Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COMPLETE CARE AT KIMBERLY HALL NORTH
WINDSOR, CT · 150 certified beds · Last Life Safety survey September 19, 2024
CMS Certification Number 075279 · first certified January 1977
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
- Ownership changed November 15, 2022 (change of ownership)to COMPLETE CARE AT KIMBERLY HALL NORTH LLC from 1 EMERSON DRIVE NORTH OPERATIONS LLC
Position within CT
19 citations — more than 77% of the 191 certified nursing homes in CT. Compared within CT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: July 2026 to January 2027. This facility’s last Life Safety survey was September 2024. Facilities in CT are typically surveyed 21–28 months after the last one (median 24), measured over 181 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 19 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in CT, and nationally. Surveyors differ markedly between states, so the CT figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in CT | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 26, 2019 | 1 |
| May 26, 2022 | 14 |
| September 19, 2024 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2022-05-26 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2024-09-19 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2022-05-26 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2022-05-26 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2022-05-26 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2022-05-26 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2024-09-19 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2022-05-26 |
What the citations cover
- Smoke Deficiencies 7
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 3
- Miscellaneous Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 19, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 26, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (October 28, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (November 26, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 28, 2024) |
May 26, 2022 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 15, 2022) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (July 15, 2022) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 15, 2022) |
September 26, 2019 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 12, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.