Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COMPLETE CARE AT KIMBERLY HALL-SOUTH
WINDSOR, CT · 180 certified beds · Last Life Safety survey November 19, 2024
CMS Certification Number 075237 · first certified November 1975
Ownership
Operated by COMPLETE CARE · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CT
7 citations — more than 37% 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 1 citation; the earlier surveys in the window averaged 3. 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: September 2026 to March 2027. This facility’s last Life Safety survey was November 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
Get an email about COMPLETE CARE AT KIMBERLY HALL-SOUTH
One email when it happens. No account; stop it any time with one click.
Physical environment (health survey)
5 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 7 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
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 | 7 |
| Median facility in CT | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 24, 2019 | 2 |
| May 23, 2022 | 4 |
| November 19, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2022-05-23 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2019-10-24 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2019-10-24 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-11-19 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2022-05-23 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2022-05-23 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2022-05-23 |
What the citations cover
- Smoke Deficiencies 5
- Services Deficiencies 1
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Services Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 19, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 6, 2025) |
May 23, 2022 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has plan of correction (July 15, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has plan of correction (July 15, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has plan of correction (July 15, 2022) |
October 24, 2019 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 8, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 8, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.