Caroline Kline Galland Home

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, and interview the facility failed to conduct resident and/or resident representative involved care conferences within seven days of each quarterly assessment for 4 of 7 residents (Residents 54, 68, 36, & 123) and failed to ensure resident Care Plans (CP) were updated as needed for 3 of 7 residents (Residents 190, 123 & 4) reviewed for care planning. These failures placed residents at risk for inconsistent and/or inadequate care and treatment, unmet care needs, unnecessary care, frustration, other negative health outcomes, and a diminished quality of care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the following: appropriate delegation of nursing tasks to non licensed staff; preparation and administration of insulin in accordance with manufacturer instructions; clarification and following of physician orders; and accurate documentation of nursing tasks for 5 of 35 sampled residents (Residents 218, 7, 8, 205, and 206) and 3 supplemental residents (Residents 225, 226, and 171). These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided meaningful, life enriching activities for 4 of 4 residents (Residents 213, 215, 217, & 212) reviewed for activities. This failure placed residents at risk for boredom and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain provider orders, complete safety assessments, and obtain consents for the use of seatbelts for 4 of 4 residents (Residents 59, 68, 123, & 186) reviewed for the use of physical restraints. This failure placed the residents at risk of injury, unmet needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided the portion size they were assessed to require for 2 (Residents 7 & 17) of 36 sample residents reviewed and 4 supplementary residents (Residents 224, 22, 202, and 223). This failure placed residents at risk for hunger and weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure meals were prepared in sanitary conditions for 1 of 1 main kitchens reviewed, failed to ensure food was reheated in unit kitchens on 2 of 5 units (100 East unit and 200 East unit), and failed to reheat lunch meals for 1 of 2 (Resident 213) resident's that required feeding assistance. These failures placed residents at risk for eating contaminated or unsafe food, foodborne illnesses and food not palatable according to resident's preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow 3 (Residents 8, 186, & 123) of 6 residents reviewed for choices, the right to make choices regarding important daily routines including accommodating preferences for the frequency and/or type of bathing and food choices. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to thoroughly investigate a fall for 1 of 7 sampled residents (Resident 190) reviewed for accidents. Facility failure to complete thorough investigations placed residents at risk for further accidents, negative health outcomes, and poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 2 of 6 residents (Resident 190 & 52) reviewed for PASRR. This failure placed residents at risk of not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to assist residents with Activities of Daily Living (ADLs - personal hygiene, grooming, bathing,) for 2 of 5 residents (Residents 6 & 217) reviewed who were assessed to be dependent on staff for ADLs including oral care, nail care, and bathing. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were monitored and received the treatment they were assessed to require for 2 of 3 (Residents 3 & 7) residents for edema (swelling) management and blood pressure monitoring. The failure to monitor and implement interventions for edema management and blood pressure management placed residents at risk for decline in medical status, quality of life related to unmet care needs and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services for catheter care for 1 of 4 residents (Resident 54) reviewed for Urinary Catheters (a tube inserted to drain the bladder). This failure placed residents at risk for unmet care needs, diminished quality of life, and poor health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to: provide medically related social services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of residents for 1 of 5 residents (Resident 190) reviewed for nutrition; assist residents in obtaining resolution regarding refusals of treatment and care for 1 of 5 residents (Resident 190) reviewed for nutrition. This failure placed residents at risk of unmet social service needs, negative health outcomes, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 5 sampled residents (Resident 190) reviewed for nutrition, received necessary treatment and services consistent with professional standards of practice to treat broken or missing teeth and oral/dental pain. This failure placed all other residents at risk for lack of dental services, unmet care needs, negative health outcomes, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure staff followed contact precautions (a type of isolation precaution used to prevent the spread of infections transmitted by direct or indirect contact) for 2 (2 East unit and 1 East unit) of 4 units reviewed for contact precautions; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear and gowns used to prevent exposure to infectious materials) for 1 of 3 residents (Resident 68) and 2 supplemental residents (4 & 142) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms in long-term care settings); and ensure staff used appropriate Hand Hygiene (Staff P & BBB) during wound and catheter care. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to establish an infection prevention and control program that included implementation of the Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 2 (Resident 10 & 68) of 5 residents reviewed for ABO use. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABOs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 3 (Residents 133, 17, & 142) of 6 residents reviewed for hospitalizations. Failure to ensure written notification was provided to the resident and/or the resident's representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about transfers/discharges.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the resident's mental health condition and refer the residents to the appropriate state authority for Level II evaluation and determination for 5 of 9 (Resident 159, 27, 48, 169, & 115) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and /or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 5 residents (Resident 159, 142, & 45) reviewed for unnecessary medications were free from unnecessary psychotropic medications and monitored for behaviors. Failure to discontinue as needed psychotropic medications after 14 days and to identify/monitor target behaviors for as needed antipsychotic medications placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects.

