Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Florence during CMS and state inspections, most recent first.
Late quarterly MDS assessments were found for multiple residents, with 19 of 19 quarterly reviews completed beyond the 92-day requirement. Record review showed several assessments were completed 124 to 144 days after the prior quarterly review or ARD, and one assessment had no completion date. The DON said the ADON signs off on MDS assessments behind the LPN AA and did not know the due timeframes, while the RNC acknowledged several late assessments.
Failure to Address Ongoing Low Water Temperatures: The facility did not implement an effective QAPI/PIP to address persistent low water temperatures and plumbing issues. QAPI minutes showed no PIP related to the problem, while logs and observations found tepid water in resident rooms, shower areas, and other care areas, with temperatures as low as 68 degrees. Staff, including CNAs, an LPN, and maintenance personnel, reported the issue had been ongoing for months, and residents stated they had no hot water in their room bathrooms and were routinely cleaned with cold to tepid water.
Inconsistent hot water temperatures in resident care areas. The facility had multiple areas with only cold or tepid water, including resident room bathrooms, a shower room, and staff/visitor bathrooms. A Maintenance Director said water temperatures were checked weekly, but staff and residents reported ongoing problems for months, with some residents routinely cleaned with cold to tepid water and staff sometimes needing to use water from other rooms for bathing and handwashing.
A facility failed to document and resolve resident grievances about water temperatures. Several residents reported no hot water in their room bathrooms and said they were bathed with cold to tepid water, while another resident said the water in his room was never warm. Surveyors also observed low water temperatures in multiple rooms and a shower room. The DON stated the concerns were treated as situational reports rather than a formal grievance, and no resident meeting or grievance resolution occurred.
Late MDS Assessments: The facility failed to complete Annual MDS assessments within the required timeframe for eight residents and failed to complete admission MDS assessments within 14 days for two residents. Record review showed multiple assessments were completed well past the ARD or admission date, and staff interviews indicated confusion about MDS due dates and submission timeframes.
A resident with multiple diagnoses, including DM, COPD, respiratory failure, pressure and venous/arterial ulcers, and hospice/palliative care, had a significant change MDS completed far beyond the required timeframe. The record showed the significant change date was identified well before the assessment completion, and CAAs were completed at the same time as the late MDS. An LPN stated assessments are due within 14 days, while the DON said she did not know the assessment or submission timeframes.
The facility did not implement a comprehensive, data-driven QAPI program as required, particularly in the area of abuse prevention. The only documented performance improvement project was a brief, inadequately documented effort by the Administrator, lacking analysis, supporting documentation, or sub-committee involvement. Multiple abuse complaints were substantiated during the survey, and the facility's approach did not meet its own policy standards.
The facility did not consistently monitor or evaluate antibiotic use, as antibiotics were started for several residents without obtaining appropriate cultures or laboratory confirmation. In multiple cases, antibiotics were prescribed after hospital visits or for wound care without following the facility's policy for antibiotic stewardship, and staff interviews confirmed that required cultures were not always obtained before starting treatment.
A resident who had been certified by two physicians as unable to make healthcare decisions was given information about psychotropic medication and signed the informed consent form, rather than the resident's representative. The DON relied on the resident's BIMS score and was unaware of the incapacity certification, resulting in the failure to properly inform and obtain consent from the appropriate party.
A medication cart was left unattended in a hallway with its computer screen displaying resident names, allowing multiple individuals to pass by and potentially view protected health information (PHI). An LPN admitted to leaving the screen open and not knowing how to lock it, while the DON confirmed that staff are required to keep such information out of sight and secure.
The facility did not conduct comprehensive investigations into incidents of resident-to-resident abuse, failing to interview all involved parties and witnesses, and omitting key documentation. In two separate altercations involving residents with cognitive impairments, the facility's investigations lacked statements from all involved individuals and did not identify or interview staff witnesses, contrary to policy requirements.
