Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carlyle Senior Care Of Williston during CMS and state inspections, most recent first.
Resident Bathrooms Not Kept Clean and Maintained: Multiple resident rooms and shared bathrooms had cloudy mirrors, empty or damaged soap and toilet paper dispensers, rust-colored toilet and sink stains, a brown smudge on a toilet, damaged walls behind replaced dispensers, resident equipment stored in a bathroom, and a roll of toilet paper in a toilet bowl. The Maintenance Director stated rooms and bathrooms were expected to be cleaned daily, but also said rounds were not done often enough and some issues had not been reported.
MDS assessments were not accurately coded for two residents. One resident’s annual MDS still showed tube feeding even though the feeding tube had been discontinued, and another resident’s quarterly MDS omitted lymphedema from active diagnoses despite the diagnosis, care plan, and active order for treatment. The MDS Nurse, CDM, DON, and CCC acknowledged the assessments should have reflected the residents’ actual status.
Failure to Change Wound Dressing as Ordered: A resident with a chronic right lower leg ulcer had an order for daily wound care, but the TAR showed the dressing change was not completed as ordered and the dressing remained dated from the prior day. The resident stated the dressing was supposed to be changed daily but was not, and an LPN confirmed the dressing date and daily frequency. The DON, CCC, and ADM stated physician orders were expected to be followed.
Medication Labeling Errors in Refrigerator: An opened tuberculin PPD vial and an opened semaglutide injection pen were observed without required opened or discard dates, and another PPD vial had an expired discard date. Facility policy required multi-use vials and other medications to be labeled with applicable dates, and the DON, Corporate Clinical Consultant, and IP all confirmed that opened medications should have opened and expiration/discard dates.
Failure to Follow EBP During Resident Care: An LPN did not wear a gown while providing wound care to a resident with chronic leg wounds and EBP orders. In a separate observation, an LPN wore gloves while administering eye drops to a resident with wounds and lymphedema, then exited the room without removing the gloves or performing hand hygiene. Facility policy required gown and glove use for high-contact care activities, including wound care, and staff interviews confirmed the expected EBP practices.
The facility failed to provide written notification to the responsible parties of three residents regarding their hospital transfers due to conditions like hyperkalemia and sepsis. The Director of Nursing was unaware of the requirement for written notification, relying instead on verbal communication documented in the medical records.
The facility failed to provide written information about its bed hold policy to the responsible parties of three residents transferred to the hospital due to conditions like hyperkalemia and sepsis. Despite the policy requiring this information to be given at the time of transfer, there was no documentation confirming it was provided. The DON was unaware of the need to provide this information to the resident's RP.
Resident Bathrooms Not Kept Clean and Maintained
Penalty
Summary
The facility failed to ensure residents’ right to a safe, clean, comfortable, and homelike environment because routine cleaning of resident rooms and bathrooms was not consistently completed. During an initial tour, multiple bathrooms in Rooms 1, 2, 7, 8, 9, 10, 11, and 12 had visible cleanliness and maintenance issues, including cloudy or milky residue on mirrors, empty soap dispensers, damaged walls behind replaced soap dispensers, a plastic bag hanging over a toilet paper dispenser, a broken toilet paper dispenser with sharp edges, rust-colored stains in toilets and sinks, a brown smudged substance on the back of a toilet, resident equipment stored in a bathroom, and a roll of toilet paper inside a toilet bowl. On follow-up observation later the same day, the same conditions remained in the affected bathrooms. The damaged walls behind soap dispensers were still present, the cloudy or milky residue on mirrors remained, the broken toilet paper dispenser with sharp edges was still in place, rust-colored stains and the brown smudged substance were still visible, resident equipment remained stored in a bathroom, and the roll of toilet paper was still inside the toilet bowl. The Maintenance Director stated that every resident room and bathroom was expected to be cleaned at least once a day and more often if needed, and that even empty rooms were expected to have their bathrooms cleaned. During interviews and joint observation with the Maintenance Director and the Administrator, the Maintenance Director stated that some areas had not been reported for repair, that he did rounds with the Administrator only every couple of months, and that he did not make rounds often enough. He also stated that if staff could not remove stains, the toilet should be replaced, and that the wall behind the soap dispenser should have been repaired before the new dispenser was hung. The Administrator stated he expected the rooms to be in better condition and that a system such as a check-off list might be needed to increase rounds. Housekeeper #5 stated she was aware of the broken toilet paper dispenser and had written it in the maintenance book, but could not recall when it was reported.
MDS Assessments Were Not Accurately Coded
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ status. Facility policy stated that residents are to be assessed through a comprehensive, accurate, and standardized process, that each section of the MDS must be assigned and attested to by the responsible discipline, and that errors in transmitted assessments must be corrected when identified. For one resident, the annual MDS with an ARD of 01/16/26 indicated the resident still had a feeding tube and received 51% or more of total calories through tube feeding, even though the resident’s enteral feeding order had been discontinued on 12/04/25 because the feeding tube was discontinued. The resident’s record showed diagnoses including adult failure to thrive, protein-calorie malnutrition, Alzheimer’s disease, dysphagia, and gastrostomy status. During interview, the MDS Nurse and CDM both acknowledged the tube feeding information on the MDS was incorrect and stated it should have reflected that tube feeding had been discontinued. For another resident, the quarterly MDS with an ARD of 02/21/26 did not include lymphedema under active diagnoses, even though the resident’s record listed lymphedema and the care plan addressed edema related to a history of lymphedema. The resident also had an active order for a lymphatic boot for the right leg for lymphedema. The MDS Nurse stated the diagnosis should have been represented on the MDS, and the DON and CCC stated they expected the MDS to be accurately coded.