Inspectors wroteBased on observation, interview and record review the facility failed to implement an effective Infection Control Program for 4 of 5 units (Units 300 East, 300 North, 300 South, & 100 East) The failure to: ensure facility staff sanitized glucometers (a blood sugar monitoring device); ensure food and drinks were handled in accordance with infection control standards when being distributed on the unit; ensure staff used Personal Protective Equipment (PPE) when required for residents with infectious diseases; perform hand hygiene as required; use appropriate infection control standards during incontinence care and wound care (Residents 156 & 119); and ensure resident rooms were free from staff property; placed residents at risk for exposure to infectious materials, communicable diseases, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided care and services in a dignified manner for 7 (Residents 106, 12, 144, 123, 45, 123, & 156) of 36 sample residents reviewed. The failure to: provide dignified toileting assistance (Residents 106, 12, & 144), ensure staff sat when feeding residents (Resident 45), provide bodily privacy when transporting residents to and from the shower room (Resident 123), and ensure catheter bags (bags that collect urine from tubing placed in the body to assist with urinary drainage) were covered to obscure their contents (Resident 156) placed residents at risk for undignified care and a diminished sense of self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and/or implement comprehensive Care Plans (CPs) for 7 (Residents 88, 83, 81, 119, 115, 159, & 429) of 36 sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, in appropriate care, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated as needed to reflect changes in resident's care needs for 5 (Residents 45, 83, 156, 106, 169) of 36 sample residents whose CPs were reviewed and failed to provide care conferences as required for 2 (Residents 134 & 17) of 36 sample residents whose CPs were reviewed. The failure to update CPs with changes in residents' health status placed residents at risk for unmet care needs, unnecessary care, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician's orders were clarified for 2 of 36 sampled residents reviewed (Residents 88 & 144), and failed to ensure medications were administered timely for 1 of 5 sample residents (Resident 432) observed during medication pass. These failures placed residents at risk for ineffective treatments, inappropriate medications, and delayed treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL) related to toileting, cleanliness, and grooming for 2 (Residents 106 & 119) of 7 sample residents reviewed for ADLs. The failure to provide residents who were dependent on staff assistance the toileting, dressing, and shaving assistance they required placed the residents at risk for poor hygiene, long facial hair, embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 2 of 2 sampled residents (Resident 106 & 142) reviewed for activities. Failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of 36 sampled residents (Residents 429, 142, & 169) reviewed for care and services, received the necessary care and services they required in accordance with professional standards of practice. The facility failed to monitor resident's hypo/hyperglycemia (high and low blood sugar levels) symptoms and follow bowel management protocols that placed residents at risk for delays in treatment, potential decline in health, and other negative health outcomes. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Restorative Nursing Program (RNP), rehabilitative treatment/services and to follow the physician orders for 3 of 5 residents (Residents 27, 134, & 144) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 (Resident 45 & 169) of 5 sampled residents, reviewed for vaccinations, were up to date on the current recommendations from the Center for Disease and Control and Prevention (CDC) related to pneumococcal vaccinations. This failure placed residents at risk for contracting pneumonia, with their associated complications of infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medication and medical supplies were disposed timley for 4 of 4 medication rooms (East 2A, East 2B, North, & East 1) reviewed. These failures placed residents at risk for receiving medications with decreased or no potency, and use of medical supplies with compromised integrity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident safety from accidents and hazards for 3 of 4 (Residents 149, 27 & 104) residents reviewed for falls. The failure to determine the basic factors that caused resident falls and implement interventions related to the identified cause, placed residents at risk for further falls, significant injuries, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure indwelling urinary catheter (a tube to empty the bladder) care met infection control standards for 1 of 4 residents (Resident 12) reviewed for catheters. The failure to 1) review the risks and benefits of placing the catheter bag on the floor per Resident 12's preference, 2) update the care plan and 3) implement interventions to prevent contamination and Urinary Tract Infections (UTI), placed Resident 12 at risk for continued UTIs, sepsis (a blood infection) and a diminished quality of life.