Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Kimball Farms Nursing Care Center during CMS and state inspections, most recent first.
A resident with dementia and generalized anxiety disorder experienced significant weight loss while CNA meal intake documentation in the EHR was frequently left incomplete, contrary to the facility’s Clinical Documentation policy requiring point-of-care charting every shift. Review of the resident’s Meal Intake by Day report over several months showed numerous blank entries for breakfast, lunch, and dinner where food and fluid intake amounts should have been recorded. The DON confirmed that blank spaces indicated CNAs had not completed required documentation of the resident’s meal consumption.
Infection control and PPE use failures were observed for residents on isolation precautions and for a resident on EBP for an indwelling urinary catheter. Staff entered isolation rooms without the required PPE, failed to change an N95 between residents, reused a gown that had fallen on the floor, and entered rooms without eye protection. On another unit, a CNA provided care for a resident with a Foley catheter without wearing the required gown under EBP signage.
A nurse exceeded the 5% medication pass error threshold while administering meds to a resident with dementia and HF. The nurse crushed ER Potassium Citrate and Metoprolol Succinate that were ordered to be swallowed whole, gave chewable ASA instead of enteric-coated ASA, and administered Polyethylene Glycol eye drops instead of the ordered Natural Tears; the DON stated there could be an adverse reaction.
A facility failed to coordinate assessments with the PASRR Unit for a resident admitted with Unspecified Dementia and Major Depressive Disorder. The resident was initially approved for a Provisional Emergency admission limited to seven days, but the facility did not complete a required Level II Resident Review when the stay exceeded this period. The Social Worker confirmed the absence of necessary documentation, indicating non-compliance with procedures.
A facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition. A resident with Major Depression and Anxiety Disorder experienced a suicide attempt, leading to emergency interventions and a psychiatric program transfer. Despite this, the facility did not conduct a required PASRR Level II screen to assess the need for additional support services, as mandated by their policy.
A resident over 65 with Dementia and Parkinson's Disease was not offered the Pneumococcal Vaccination upon admission, as required by facility policy. The consent form lacked documentation of vaccine information being provided or consent obtained. The Infection Preventionist admitted to documenting the vaccine as declined without proper consent, although the resident's representative later consented to the vaccination.
Incomplete CNA Meal Intake Documentation for a Resident with Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident when CNA documentation of meal intake was left incomplete. The facility’s Clinical Documentation policy, last revised 12/29/25, requires that Nursing Assistant documentation be completed at point of care in the electronic health record and that the facility meet Department of Public Health requirements for documentation every shift. Resident #1, admitted in May 2025 with diagnoses including dementia and generalized anxiety disorder, had a Meal Intake by Day report used to record the amount of food and fluids consumed daily. Review of this resident’s Meal Intake by Day report showed multiple blank entries where intake amounts should have been recorded. In July 2025, breakfast intake was left blank for 2 of 31 opportunities and lunch for 7 of 31 opportunities. In August 2025, breakfast was blank for 4 of 31, lunch for 7 of 31, and dinner for 1 of 31 opportunities. In September 2025, breakfast was blank for 6 of 30 and lunch for 10 of 30 opportunities. In October 2025, breakfast was blank for 7 of 23, lunch for 12 of 23, and dinner for 1 of 23 opportunities. During an interview, the DON confirmed that any blank spaces meant the CNA did not complete their documentation as required and stated that the CNA should have entered the appropriate amount of food and fluids consumed, especially given that the resident had experienced significant weight loss.
Infection Control and PPE Use Failures
Penalty
Summary
The facility failed to follow infection control practices for residents on Contact/Droplet Isolation for COVID-19 on the Windemere unit. During breakfast tray delivery, a unit manager entered a resident’s room with only a surgical mask and did not don a gown, gloves, eye protection, or change to an N95 respirator before entering. In another room, a CNA wore PPE for one resident on isolation but did not change the N95 respirator before entering a second resident’s room that also had Contact/Droplet Precautions posted outside the door. Additional observations on the Windemere unit showed staff not using PPE correctly while entering isolation rooms. A nurse dropped a gown on the floor, picked it up, and donned the same gown before entering a resident’s room. A CNA entered one resident’s room and then another resident’s room without eye protection in either room, despite Isolation Droplet/Contact Precautions signage posted outside both doors. The Infection Control Preventionist confirmed that the staff should have worn the required PPE and that not wearing or changing PPE as indicated was a concern due to the risk of transmission of infection. On the Sedgewick unit, a resident with diagnoses including obstructive and reflux uropathy had an indwelling Foley catheter and an order to maintain the catheter every shift. EBP signage was posted outside the resident’s room and a PPE bin with gowns and gloves was available. A CNA was observed providing care in the room and exited while removing gloves but without wearing a gown. The CNA stated she was not aware of the EBP sign and did not wear the appropriate PPE when providing care, and another CNA stated staff are required to wear PPE when providing care because the resident had a urinary catheter.
