Caroline Kline Galland Home

In the surveyor’s words

From the most serious findings on record at Caroline Kline Galland Home, in the surveyor’s own words.

• Actual harm, isolatedF689May 27, 2022

  Based on observation, interview, and record review the facility failed, to implement interventions including adequate supervision and assistive devices consistent with a resident's needs, goals, and care plan for one of four residents (Resident 1), reviewed for abuse and neglect. This failure caused Resident 1 to have an avoidable fall that resulted in harm, the fracture of both bones in the shin, that caused pain, suffering and loss of confidence in Staff. Findings included . Review of 05/03/2022 Quarterly Minimum Data Set, (MDS-an assessment tool), showed Resident 1 had diagnoses including an above the knee amputation of the left leg, muscle weakness, reduced mobility, and required extensive physical assistance of two persons for transfer. […]

• No harm, potential for more than minimal, widespreadF851May 28, 2026

  Based on interview and record review the facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS - a federal agency managing health care programs and health insurance standards) for Quarter 4 (October 1, 2025 to December 31, 2025) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure affected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact the provision of resident care and services.Findings included.Review of the facility's 02/06/2026 CMS PBJ - Upload Data File confirmation page showed the data file was sent by the facility to CMS on 02/06/2026 at 12:50 PM. […]

• No harm, potential for more than minimal, widespreadF812Apr 7, 2022

  Based on observation, interview, and policy review the facility failed to store, prepare, and serve food under sanitary conditions for 190 out of 193 residents who received food from the facility kitchen. Specifically, the facility failed to ensure a meat slicer was clean and sanitary; and that beard restraints were available for use and worn by staff with beards during food preparation. The facility reported a census of 193 and three residents received tube feedings. Findings included . During an observation on 04/04/22 at 9:20 AM, Staff N had a beard measuring 0.50 - 1.00 inch in length. Staff N was working in the food preparation area of the kitchen in preparation for the noon meal. Staff N was wearing a surgical mask for COVID-19 prevention but failed to wear a beard restraint. […]

• No harm, potential for more than minimal, patternF565Mar 4, 2026

  Based on interviews and record reviews the facility failed to ensure resident concerns were dealt with timely, verbal grievances were identified as such, resident rights were promoted periodically as required, and residents were provided the opportunity to make a grievance anonymously for 1 of 1 Resident Council groups reviewed. These failures placed residents at risk for unmet needs, frustration, untimely resolution of grievances, and a diminished quality of life.Findings included.<Policy>According to the facility policy titled, Resident and Family Grievances, dated 2026, a resident or family member may voice a grievance to staff. The policy showed the Administrator was the Grievance Official. […]

• No harm, potential for more than minimal, patternF641Mar 4, 2026

  Based on observation, interview, and record review the facility failed to accurately assess 4 of 4 residents (Residents 59, 68, 123, & 186) reviewed for restraints. Failure to ensure resident assessments were completed accurately on the Minimum Data Set (MDS- an assessment tool) placed residents at risk for unidentified and/or unmet care needs, and diminished quality of life.Findings included.<Resident 59>According to the 11/20/2025 Quarterly MDS Resident 59 had no memory impairment. The MDS showed Resident 59 had diagnoses of autoimmune disorder and depression. […]