Carlyle Senior Care of Williston

In the surveyor’s words

From the most serious findings on record at Carlyle Senior Care of Williston, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 14, 2023

  Based on interview, observation, and record review, the facility failed to protect 1 of 3 residents from physical abuse. On 04/02/23 at approximately lunchtime, Resident (R)24 was slapped by Certified Nursing Aide (CNA)2 after a combative incident. This was witnessed by CNA3 and the Activities Director. Because a wheelchair-bound resident was struck by a nursing aide, the resident was placed at increased risk for severe harm and mental anguish. On 06/13/23 at approximately 3 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. […]

• No harm, potential for more than minimal, widespreadF583Jun 14, 2023

  Based on observations, interviews, and facility policy reviews, the facility failed to protect the confidential health information of residents on 2 of 2 halls. Specifically, the facility posted the username and password to the electronic health record (EHR) on the wall. This had the potential to affect all residents. Findings include: Review of a policy titled Confidentiality of Personal and Medical Records, dated 10/24/2022, revealed, this facility honors the resident's right to secure, and confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. 1. […]

• No harm, potential for more than minimal, patternF584Apr 17, 2026

  Based on facility policy review, observation, and interview, the facility failed to ensure residents' right to reside in a safe, clean, comfortable, and homelike environment, related to routine cleaning of resident rooms and bathrooms. The deficient practice affected 8 (Rooms 1, 2, 7, 8, 9, 10, 11, and 12) of 9 resident rooms reviewed for environmental concerns. Findings included: Review of an undated facility policy titled, Routine Bathroom Cleaning indicated, It is the policy of this facility to establish policies, procedures and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare associated infection (HAI). The policy's Procedure included 1. […]

• No harm, potential for more than minimal, patternF641Jan 8, 2021

  Based on record review and interview the facility failed to ensure the most recent Minimum Data Set (MDS) assessments were coded accurately in the area of falls for three (3) of three (3) residents reviewed for falls (Residents #3, #5 and #6). The findings include: 1. Review of the Face Sheet for Resident #3 revealed he/she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #3 expired on [DATE]. Review of the Nursing Progress Notes dated [DATE] for Resident #3 revealed he/she had a fall with a laceration to the right forehead. The Nursing Progress Notes dated [DATE] revealed Resident #3 had a fall with a laceration to the left forehead which required stitches. […]

• No harm, potential for more than minimal, isolatedF641Apr 17, 2026

  Based on facility policy review, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents' status, which affected 1 (Resident (R)32) of 2 residents reviewed for tube feeding and R40, 1 of 1 resident reviewed for edema. Findings included: An undated facility policy titled, MDS [Minimum Data Set] 3.0 Completion, revealed Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The policy revealed, 1. […]