Complete Care at Kimberly Hall-South

In the surveyor’s words

From the most serious findings on record at Complete Care at Kimberly Hall-South, in the surveyor’s own words.

• Immediate jeopardy, isolatedF698Feb 3, 2025

  Based on clinical record review, interviews, and review of facility documentation for one (1) of three (3) residents (Resident #1) reviewed for dialysis, the facility failed to adequately assess an Arteriovenous Fistula (AVF) (a surgical connection made between an artery and a vein accessed by needles to administer hemodialysis treatment) dialysis access site that was bleeding status post hemodialysis treatment to ensure bleeding had stopped, subsequently the resident had a significant bleed and was sent to the hospital and diagnosed with hemorrhagic shock requiring four (4) units of blood resulting in a finding of Immediate Jeopardy. The findings included: Resident #1's diagnoses included end stage renal disease and Type 2 diabetes mellitus. […]

• No harm, potential for more than minimal, patternF568Jul 7, 2026

  Based on interviews, review of the resident trust accounts, facility documentation, and facility policy for 6 of 6 residents (Resident #3, Resident #4, Resident #11, Resident #15, Resident #21, and Resident #84) reviewed for personal funds, the facility failed to ensure quarterly statements were provided to the residents. The findings include:1.Resident #3 had diagnoses that included diabetes, neurogenic bladder, and depression.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14 indicative of intact cognition. […]

• No harm, potential for more than minimal, patternF802Jul 7, 2026

  Based on observations, review of facility policy, and interviews, the facility failed to ensure sufficient dietary personnel were on duty to safely and effectively prepare and serve meals in accordance with scheduled mealtimes and resident needs and preferences. The findings include:1.Resident #47 had diagnoses that included anemia, high blood pressure, adjustment disorder with anxiety, and a history of alcohol abuse.Dietitian #1's note dated 4/21/26 identified the kitchen was aware of Resident #47's food preferences, including a preference for large portions, and would continue to honor these preferences and provide snacks between meals.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 had intact cognition and independent with eating and ambulation.The… […]

• No harm, potential for more than minimal, patternF809Jul 7, 2026

  Based on observation, review of facility policy, and interviews, the facility failed to ensure the resident meals were delivered timely. The findings include:Review of facility documentation, identified in part, steam cart delivery times for lunch were as follows:LUNCHBranford unit: 12:00 PMCornwall unit: 12:15 PMUnit F: 12:30 PMUnit E: 12:45 PMUnit D: 1:00 PMObservation on 6/30/26 at 12:23 PM identified the lunch steam table arrived at the [NAME] unit (16 residents) and the Dietary Director began plating lunch. […]

• No harm, potential for more than minimal, patternF812Jul 7, 2026

  Based on tours of the Dietary Department, observations, review of facility policy and interviews, the facility failed to ensure stored food was labeled and dated when opened, expired food was discarded, failed to ensure nourishment refrigerators were maintained in a clean sanitary manner, and failed to ensure the kitchen was maintained in a clean sanitary manner. The findings included:A tour of the Dietary Department on 6/29/26 at 7:45 AM with the Dietary Director identified: 1. The walk-in refrigerator was observed to contain the following opened food items that were undated when they were opened: a. One 3-liter container of egg salad (1/2 full) b. One pitcher of an unidentified red liquid (1/4 full) c. One half of a tomato d. 1/2 of two cut onions e. 1/2 of one cut tomato 2. […]