Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Kimberly Hall-south during CMS and state inspections, most recent first.
A resident with dementia and a history of falls experienced two unwitnessed falls, after which neurological checks were ordered by both nursing staff and a physician. However, there was no documentation that these neurological assessments were completed as required by facility policy, and the DNS could not provide the missing records.
A resident receiving hospice care with orders for as-needed morphine did not receive timely or effective pain management during the dying process. Despite clear signs of distress and repeated family requests, staff failed to administer additional morphine for approximately six hours after an ineffective dose, and did not document follow-up assessments or notify the physician as required by facility policy.
A resident with multiple medical conditions and moderate cognitive impairment developed several wounds, including pressure ulcers and skin tears, which were documented in clinical records. However, staff did not update the care plan to address these actual skin integrity issues, instead maintaining only a plan for risk of impairment. Facility staff confirmed the care plan should have included the resident's current wounds and specific interventions.
A resident with end stage renal disease experienced significant bleeding from an AVF dialysis access site after hemodialysis. Facility staff applied pressure dressings but did not manually apply pressure or remove the dressing to directly assess if bleeding had stopped, relying instead on the appearance of the dressing. The resident suffered recurrent bleeding, was sent to the hospital in hemorrhagic shock, and required multiple blood transfusions. The facility lacked specific training and guidelines for managing bleeding dialysis accesses.
A resident with end stage renal disease and an AVF experienced significant bleeding from the access site. Nursing staff applied dressings but did not initially use manual pressure or verify bleeding had stopped, leading to further blood loss and emergency intervention. Staff interviews revealed a lack of training and knowledge regarding proper AVF bleeding management, and the facility lacked formal guidelines or documented training on this issue.
A resident with significant mobility and cognitive impairments was transferred from bed to wheelchair using a Hoyer Lift by two aides. After the transfer, the lift tilted and its overhead bar struck the resident's head, causing a scalp abrasion. Staff interviews confirmed proper training and two-person assistance, but the cause of the tilt was not identified.
A nursing assistant failed to perform hand hygiene between glove changes while providing incontinent care to a resident with diabetes and a UTI, despite facility policy requiring hand hygiene after glove removal. The lapse was observed during care, and the staff member acknowledged forgetting the required step.
A resident with quadriplegia and intact cognition expressed dissatisfaction with a nurse aide due to personality conflicts and delayed care, specifically being assisted to bed later than the physician-ordered time. Despite the resident's repeated requests to not have this aide provide care, the facility continued to assign the aide, citing staffing assignments and the need for assistance with transfers. The facility's policy on resident rights was not followed, as the resident's preference was not accommodated until after surveyor inquiry.
The facility failed to properly review and document advance directives for two residents, leading to deficiencies in honoring their treatment preferences. One resident's DNR wishes were delayed due to communication issues with their conservator, while another resident's advance directive was signed by an unidentified individual, and not reviewed with the actual representatives. These oversights highlight a lack of adherence to the facility's policy on advance directives.
Two residents experienced deficiencies in care at an LTC facility. A resident with dementia and renal disease had a forehead scab that was not properly assessed or reported, violating the facility's skin assessment policy. Another resident reported an abuse incident involving a nurse aide, but their conservator was not notified, breaching the notification of changes policy. Staff interviews confirmed the lack of documentation and communication in both cases.
A facility failed to conduct quarterly resident care conferences for a resident with multiple health conditions, including congestive heart failure and chronic kidney disease. Despite the care plan identifying the resident's risk for limited engagement, the facility did not document required RCCs from admission through a specified period. Interviews revealed informal meetings occurred, but official RCCs were missed, contrary to facility policy.
The facility failed to document an RN assessment for a resident with a recurring forehead wound and did not set another resident's specialty air mattress according to the physician's order. The first resident's wound was not properly assessed by an RN, despite a physician's order for a wound consult. The second resident's mattress was set significantly below their actual weight, contrary to the care plan. These deficiencies highlight a lack of adherence to facility policies and physician orders.
A facility failed to monitor fluid intake and output for a resident with end-stage renal disease and congestive heart failure, who was on a fluid restriction and required hemodialysis. The care plan included specific fluid restrictions, but documentation of daily fluid intake was missing. Staff interviews revealed a lack of awareness and communication regarding the resident's fluid restrictions and the absence of a system for documenting fluid intake and output.
