Carlyle Senior Care of Williston

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Working from clean areas to dirty areas, which included d. Clean inside and outside the sink, sink faucets and mirror. Wipe plumbing under the sink. Apply disinfectants to interior of sink and allow sufficient contact time with disinfectant according to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. The policy revealed, 4. Care Plan Team Responsibility for Assessment Completion included a. Interdisciplinary Responsibility for Completion of MDS Sections, which included i. The responsibility of all sections of the MDS will be clearly assigned; ii. Persons completing part of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure treatment in accordance with professional standards of practice for 1 (Resident (R)25) of 2 sampled residents reviewed for wound dressing changes. Specifically, R25's wound dressing was not changed on 04/13/26 as ordered. Findings included: Review of the facility policy titled, Documentation of Wound Treatments, dated 08/01/2025, indicated, Wound treatments are documented at the time of each treatment. Review of the facility policy titled, Clean Dressing Change, dated 11/30/2025, indicated, Physician's orders will specify type of dressing and frequency of changes. An admission Record indicated the facility admitted R25 on 10/24/25. According to the admission Record, the resident had a medical history that included a diagnosis of a chronic non-pressure ulcer of the right lower leg with unspecified severity (a persistent sore or wound not caused by pressure). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/26, revealed R25 had a Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, facility document review, observation, and interview, the facility failed to ensure drugs and biologicals were labeled in accordance with professional principles. Specifically, the facility failed to date a multi-dose vial of tuberculin purified protein derivative (PPD) (a solution used to detect tuberculosis infection) with an opened date and a discard date and failed to discard an expired multi-dose vial of tuberculin PPD. The facility also failed to date a semaglutide (an antidiabetic) injection pen with an opened date and discard date. The deficiencies were identified in 1 of 2 medication storage refrigerators observed. Findings included: Review of a facility policy titled, Medication Management, dated 04/10/2019, indicated, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. The policy indicated, 4. Labels for individual drug containers must include, which included f. The date the drug was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 2 (Resident (R)25 and R40) of 4 residents reviewed for EBP. Specifically, staff failed to don gowns prior to high contact resident care activities for R25 and R40. Additionally, Licensed Practical Nurse (LPN)2 failed to dispose of worn gloves prior to leaving R40's room. Findings included: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated 05/30/2024, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms [MDRO]. The policy also indicated, 'Enhanced barrier precautions [EBP] refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy also indicated, Wounds (e.g. [exempli gratia, for example], chronic wounds such as pressure ulcers, diabetic foot ulcers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify in writing the resident's responsible party (RP) of three of three Residents (R4, R23, and R33) transfer to the hospital out of a sample of 17 residents. This had the potential for the resident's RP not to be informed of the resident's transfer to the hospital and the reasons why. Findings include: 1.Review of the electronic medical record (EMR) under the Face Sheet tab revealed R4 was initially admitted to the facility on [DATE]. Review of R4's EMR under the Notes tab revealed R4 was admitted to the hospital on [DATE] due to hyperkalemia. There was no documentation, located in the EMR, of written notification regarding R4's transfer to R4's RP. 2.Review of the EMR under the Face Sheet tab revealed R23 was initially admitted to the facility on [DATE]. Review of R23's EMR under the Notes tab revealed R23 was admitted to the hospital on [DATE] due to sepsis. There was no documentation located in the EMR, of written notification regarding R23's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to provide written information regarding the facility's bed hold policy to the resident's responsible party (RP) at the time of transfer or within 24 hours of the transfer for three residents (Resident (R) 4, R23 and R33) of three reviewed for hospitalization out of a total sample of 17 residents. This failure has the potential to negatively impact any resident transferred to the hospital due to the RP not being aware of the bed hold options. Findings include: Review of the facility's policy titled, Bed Hold Notice Upon Transfer dated 02/01/23 indicated, Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide the resident and/or the resident's representative written notice which specifies the duration of the bed-hold policy and addresses the information explaining the return of the resident to the next available bed .Bed Hold Notice Upon Transfer 1. Before a resident is transferred to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Personal and medical records include all types of records the facility might keep on a resident, whether they are medical, social, fund accounts, automated, or other. On 06/12/2023 at 12:17 PM, an activities of daily living (ADL) coding poster was observed hanging on the wall, located on A-hall, next to an electronic touch screen kiosk, next to resident room [ROOM NUMBER]. There was a yellow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, facility document review, and facility policy review, the facility failed to provide services to a resident who was unable to carry out activities of daily living (ADL) necessary to maintain good grooming and personal hygiene for 1 (Resident (R)24) of 6 sampled residents reviewed for assistance ADL care. Specifically, R24 had toenails that were long, thick, and jagged. Findings include: Review of the facility policy titled, Nail Care, dated 11/27/2017, revealed, the purpose of this procedure guidelines for the provision of care to a resident's nails for good grooming and health. 1. Assessments of resident nails will be conducted on admission and readmission to determine the resident nail condition, needs, and preferences for nail care. 6. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. c. If a resident had a toe infection, diabetes mellitus, neurologic disorders, renal failure, or peripheral vascular disease (PVD), toenail trimming should be performed by a physician or practitioner. Review of the facility policy titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility policy, observation and interviews, the facility failed to complete ensure appropriate infection control and hand hygiene protocols were followed during an observation of the laundry for 1 of 1 laundry facility reviewed. Findings include: Record review of facility policy titled, Linen and Personal Laundry revealed All contaminated linen and personal laundry will be handled appropriately to prevent cross-contamination. Laundry will be hygienically cleaned and handled to prevent recontamination from dust and dirt during loading and transport. When moving from the soiled area to the clean area (drying, folding, and storage), staff will remove the gown and gloves, and wash their hands with antibacterial soap. An observation and interview on 6/14/23 at 8:54 AM revealed Housekeeping Staff (HK)1 with appropriate PPE and handling linen to be put in the washing machine. After putting the linen in the machine, HK1 was observed walking into the dirty linen room and doffing PPE appropriately. Observation revealed HK1 exiting the dirty linen area without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.