-05-23 | 18 | 13.2 | 9.8 | +4.8 worse |
| 3 | 2019-10-24 | 9 | 8.6 | 9.3 | +0.4 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 4 |
| Resident assessment and care planning | 2 |
| Resident rights | 4 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.69 | 21.6% |
| RN staffing (reported) | 0.83 | 45.5% |
| Total nurse staffing (adjusted) | 3.12 | — |
Fines & penalties
- Total fines
- $14,728
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- COMPLETE CARE
- Facilities in chain
- 85
- Chain avg overall
- 3.20 / 5
Inspection citations (37)1 immediate jeopardy
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-05-01 · Health · corrected 2025-06-12
Potential for more than minimal harm
- DF0697Provide safe, appropriate pain management for a resident who requires such services.2025-05-01 · Health · corrected 2025-06-12
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-04-03 · Health · corrected 2025-02-20
Potential for more than minimal harm
- JF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2025-02-03 · Health · corrected 2025-02-03
Immediate jeopardy
- DF0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.2025-02-03 · Health · corrected 2025-02-07
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-01-14 · Health · corrected 2025-02-14
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-01-14 · Health · corrected 2025-02-14
Potential for more than minimal harm
- DF0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.2024-11-19 · Health · corrected 2024-12-26
Potential for more than minimal harm
- DF0578Honor 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.2024-11-19 · Health · corrected 2024-12-26
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-11-19 · Health · corrected 2024-12-26
Potential for more than minimal harm
- BF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2024-11-19 · Health · corrected 2024-12-26
Potential for minimal harm
- DF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2024-11-19 · Health · corrected 2024-12-26
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-11-19 · Health · corrected 2024-12-26
Potential for more than minimal harm
- DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2024-11-19 · Health · corrected 2024-12-26
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-09-13 · Health · corrected 2024-10-17
Potential for more than minimal harm
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2024-09-13 · Health · corrected 2024-10-17
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-09-13 · Health · corrected 2024-10-17
Potential for more than minimal harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-07-15 · Health · corrected 2024-08-21
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-07-15 · Health · corrected 2024-08-21
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-07-03 · Health · corrected 2024-08-07
Potential for more than minimal harm
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2023-10-19 · Health · corrected 2023-11-30
Potential for more than minimal harm
- BF0585Honor 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.2022-05-23 · Health · corrected 2022-06-30
Potential for minimal harm
- DF0625Notify 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.2022-05-23 · Health · corrected 2022-06-30
Potential for more than minimal harm
- DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2022-05-23 · Health · corrected 2022-06-30
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2022-05-23 · Health · corrected 2022-06-30
Potential for more than minimal harm
- EF0761Ensure 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.2022-05-23 · Health · corrected 2022-06-30
Potential for more than minimal harm
- EF0800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.2022-05-23 · Health · corrected 2022-06-30
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2022-05-23 · Health · corrected 2022-06-30
Potential for more than minimal harm
- DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2022-05-23 · Health · corrected 2022-06-30
Potential for more than minimal harm
- DF0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.2019-10-24 · Health · corrected 2019-12-05
Potential for more than minimal harm
- BF0584Honor 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.2019-10-24 · Health · corrected 2019-12-05
Potential for minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2019-10-24 · Health · corrected 2019-12-05
Potential for more than minimal harm
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2019-10-24 · Health · corrected 2019-12-05
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2019-10-24 · Health · corrected 2019-12-05
Potential for more than minimal harm
- DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2019-10-24 · Health · corrected 2019-12-05
Potential for more than minimal harm
- DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2019-10-24 · Health · corrected 2019-12-05
Potential for more than minimal harm
- DF0791Provide or obtain dental services for each resident.2019-10-24 · Health · corrected 2019-12-05
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| PC GEN CT OPCO HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2022-11-15 |
| PC GEN CT OPCO TOPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2022-11-15 |
| PC GEN CT TOPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2022-11-15 |
| PEACE CAPITAL HOLDINGS LLC (DE) | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2022-11-15 |
| SMS 2021 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | — | 2022-11-15 |
| GALLAGHER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-11-15 |
| HOCH, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-11-15 |
| LAGANA, KRISTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-11-15 |
| RUSSO, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-11-15 |
| TETREAULT, MARNIE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2022-11-15 |
| STEIN, SHALOM | Individual | CORPORATE OFFICER | — | 2022-11-15 |
Other facilities in WINDSOR
| Name | Overall | Beds |
|---|---|---|
| COMPLETE CARE AT KIMBERLY HALL NORTH | ★★★☆☆ | 150 |
| AUTUMN LAKE HEALTHCARE AT WINDSOR | ★☆☆☆☆ | 108 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.