The facility failed to notify the Office of the State LTC Ombudsman about hospital transfers for six residents with various medical conditions. Staff interviews revealed a lack of awareness about the notification requirement, and the facility's policy on transfers and discharges was not followed, leading to a deficiency in compliance.
Failure to Complete and Document Neurological Checks After Unwitnessed Falls
Penalty
Summary
A deficiency occurred when the facility failed to complete and document neurological checks after an unwitnessed fall for one resident reviewed for falls. The resident, who had diagnoses including encephalopathy, dementia, and adult failure to thrive, was assessed as having moderately impaired cognition and was at risk for falls due to dementia-related forgetfulness and impulsive behavior. The care plan included specific fall prevention interventions, and after two separate unwitnessed falls, nursing notes and physician orders directed that neurological checks be performed per facility protocol. Despite these directives, review of the accident and incident forms, medical records, and facility documentation did not show evidence that neurological checks were completed or documented following either fall. The Director of Nursing Services was unable to provide the required neurological check documentation for the relevant dates. Facility policy required neurological assessments at specific intervals after an unwitnessed fall, but these were not found in the resident's records.
Failure to Provide Timely and Effective Pain Management During Hospice Care
Penalty
Summary
A deficiency occurred when a resident receiving hospice care, with diagnoses including encephalopathy, dementia, and failure to thrive, did not receive appropriate pain management during the dying process. The resident had a provider order for morphine to be administered by mouth every two hours as needed for pain, and later, the order was changed to every hour as needed. On the day in question, the resident was noted to be unresponsive, with vital signs indicating distress, including tachycardia, increased respirations, and low oxygen saturation. The medication administration record showed that morphine was given at 9:45 AM and documented as ineffective, but there was no evidence of follow-up interventions or reassessment for several hours. Family members observed the resident to be agitated, air hungry, and sweating, and repeatedly requested additional morphine administration and a change in dosing frequency. Despite these requests and the resident's ongoing symptoms, no further morphine was administered until approximately six hours after the initial dose. During this period, there was a lack of documentation regarding assessment, intervention, or communication with the physician or hospice team about the ineffective pain control. Nursing staff interviews confirmed that standard procedures for ineffective as-needed medication, such as notifying the physician and documenting follow-up, were not followed. Facility policies required staff to assess for pain, monitor effectiveness of interventions, and update care plans as necessary. The failure to administer prescribed morphine in a timely manner, reassess the resident's pain, and communicate with the physician or hospice team as required by policy led to prolonged unmanaged pain and discomfort for the resident during the end-of-life process.
Failure to Update Care Plan for Actual Skin Integrity Alterations
Penalty
Summary
Staff failed to develop and implement a comprehensive care plan addressing an actual alteration in skin integrity for a resident with multiple complex medical conditions, including hemiplegia, diabetes, chronic kidney disease, and heart failure. The resident was assessed as having moderate cognitive impairment, required total assistance for activities of daily living, and was frequently incontinent. Although the care plan identified a risk for skin integrity impairment and included general interventions such as pressure-relieving devices and scheduled repositioning, it did not address the resident's actual wounds and skin alterations that were documented in clinical records. Clinical documentation revealed the presence of moisture-associated skin damage to the left buttock and scrotum, a skin tear on the left arm, multiple pressure ulcers on the buttocks, an open area near the G-tube, and an unstageable wound to the left sacrum. Despite these findings, the care plan was not updated to reflect these actual skin integrity issues. Interviews with facility staff confirmed that the care plan should have been revised to include the resident's current wounds and specific interventions for their management, as required by facility policy.
Failure to Properly Assess and Manage Dialysis Access Bleeding Results in Immediate Jeopardy
Penalty
Summary
A deficiency occurred when staff failed to adequately assess and manage a resident's arteriovenous fistula (AVF) dialysis access site following hemodialysis. The resident, who had end stage renal disease and moderately impaired cognition, returned from dialysis with no visible bleeding at the AVF site. Several hours later, staff were alerted to bleeding at the site. The initial response involved applying a pressure dressing, but staff did not apply manual pressure or remove the dressing to directly visualize the access site to confirm that bleeding had stopped. Instead, they relied on the appearance of the dressing to determine if bleeding had ceased. Subsequent checks by staff continued to assess only the external dressing, without removing it to inspect the actual puncture sites. The resident experienced recurrent bleeding, with blood saturating the dressings and soiling the bed linens. At this point, staff applied additional dressings and eventually manual pressure, but only after significant blood loss had occurred. Emergency medical technicians arrived to find the resident with heavily blood-soaked bandages and applied effective pressure to control the bleeding. During transport, the resident experienced a sudden change in condition, requiring emergency intervention. The resident was transported to the hospital and diagnosed with hemorrhagic shock, necessitating transfusion of four units of blood and one unit of fresh frozen plasma. Interviews with facility staff and leadership revealed that there was no specific training or guideline in place for managing bleeding dialysis accesses, and that staff did not follow professional standards of practice for assessing and managing AVF bleeding. The facility's own policy required care consistent with professional standards, but this was not followed in the incident.
