Williston Care Center and Rehab

In the surveyor’s words

From the most serious findings on record at Williston Care Center and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF678Nov 8, 2023

  Based on interviews and record review, the facility failed to honor a resident's expressed advanced directive for end of life by failing to ensure life saving measures, such as cardiopulmonary resuscitation [CPR], were initiated when Resident #1 was found unresponsive and absent of life. Staff A, Licensed Practical Nurse stated the resident was dead and she did not provide cardiopulmonary resuscitation or contact Emergency Medical Services. The resident was not legally pronounced deceased until the Medical Director wrote a clarification statement on [DATE] at 8:27 PM stating that he had acknowledged the resident's death by releasing the remains to a funeral home. […]

• Immediate jeopardy, patternF726Nov 8, 2023

  The facility failed to ensure nursing staff followed policy/procedure and the nurse practice act related to initiating emergency care for a resident found to be without a pulse or respiration such as initiating cardiopulmonary resuscitation (CPR) or calling emergency medical services. Staff A, a Licensed Practical Nurse, observed Resident #1 on [DATE] at 6:30 AM, unresponsive and absent of life, pronounced Resident #1 as deceased and withheld cardiopulmonary resuscitation despite the resident's full code status. The Licensed Practical Nurse stated the resident was dead and she did not provide cardiopulmonary resuscitation or contact Emergency Medical Services. […]

• No harm, potential for more than minimal, widespreadF806Mar 6, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident received foods that accommodated their preferences for 5 of 5 sampled residents, Residents #1, #2, #3, #4, and #5. Finding include: 1. During an observation on 3/6/2023 at 8:25 AM, Resident #1 was eating breakfast, which included ham, scrambled eggs and apple juice. During an interview on 3/6/2023 at 8:25 AM, Resident #1 stated the trays and items served do not match, stating, Look at it. […]

• No harm, potential for more than minimal, widespreadF684Jul 20, 2022

  Based on observation, interview, and record review, the facility failed to ensure the residents received care for peripherally inserted central catheters in accordance with professional standards of practice for 2 of 2 residents with central venous catheters, Residents #200 and #206, in a total sample of 48 residents. Findings include: 1. During an observation on 7/17/2022 at 10:51 AM, Resident #200 had a left upper arm midline catheter with a dressing date of 7/10/22, with 2 sides lifting up and exposing the insertion site and a 2x2 gauze under the transparent dressing. During an interview on 7/17/2022 at 10:51 AM, Resident #200 stated, They haven't changed this dressing since it was put in. […]

• No harm, potential for more than minimal, widespreadF812Jul 20, 2022

  Based on observation, interview, and record review, the facility failed to maintain the food production area and equipment in a clean and sanitary manner. Findings include: During the initial tour on 7/17/2022 beginning at 9:07 AM with the Certified Dietary Manager (CDM), observation of the food production area and equipment showed: 1. The oven had a black sticky substance around the control knobs under both the stove top and flat top. The stove front had long black, brown and white drips running down the length of the stove front. The stove door handles had a brown substance on them. 2. The fryer had white drips and splatter on both the front and sides of the fryer. 3. The tile floor between the fryer and convection oven had large amounts of black substances on the floor. […]