All citations for Complete Care at Kimberly Hall North

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Complete Care at Kimberly Hall North

Last standard health inspection on record

July 17, 2026

Showing 1 to 24 of 24 citations

  1. Immediate jeopardy to resident health or safety

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 12, 2022).

  2. Immediate jeopardy to resident health or safety

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level J.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (June 12, 2022).

  3. Harm to a resident

    Provide safe, appropriate pain management for a resident who requires such services.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0697, Quality of Life and Care Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 6, 2022).

  4. No harm, with potential for more than minimal harm

    Establish emergency prep training and testing.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0036, Emergency Preparedness Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  5. No harm, with potential for more than minimal harm

    Establish staff and initial training requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  6. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  7. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  8. No harm, with potential for more than minimal harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  9. No harm, with potential for more than minimal harm

    Provide a written emergency evacuation plan.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0711, Miscellaneous Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  10. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  11. No harm, with potential for more than minimal harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 6, 2022).

  12. No harm, with potential for more than minimal harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0609, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 6, 2022).

  13. No harm, with potential for more than minimal harm

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0882, Infection Control Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 6, 2022).

  14. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Pattern (more than a few residents). CMS level E.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  15. No harm, with potential for more than minimal harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0211, Egress Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  16. No harm, with potential for more than minimal harm

    Provide properly protected cooking facilities.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0324, Smoke Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  17. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  18. No harm, with potential for more than minimal harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0550, Resident Rights Deficiencies. Inspection of May 8, 2024. Found during a complaint inspection.

    Past non-compliance: already corrected by the time of the inspection (April 19, 2024).

  19. No harm, with potential for more than minimal harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of May 8, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 19, 2024).

  20. No harm, with potential for more than minimal harm

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0757, Pharmacy Service Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 6, 2022).

  21. No harm, with potential for more than minimal harm

    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0887, Infection Control Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 6, 2022).

  22. No harm, with potential for more than minimal harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0355, Smoke Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  23. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

  24. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of May 26, 2022. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2022).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.