Failure to Ensure Staff Competency in Managing Bleeding Dialysis Access
Penalty
Summary
The facility failed to ensure that nursing staff and nurse aides were adequately educated and competent in managing bleeding from an arteriovenous fistula (AVF) in a resident receiving hemodialysis. The resident, who had end stage renal disease and moderately impaired cognition, was care planned for monitoring and intervention related to dialysis access, including instructions to apply pressure and notify a physician if bleeding occurred. Despite these directives, when the resident was found bleeding from the AVF, staff actions did not align with professional standards or the care plan. Nursing staff, including an LPN and an RN, responded to the bleeding by applying dressings and securing them, but did not initially apply manual pressure to the site as required. Both staff members relied on absorbent pads and pressure dressings without verifying that the bleeding had stopped by visualizing the access site. The situation escalated when the bleeding recurred, resulting in soaked bandages and blood loss, at which point emergency services were called. Upon arrival, EMTs found the resident with multiple blood-soaked bandages and controlled the bleeding with direct pressure, but the resident experienced a sudden decline in condition, requiring emergency intervention and subsequent hospitalization for hemorrhagic shock and blood transfusion. Interviews with staff revealed a lack of knowledge and training regarding the appropriate response to AVF bleeding. One LPN was unsure of the correct procedure and mentioned the use of a clamp, which is not standard practice for AVF management. The Staff Development Nurse confirmed that there was no formal training or guideline provided to staff on managing bleeding dialysis accesses, and no documentation was available to show that staff had received such training. The facility's policy stated that care should be consistent with professional standards and physician orders, but this was not reflected in staff actions or training.
Injury During Mechanical Lift Transfer Due to Hoyer Lift Tilting
Penalty
Summary
A deficiency occurred when a resident with a history of transient ischemic attack, cerebral infarction, difficulty walking, syncope, and moderate cognitive impairment was transferred from bed to wheelchair using a Hoyer Lift by two nurse aides. The resident was dependent on staff for transfers and required a mechanical lift with two-person assistance, as documented in the care plan. During the transfer, after the resident was placed in the wheelchair, the Hoyer Lift tilted and the overhead bar struck the resident's head, resulting in an abrasion to the scalp. Interviews with staff revealed that both aides were present and had been trained in the use of the Hoyer Lift, with one guiding the resident and the other moving the lift. However, neither the Regional Resource Nurse nor the Director of Nurses could identify the cause of the Hoyer Lift tilting after the transfer. The incident was documented, and the resident's injury was assessed and treated.
Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
A deficiency was identified when a nursing assistant (NA) failed to perform hand hygiene in accordance with facility policy during incontinent care for a resident. The resident had diagnoses including Type 2 diabetes mellitus without complications and a urinary tract infection, and was assessed as having moderate cognitive impairment with frequent incontinence and dependence on staff for toileting hygiene. The resident's care plan required extensive assistance for toileting hygiene. During observation, the NA prepared for incontinent care by gathering supplies and donning gloves, then removed the resident's brief and performed cleaning. After removing gloves, the NA applied a new set of gloves without performing hand hygiene, applied barrier cream, and again changed gloves without hand hygiene before applying a clean brief. Hand hygiene was only performed after the care was completed and gloves were removed. The NA acknowledged in an interview that facility policy required hand hygiene after glove removal during incontinence care and admitted to forgetting this step. Review of the facility's glove policy confirmed the requirement to wash hands after removing gloves.