Multiple incidents occurred where residents were not protected from physical and verbal abuse, including a cognitively impaired resident striking another, a staff member verbally abusing a resident with threats and profanity, and two residents with dementia engaging in a physical altercation after one wandered into the other's room. Staff did not always intervene promptly or complete required assessments in a timely manner, resulting in lapses in abuse prevention and resident care.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS assessments within 92 days of the most recent prior quarterly review or comprehensive assessment for 14 of 16 residents reviewed, with 19 of 19 quarterly assessments found to be late. The report states that the facility policy required quarterly assessments to be completed using an ARD no greater than 92 days from the most recent prior quarterly or comprehensive assessment, but multiple resident records showed assessments completed well beyond that timeframe. Examples included quarterly assessments for residents with ARDs or prior quarterly review dates that were 124, 129, 132, 135, 136, 138, 139, 143, and 144 days apart from completion dates, and one quarterly assessment had no completion date as of the survey date. The records reviewed identified late quarterly assessments for residents including R17, R7, R27, R33, R42, R48, R52, R55, R60, R63, R73, R74, R9, and R8. The DON stated that the ADON signs off on MDS assessments behind the LPN AA and said she did not know the assessment or submission timeframes for due dates. The RNC stated that assessments are due by the 92nd day and submissions are due after that, and acknowledged several late assessments when shown the list of 16 residents' assessments.
Failure to Address Ongoing Low Water Temperatures
Penalty
Summary
The facility failed to implement an effective Performance Improvement Plan to address ongoing low water temperatures throughout the building. Review of the facility QAPI document and QAPI meeting minutes from 2/2025 through 2/2026 showed no indication of a Performance Improvement Plan related to plumbing problems or water temperatures. The Water Temperature Log for 2026 documented temperatures below 100 degrees in multiple weeks, including the whirlpool and resident rooms. During observations on 3/24/26, 3/25/26, and 3/26/26, surveyors found tepid water in resident care areas, including temperatures as low as 68 degrees in the west hall shower room and temperatures in resident rooms ranging from 70 to 98.5 degrees. Interviews confirmed the water issue had been ongoing and widely known among staff and residents. The Director of Maintenance stated water temperatures were checked weekly and adjusted as needed, but he was not sure of a minimum hot water temperature. Maintenance staff reported checking hot water heaters when temperatures were below 100 degrees. CNAs and an LPN reported inconsistent water in resident rooms and shower areas, with staff sometimes needing to use water from other rooms to bathe residents or wash hands. Four cognitively intact residents stated they had no hot water in their room bathrooms and were routinely cleaned with cold to tepid water. The Administrator stated he was unaware of the low water temperatures and the nonworking hot water faucet in the center employee/visitor restroom, and the Administrator, DON, and Senior Nurse Consultant stated they had not put a PIP in place to address the low water temperatures.
Inconsistent hot water temperatures in resident care areas
Penalty
Summary
The facility failed to ensure comfortable water temperatures were maintained throughout resident care areas. Review of facility policies showed the facility was expected to maintain appropriate water temperatures in resident care areas and to report abnormal findings such as water that was too cold or hot. During observations, the center hall visitor/employee bathroom had only cold water from the faucet, and the west hall visitor/employee bathroom had only cold water flowing from both the hot and cold faucets after the water was allowed to run for five minutes. Additional observations in resident rooms and the west hall shower room showed water temperatures ranging from 98.5 degrees to 68 degrees, with several readings below 100 degrees and some as low as 70 degrees and 68 degrees. Interviews confirmed the issue had been ongoing for months. The Director of Maintenance stated water temperatures were checked weekly and adjusted as needed, but he was not sure of a minimum hot water temperature. A Maintenance Assistant stated that when water temperatures were lower than 100 degrees, he checked the hot water heaters to ensure the temperature at the heater was 120 degrees. CNAs and an LPN reported that some resident rooms and the shower room had only cold or tepid water, and staff sometimes had to go to other rooms to obtain hot water for bathing or handwashing. Four cognitively intact residents who participated in Resident Council stated they had no hot water in their room bathrooms and were routinely cleaned with cold to tepid water; one resident also reported the shower room water was often too cold. The Administrator, DON, and Senior Nurse Consultant stated they were not aware of complaints about hot water not being available in various parts of the facility.
Failure to Document and Resolve Resident Grievances About Water Temperature
Penalty
Summary
The facility failed to ensure resident grievances were documented and resolved regarding uncomfortable water temperatures. During a group interview, four cognitively intact residents stated there was no hot water in the bathrooms in their rooms and that they were routinely cleaned with cold to tepid water; one resident also stated the shower room water was often too cold. The residents said they had discussed the issue with the former Activities Director, but the current AD’s resident council notes from December 2025 through March 2026 contained no documented concerns about water temperature, and the grievance logs from March 2025 through March 2026 contained no grievances related to water temperatures. One resident also reported that the water in his room was never warm and that staff sometimes bathed him in cool water or obtained water from another room. During observation, water temperatures in several resident rooms and the west hall shower room were measured at 98.5 degrees, 97 degrees, 90 degrees, and 90 degrees. The Maintenance Assistant stated that when water temperatures were lower than 100 degrees, he checked the hot water heaters to confirm the temperature at the heater was 120 degrees. The DON stated the residents’ concerns had been reported situationally rather than as a formal grievance, so no grievance was addressed and she had not met with the residents regarding a resolution. The Administrator, DON, and Senior Nurse Consultant later stated they were not aware of complaints about hot water not being available in various parts of the facility, and they said the Maintenance Director did not notify them of abnormal temperature findings during weekly checks.