Medication Pass Errors With Crushed ER Medications and Wrong Ordered Forms
Penalty
Summary
The facility failed to maintain a medication pass error rate of less than 5% for Resident #58 during observation, interview, and record review. Of 26 medication pass opportunities, the observed error rate was 15.38%. Resident #58 was admitted in July 2024 with diagnoses including dementia and heart failure. The resident’s December 2025 MAR included orders for Aspirin 81 mg enteric coated, Metoprolol Succinate 50 mg extended-release to be swallowed whole and not crushed or chewed, Potassium Citrate 10 mEq extended-release to be swallowed whole and not crushed or chewed, and Natural Tears (Dextran 70/Hypromellose 0.1% - 0.3%) eye drops. During medication administration observation, Nurse #2 poured Potassium Citrate extended-release tablets, Metoprolol Succinate extended-release tablets, and a chewable Aspirin tablet into a medication cup, then crushed all tablets together and mixed them with pudding before giving them to the resident. Nurse #2 also administered Polyethylene Glycol eye drops instead of the ordered Natural Tears eye drops. In interview, Nurse #2 acknowledged that the Potassium Citrate and Metoprolol Succinate orders specified not to crush, that the Aspirin order required the enteric coated form, and that the eye drop order specified Natural Tears; she stated she should have contacted the provider for different forms instead of administering medications that did not follow the physician orders. The DON stated the concern was that there could be an adverse reaction to the medication administration.
Failure to Coordinate PASRR Assessments for Resident
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission and Resident Review (PASRR) Unit for a resident who was admitted with diagnoses of Unspecified Dementia with Behavioral Disturbance and Major Depressive Disorder. The resident was initially approved for a Provisional Emergency admission, which is limited to a maximum of seven calendar days. However, the facility did not ensure that a Level II Resident Review was completed when it became apparent that the resident's stay would exceed this time frame. The facility's policy required notification and a request for a Level II PASRR from the Department of Mental Health when a resident's stay was to exceed the Provisional Emergency period. Despite this requirement, there was no documentation indicating that the PASRR Unit received an updated PASRR Level I Screening after the resident exceeded the seven-day approval. During an interview, the Social Worker confirmed the absence of the original PASRR Level I Preadmission Assessment and the lack of documentation for an updated screening, highlighting the facility's failure to comply with the necessary procedures.
Failure to Conduct PASRR Level II Screen After Significant Change in Condition
Penalty
Summary
The facility failed to notify the State Mental Health Authority for a resident review after a significant change in mental condition occurred for one resident. The resident, who was admitted in June 2023 with diagnoses of Major Depression and Anxiety Disorder, experienced a significant change in condition when they had an incident that appeared to be a suicide attempt. This led to emergency mental health interventions, including a transfer to an inpatient psychiatric program. Despite these events, the facility did not conduct a Preadmission Screening and Resident Review (PASRR) Level II screen, which is required to determine if the resident needs additional specialized support services. The facility's policy on PASRR, revised in September 2023, mandates a referral to the Department of Developmental Services or Department of Mental Health when a resident experiences a significant change in condition that may impact their PASRR disability status. However, the facility did not follow this policy, as there was no documented evidence of a PASRR resident review after the resident's significant change in mental condition. The Social Worker confirmed during an interview that a resident review should have been completed and submitted to the PASRR office, indicating a failure to adhere to the required procedures.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the Pneumococcal Vaccination to a resident, identified as Resident #57, at the time of admission or shortly thereafter, as required by their policy. The resident, who was over 65 years old and diagnosed with Dementia and Parkinson's Disease, was admitted in June 2023. The facility's policy, revised in September 2023, mandates that residents be offered immunization against Pneumococcal disease unless contraindicated or previously immunized. However, the resident's consent form dated October 18, 2023, showed no evidence that the Pneumococcal Vaccine information was provided, nor was there any consent or declination documented. During an interview, the Infection Preventionist (IP) acknowledged that the vaccine consent form did not indicate that the Pneumococcal Vaccine information had been provided or that the vaccine had been consented to or declined. The IP admitted to documenting that the vaccine was offered and declined without obtaining proper consent. It was later confirmed that the resident's representative consented to the vaccinations, but the resident had not received the PCV-20 vaccine as required.
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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 Lenox
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Carmel Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Lee Healthcare | 2.7 mi | ★★★★★ | 17 | 0 |
| Springside Rehabilitation And Skilled Care Center | 5.3 mi | ★★★★★ | 2 | 0 |
| Berkshire Place | 5.9 mi | ★★★★★ | 2 | 0 |
| Hillcrest Commons Nursing & Rehabilitation Center | 6.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.