Failure to Honor Resident's Care Preferences
Penalty
Summary
The facility failed to honor a resident's choices related to care, specifically regarding the assignment of a nurse aide (NA) to the resident. The resident, who was admitted with diagnoses including quadriplegia, neuralgia, and neurogenic bowel, had intact cognition and was dependent on staff for activities of daily living. The resident had a physician's order to be assisted to bed by 8 PM, but due to issues with NA #1, this was often delayed until 10 PM. The resident expressed dissatisfaction with NA #1, citing personality conflicts and a lack of timely response to call lights, and had refused care from NA #1 multiple times. Despite the resident's repeated requests to not have NA #1 provide care, the facility continued to assign NA #1 to the resident, citing staffing assignments based on seniority and the need for two staff members for transfers. Interviews with various staff members revealed that while some were aware of the resident's preferences, there was no documentation of grievances or actions taken to address the resident's concerns. The Director of Nursing Services (DNS) and the Administrator were not aware of the resident's requests until the time of the surveyor's inquiry. The facility's policy on resident rights emphasizes the importance of respecting residents' choices and preferences, including the right to choose healthcare providers. However, the facility did not adhere to this policy in the case of the resident, as the resident's preference to not have NA #1 provide care was not accommodated. The DNS acknowledged the resident's right to choose their caregiver and indicated that there were no issues with reassigning NA #1 to another unit, yet this was not done until after the surveyor's inquiry.
Failure to Review and Document Advance Directives
Penalty
Summary
The facility failed to properly review and document advance directives for two residents, leading to deficiencies in honoring their treatment preferences. Resident #66, who was admitted with conditions including congestive heart failure and chronic kidney disease, had an advance directive indicating a preference for DNR (Do Not Resuscitate). However, there was a delay in updating and confirming these wishes due to communication issues with the resident's conservator, Person #1. The facility's social worker struggled to contact Person #1, and there was a lack of documentation and follow-up on the resident's initial refusal to sign the advance directive. This resulted in a gap in the completion of the Resident/Patient Health Care Instructions document, which was only resolved after surveyor inquiry. Resident #70, admitted with a history of stroke and severe cognitive impairment, had an advance directive form signed by an unidentified individual. The facility failed to verify the authenticity of the signature or review the advance directives with the resident's actual representatives. Despite having a physician's order for DNR/DNI/RNP, the facility did not ensure that the advance directives were reviewed or updated with the resident's legal representatives since admission. This oversight was only identified after surveyor inquiry, highlighting a lack of adherence to the facility's policy on advance directives. The facility's policy requires that advance directives be reviewed and updated with the resident or their representative during the care planning process and as needed. However, in both cases, the facility did not comply with this policy, resulting in deficiencies in the management of advance directives. The failure to ensure timely and accurate documentation of residents' treatment preferences reflects a significant lapse in the facility's responsibility to support residents' rights regarding treatment and advance directives.
Failure to Notify of Change in Condition and Abuse Allegation
Penalty
Summary
The facility failed to notify the provider or resident representative of a change in condition and an allegation of abuse for two residents. Resident #8, who was admitted with dementia and end-stage renal disease, had a scab on the forehead that was not properly assessed or reported to the appropriate parties. Despite a physician's order for wound consults and regular skin checks, the scab was not documented in the nurse's notes, and there was no RN assessment or notification to the APRN/MD and resident representative. Interviews with staff revealed that the expected protocol for change in condition was not followed, as there was no documentation or notification regarding the scab on Resident #8's forehead. Resident #66, admitted with congestive heart failure and other conditions, reported an incident where a nurse aide allegedly put a washcloth in their mouth. The resident's conservator was not notified of this abuse allegation, and there was no documentation in the nurse's or social service notes about the notification. Interviews with staff indicated that the conservator should have been informed, and the DNS expected documentation of such notifications in the clinical record. However, RN #3 admitted to not documenting the notification attempt, which was against her usual practice. The facility's policies on skin assessment and notification of changes were not adhered to in these cases. The Skin Assessment Policy requires thorough documentation and notification of changes in skin condition, while the Notification of Changes policy mandates informing the resident, physician, and representative of significant changes. Both policies were violated, leading to deficiencies in care and communication for Residents #8 and #66.