Late MDS Assessments
Penalty
Summary
The facility failed to ensure comprehensive Annual MDS assessments were completed within 366 days of the ARD for eight of eight residents reviewed who required an Annual MDS assessment. The record review showed that the Annual MDS assessments for R7, R17, R27, R33, R52, R60, R63, and R73 were completed after the required timeframe, with completion dates ranging from 21 to 52 days past the ARD. The facility policy titled MDS 3.0 Completion stated that an Annual Assessment is a comprehensive assessment completed using an ARD no more than 366 days from the most recent prior comprehensive assessment and no more than 92 days from the most recent quarterly assessment. The facility also failed to ensure comprehensive admission MDS assessments were completed within 14 days of admission for two of six residents reviewed for admission MDS assessment. R55's admission MDS was completed 57 days after admission, and R81's admission MDS was completed 18 days after admission. During interview, an LPN stated that assessments are due within 14 days of the due date and are required to be submitted within 14 days of completion. The DON stated that the ADON signs off on MDS assessments behind the LPN and that she did not know the assessment or submission timeframes for due dates.
Delayed Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days of identifying a significant change in status for one resident. The resident had diagnoses including diabetes mellitus requiring insulin, hyperlipidemia, arthritis, anxiety disorder, depression, COPD and respiratory failure, chronic pain syndrome, weakness, peripheral vascular disease, psychophysiologic insomnia, pressure and venous/arterial ulcers, and hospice/palliative care. The resident’s MDS showed a significant change date of 10/30/25, but the assessment was not completed until 12/15/25, which was 46 days after the significant change date. The record also showed that 10 CAAs were completed on 12/15/25 for the significant change MDS, including cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, behavioral symptoms, falls, nutritional status, pressure ulcer, psychotropic drug use, and pain. During interview, an LPN stated that assessments are due within 14 days of the due date and must be submitted within 14 days of completion. The DON stated that the ADON signs off on MDS assessments behind the LPN and said she did not know the assessment or submission timeframes for due dates.
Failure to Implement Effective QAPI Program for Abuse Prevention
Penalty
Summary
The facility failed to develop and implement an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that addresses all aspects of care, quality of life, and resident safety, specifically related to abuse prevention. The facility's QAPI policy required systematic investigations and analysis of underlying causes or contributing factors for problems affecting facility-wide processes. However, review of the facility's performance improvement projects (PIPs) over the past year revealed that the only documented PIP on abuse prevention was a single-page document completed in two days by the Administrator, with no supporting documentation, analysis, or evidence of a sub-committee or summary of activities. The PIP used an outdated federal regulation reference and set a goal of zero abuse without further detail or analysis. During interviews, the Administrator, DON, and Infection Preventionist confirmed the lack of comprehensive documentation and analysis for the PIP. The survey team substantiated three abuse complaints during their visit, and noted that several abuse complaints had been investigated by the State Agency three weeks prior. The PIP did not include a summary, identification of the issue to QAPI, involvement of a sub-committee, or an analysis of the process, indicating a lack of systematic investigation and data-driven approach as required by the facility's own policy.
Failure to Monitor and Evaluate Antibiotic Usage
Penalty
Summary
The facility failed to monitor and evaluate antibiotic usage for four out of five residents reviewed for antibiotic use. According to the facility's Antibiotic Stewardship Program policy, antibiotic orders should be reviewed for appropriateness, and random audits should be performed to verify completeness and appropriateness. However, in multiple cases, antibiotics were started without appropriate cultures being obtained. One resident was sent to the emergency room for an indwelling urinary catheter, received an antibiotic without a culture being done, and the Infection Preventionist did not question the order. Another resident returned from the ER on an antibiotic for urinary retention without a urine analysis or culture being completed. A third resident was sent to the ER for a change in condition, received a urine analysis but no culture, and was started on an antibiotic. A fourth resident with a Stage IV pressure ulcer was started on doxycycline for 14 days after a wound odor was noted, but no wound culture was obtained prior to starting the antibiotic. Interviews with staff confirmed that cultures were not consistently obtained before starting antibiotics, and that the Infection Preventionist and wound doctor were aware that cultures should have been completed but were not. The Infection Preventionist acknowledged the need to obtain cultures from the hospital or to call for them if not provided, and the wound doctor admitted that a culture should always be completed before prescribing antibiotics. The administrator stated that the expectation is to follow CMS guidelines for antibiotic stewardship.