Failure to Change Wound Dressing as Ordered
Penalty
Summary
The facility failed to ensure treatment was provided in accordance with the physician’s order for one resident with a chronic non-pressure ulcer of the right lower leg. The resident was admitted on 10/24/25 and had a quarterly MDS showing a BIMS score of 11, indicating moderate cognitive impairment. The care plan identified a non-pressure wound to the right lower shin and directed staff to follow facility and physician orders. The active order required the right lower shin to be cleansed, xerofoam applied, and covered with a bordered gauze dressing, with the dressing changed daily and as needed until healed. The Treatment Administration Record showed the order was transcribed with a start date of 04/13/2026, but the entry for the dressing change on that date was blank, indicating the dressing change was not done. During interview and observation, the resident stated the dressing was supposed to be changed daily but was not changed daily, and the dressing observed on the right lower shin was dated 04/12/26. The LPN confirmed the dressing date and stated the dressing changes were supposed to be performed daily. The DON, CCC, and Administrator each stated physician orders were expected to be followed, and the CCC stated that if orders were not followed, it should have been documented why.
Medication Labeling Errors in Refrigerator
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with professional principles in 1 of 2 medication storage refrigerators observed. Facility policy required medications and biologicals to be labeled with applicable dates, including the date dispensed, expiration date when applicable, and for multi-use vials, the date initially opened or accessed and discard timing. A separate medication administration policy also required expiration dates to be identified, and a facility document for medications with shortened expiration dates instructed staff to write the date opened and date expired for tuberculin PPD and semaglutide products. During observation with the DON in the medication storage room, an opened and used vial of tuberculin PPD was found without an opened date or expiration/discard date, and another tuberculin PPD vial had a discard date of 04/15/25 written on it. An opened and used semaglutide injection pen belonging to a resident with diabetes mellitus and a BIMS score of 13 was also observed without an opened or discard date on the box. The DON stated used medications were expected to have opened and discard dates, the Corporate Clinical Consultant stated multi-dose vials had to have dates when opened along with expiration dates, and the IP stated opened medications should be labeled with an opened date and discard-by date.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Enhanced barrier precautions were not implemented for 2 residents with wounds. The facility policy stated that EBP required targeted gown and glove use during high-contact resident care activities, including wound care, and that residents with wounds or indwelling devices were to be placed on EBP. The facility also had a standard precautions policy stating all staff were to assume residents could be infected or colonized and use PPE as appropriate during resident care activities. One resident was admitted with a chronic non-pressure ulcer of the right lower leg and had care plan documentation for non-pressure wounds to the right and left shins. The resident’s active orders included wound care to the right lower shin and EBP every shift for a chronic wound. During observation, the resident’s room had EBP signage and a supply cart with gowns and gloves outside the door. When an LPN removed the resident’s right lower leg dressing, the LPN wore gloves but did not wear a gown. The LPN stated she should have worn a gown. The IP stated that if a resident had an open wound, whether acute or chronic, the resident had to be placed on EBP and gowns and gloves were required for patient care. A second resident had lymphedema and care plan documentation for wounds to the right leg and foot. The resident’s active orders included EBP and multiple wound care orders for the right leg and foot. During observation, an LPN entered the resident’s room to administer eye drops, performed hand hygiene and donned gloves, but then exited the room without removing the gloves or performing hand hygiene and returned to the medication cart before removing the gloves. The LPN stated she should have worn a gown when administering the eye drops and should have removed the gloves and performed hand hygiene before leaving the room. The IP stated the LPN should not have worn gloves in the hallway and should have removed them inside the room. The DON stated staff were expected to adhere to EBP guidelines and PPE should have been disposed inside the room before exiting.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the responsible parties (RPs) of three residents regarding their transfer to the hospital. This deficiency was identified through a review of electronic medical records (EMR) and interviews. Resident 4 was admitted to the hospital due to hyperkalemia, Resident 23 due to sepsis, and Resident 33 also due to sepsis. In each case, there was no documentation in the EMR indicating that written notification of the transfer was sent to the respective RPs. During an interview, the Director of Nursing (DON) explained that the standard procedure involved verbal communication with the RPs by the nurse involved in the transfer, which was then documented in the resident's medical record. However, the DON was unaware that written notification was also required. This oversight had the potential to leave the RPs uninformed about the residents' hospital transfers and the reasons for these transfers.
Failure to Provide Bed Hold Policy Information to Resident Representatives
Penalty
Summary
The facility failed to provide written information regarding its bed hold policy to the responsible parties (RPs) of three residents who were transferred to the hospital. This deficiency was identified during a review of records, interviews, and facility policy. The facility's policy requires that at the time of transfer for hospitalization or therapeutic leave, the resident and/or their representative must receive written notice specifying the duration of the bed-hold policy and conditions for returning to the facility. However, for three residents reviewed, there was no documentation confirming that this information was provided to their RPs at the time of transfer. The residents involved were transferred to the hospital due to medical conditions such as hyperkalemia and sepsis. Despite the facility's policy stating that written information should be provided to the resident or their representative before transfer or within 24 hours in case of an emergency, the Director of Nursing (DON) was unaware that this written information needed to be provided to the resident's RP. This oversight has the potential to negatively impact residents transferred to the hospital, as their RPs may not be aware of the bed hold options available.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Williston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carlyle Senior Care Of Blackville | 8.9 mi | ★★★★★ | 4 | 0 |
| Pruitthealth- Barnwell | 11 mi | ★★★★★ | 0 | 0 |
| Anchor Post Acute | 18.8 mi | ★★★★★ | 7 | 0 |
| Carlyle Senior Care Of Aiken | 20.7 mi | ★★★★★ | 8 | 2 |
| Pruitthealth- Aiken | 21.1 mi | ★★★★★ | 5 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.