Failure to Conduct Quarterly Resident Care Conferences
Penalty
Summary
The facility failed to ensure that resident care conferences (RCC) were completed quarterly for a resident admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and stage 2 chronic kidney disease. The resident was admitted from a short-term general hospital with moderately impaired cognition. The care plan identified the resident as at risk for limited meaningful engagement due to self-isolation, with interventions to provide opportunities for choice during care and activities. However, the social service notes did not document quarterly care conferences from the resident's admission through a specified period, with only a few conferences completed later. Interviews with the resident, the conservator, the social worker, and the MDS Coordinator revealed that while there were frequent informal meetings and communications, official RCCs were not scheduled or documented as required. The MDS Coordinator acknowledged that the resident's initial and subsequent quarterly RCCs were missed, and the DNS expected the first RCC to be completed shortly after admission. The facility's policy mandates that residents and their representatives be part of the interdisciplinary team and participate in care planning, with documentation if they do not participate. This deficiency highlights a lapse in adhering to the facility's policy and regulatory standards for resident care conferences.
Failure to Document RN Assessment and Incorrect Mattress Setting
Penalty
Summary
The facility failed to document an RN assessment for a resident with a non-pressure skin condition. Resident #8, who was admitted with dementia and end-stage renal disease, had a scabbed area on the forehead that was not properly assessed by an RN. Despite a physician's order for a wound consult and treatment, the RN assessments were not documented from 5/13/24 to 7/1/24 and again from 11/17/24 to 11/19/24. Interviews with staff revealed that the area on the resident's forehead had been opening and healing repeatedly without proper documentation or assessment by an RN, contrary to the facility's skin assessment policy. Another deficiency was identified for Resident #68, who was admitted with neuralgia and neurogenic bowel. The resident's specialty air mattress was not set according to the physician's order, which specified it should be adjusted to the resident's weight. Observations revealed that the mattress was set to 220 lbs, significantly below the resident's actual weight of 323.6 lbs. Interviews with staff indicated a lack of awareness and adherence to the physician's order, and the discrepancy was attributed to a recent change in the type of mattresses used by the facility. The facility's policies on skin assessment and support surfaces were not followed, leading to these deficiencies. The lack of RN assessments for Resident #8's recurring forehead wound and the incorrect setting of Resident #68's specialty mattress demonstrate a failure to adhere to established protocols. These oversights were identified during interviews and observations, highlighting gaps in communication and compliance with care plans and physician orders.
Failure to Monitor Fluid Intake for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to ensure proper monitoring of fluid intake and output for a resident with end-stage renal disease, congestive heart failure, and dependence on renal dialysis. The resident was admitted with a care plan that included hemodialysis three times a week and a fluid restriction of 1500 cc per day. However, the facility did not document the daily total of fluid intakes as required by the physician's order and facility policy. The clinical records and facility documentation from October 1 to November 18 did not reflect the necessary documentation of the resident's fluid intake, particularly the dietary intake of 1080 cc during meals. Interviews with various staff members, including the Director of Clinical Operations, unit manager, and charge nurse, revealed a lack of awareness and communication regarding the resident's fluid restrictions and the absence of a system for documenting fluid intake and output. The facility's hemodialysis policy required communication with the dialysis facility about nutritional and fluid management, including monitoring intake and output measurements. However, the facility failed to adhere to these standards, as evidenced by the lack of documentation and awareness among staff members about the resident's fluid restrictions and the necessary monitoring procedures.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding hospital transfers for six residents. These residents had various medical conditions, including diabetes, end-stage renal disease, congestive heart failure, and chronic kidney disease, and were transferred to the hospital for different reasons such as acute encephalopathy, shortness of breath, and abnormal EKG results. Despite these transfers, the facility's action summary reports did not reflect any notifications to the Ombudsman, which is a requirement. Interviews with facility staff revealed a lack of awareness and understanding of the notification requirements. The social worker responsible for updating the Ombudsman indicated that she was not informed about the need to report hospitalizations and only updated the Ombudsman on other types of resident departures, such as those leaving against medical advice or after a respite stay. The Director of Nursing Services was also unaware that hospital transfers were not being reported to the Ombudsman. The facility's policy on transfers and discharges requires that residents and their representatives receive a notice that includes the contact information for the Ombudsman. However, the facility did not maintain evidence that such notices were sent regarding hospital transfers. This oversight led to a deficiency in the facility's compliance with regulatory requirements for notifying the Ombudsman about resident hospitalizations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Windsor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Kimberly Hall North | 0 mi | ★★★★★ | 7 | 0 |
| Seabury | 2.1 mi | ★★★★★ | 0 | 0 |
| Touchpoints At Bloomfield | 2.2 mi | ★★★★★ | 19 | 0 |
| Autumn Lake Healthcare At Windsor | 2.2 mi | ★★★★★ | 48 | 0 |
| Bloomfield Center For Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 2 | 0 |
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