Failure to Obtain Proper Informed Consent for Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's representative was informed of the risks and benefits associated with the use of psychotropic medications. The resident in question was admitted with a diagnosis that included strange and inexplicable behavior. Although the resident's Brief Interview for Mental Status (BIMS) score indicated cognitive intactness, two physicians had certified that the resident was unable to make healthcare decisions for himself. Despite this certification, the informed consent for psychoactive medication use was signed by the resident rather than the resident's representative. The Director of Nursing (DON) completed the consent process by discussing the medication with the resident and obtaining his signature, relying solely on the BIMS score and not reviewing the certification of incapacity. The DON later acknowledged being unaware of the resident's incapacity status and agreed that the resident's representative should have been the one to receive information and provide consent. This oversight resulted in the resident, who had been deemed incapable of making healthcare decisions, being the sole recipient of information regarding the psychotropic medication and the one to sign the consent form.
Failure to Secure Electronic Medical Records Exposes PHI
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as required by its HIPAA Security Measures policy. During an observation, a medication cart was left unattended in the hallway with the computer screen on, displaying the names of six residents. Multiple residents and staff walked past the cart and could view the screen before the LPN returned. The LPN stated she typically leaves the screen open with residents' names visible and was unaware of how to lock the screen, acknowledging that protected health information (PHI) could be immediately accessed by clicking on a resident's name. The Director of Nursing confirmed that staff are expected to keep computer records out of sight and lock screens when not present, and that all documentation containing PHI should be secured.
Failure to Thoroughly Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of resident-to-resident abuse, as required by its own policy and regulatory standards. In one incident, two residents with cognitive impairments were involved in a physical altercation in a TV room, but the investigation did not document what occurred, who the aggressor was, or include interviews with all involved parties. Specifically, there was no interview with the cognitively intact resident involved, no identification or interview of the staff member who witnessed the incident, and no interviews with other residents who may have had knowledge of the event. In another incident, a resident with Alzheimer's disease who wandered into another resident's room was involved in a physical altercation with two other residents, one of whom had dementia and the other was cognitively intact. The facility's investigative documents did not include interviews with other residents who may have witnessed the event. The investigation relied only on statements from the directly involved residents, and there was no written statement regarding the inability to interview the resident with a low BIMS score due to cognitive impairment. Interviews with the facility's Administrator confirmed that the investigations did not include all required interviews and documentation. The Administrator acknowledged that staff should have interviewed all involved residents and witnesses, and that the investigation was incomplete in identifying and interviewing all relevant parties. The lack of thorough investigation had the potential to affect other residents at risk for abuse.
Failure to Prevent and Respond to Resident and Staff Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as well as neglect, involving both resident-to-resident and staff-to-resident incidents. In one case, a resident with severe cognitive impairment and a history of disruptive behaviors physically struck another cognitively intact resident in a common area. Staff and witnesses confirmed the altercation, and the incident was substantiated by the facility administrator. The care plan for the aggressor included interventions to de-escalate agitation, but the incident still occurred, indicating a lapse in prevention measures. Another incident involved a staff member verbally abusing a cognitively intact resident by accusing him of theft, using profane language, and threatening physical harm. Multiple staff and the resident confirmed the verbal abuse, and the staff member was immediately suspended and did not return to the facility. The facility's investigation corroborated the resident's account and the inappropriate conduct by the staff member. Additionally, there was a physical altercation between two residents, both with cognitive impairments, after one resident wandered into another's room. The altercation resulted in minor injuries, and staff intervened to separate the residents. However, the required skin assessment for one of the residents was not completed until the following day, indicating a delay in post-incident care. These events demonstrate failures in supervision, timely assessment, and adherence to abuse prevention policies.
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What surveyors actually found near you
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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 Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Faith Healthcare Center | 4.1 mi | ★★★★★ | 5 | 1 |
| Honorage Nursing Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Presbyterian Communities Of South Carolina-florenc | 4.2 mi | ★★★★★ | 0 | 0 |
| Heritage Post Acute | 4.8 mi | ★★★★★ | 7 | 0 |
| Veteran Village | 4.8 mi | ★★★★★ | 0 | 0 |
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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.