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 Kingstree during CMS and state inspections, most recent first.
A facility failed to protect residents’ right to voice grievances without fear of retaliation and did not maintain an effective grievance process for all residents reviewed. Residents reported they did not know where to get grievance forms, there was no grievance box, and complaints could be discarded or lead to retaliation. Ongoing Resident Council concerns about evening snacks, delayed call light response, and delays in care were not documented, investigated, tracked, or resolved, and the SSD, DON, CNC, AD, and Administrator confirmed there was no anonymous grievance system despite policy requiring one.
Failure to Date, Label, and Cover Stored Food: Food items in the kitchen were found stored without required dates, labels, or proper covering. An open package of bread in the refrigerator had no date, and multiple frozen items, including waffles, pork ribs, sausage links, and pork chops, were opened and/or exposed without labels or dates. The DS confirmed the findings and stated there was no schedule for checking food dates or expired items.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
A resident experienced unmanaged pain due to the facility's failure to reorder Morphine in a timely manner, resulting in missed doses and severe pain. Despite alternative pain management with Tylenol, the resident's pain remained uncontrolled, affecting mobility and oral intake. Staff interviews revealed communication lapses and policy non-adherence regarding medication ordering.
The facility failed to provide adequate pressure ulcer care and documentation for four residents, leading to deficiencies in wound assessment and implementation of care plans. Residents with conditions such as diabetes and chronic obstructive pulmonary disease were affected, with no initial wound assessments or documentation of care recommendations being implemented. The DON confirmed the lack of documentation and stated that air mattress pressure settings were not properly monitored.
A resident with moderately impaired cognition and on antiplatelet medications had several bruises that were not documented by the facility staff. Despite instructions to monitor and document side effects such as bruising, the March 2025 MAR indicated no side effects, and there was no documentation in the progress notes. Observations revealed bruises on the resident's forearms, neck, and shoulder, which the resident could not explain. Interviews with staff showed a lack of awareness and documentation regarding the bruises, contributing to the deficiency.
A resident with dementia and other conditions alleged that a CNA physically abused her during bathing. The allegation was reported to nursing staff but was not communicated to the Administrator or state agency within the required 2-hour timeframe, as confirmed by staff interviews and documentation. This failure to follow abuse reporting protocols resulted in a deficiency.
Failure to Maintain an Effective Grievance Process
Penalty
Summary
The facility failed to ensure residents were encouraged to voice grievances without fear of retaliation and failed to establish and maintain an effective grievance process for 89 of 89 residents reviewed. The facility policy stated grievances could be made verbally or during Resident Council meetings, must be documented, investigated, tracked to resolution, and responded to in writing, and residents could file anonymously. However, Resident Council meeting minutes from October 2025 through March 2026 showed repeated resident concerns about inconsistent evening snacks, excessive call light response times, and delays in receiving care, with no documentation that these concerns were treated as grievances, investigated, tracked, or resolved. March 2026 minutes contained no follow-up to the earlier concerns. During interviews, the Social Services Director, identified as the Grievance Official, stated residents were discouraged from filing grievances because of fear of retaliation and that some grievances were resolved the same day without being written down or tracked. She also confirmed Resident Council concerns were not documented as grievances and were not formally investigated or resolved through the grievance process. Residents reported they did not know where to obtain grievance forms, there was no grievance box in the facility, forms had to be requested from Social Services, and one resident stated they could not file a grievance without fear of retaliation. The DON, Corporate Nurse Consultant, Activity Director, Administrator, and SSD all confirmed there was no anonymous grievance submission system in place despite the facility policy allowing anonymous grievances, and that concerns voiced in Resident Council meetings were not consistently processed through the grievance system.
Failure to Date, Label, and Cover Stored Food
Penalty
Summary
Food products stored in the kitchen were not dated, labeled, or covered in accordance with the facility’s policy and professional standards. Review of the facility policy on Date Marking for Food Safety stated that ready-to-eat, time/temperature control for safety foods held more than 24 hours at 41F or less must be labeled and dated, and that opened items should be checked daily for expiration. During observation of the main refrigerator, four slices of white bread were found wrapped in plastic wrap with no date. In the main freezer storage room, waffles were observed in an open bag stored in a cardboard box with no date opened, and two racks of pork ribs were in an opened cardboard box without plastic wrap, leaving the ribs exposed to the freezer. Additional frozen items were also found opened and not labeled. Two plastic bags, one containing 50 frozen pork sausage links and the other containing eight bone-in pork chops, had been opened, resealed with plastic wrap, and had no label. During interview, the Dietitian Supervisor confirmed the observations and stated that bread should be in closed packaging and dated when taken out of the main refrigerator, and that all frozen items once opened should be dated by staff. The Dietitian Supervisor also stated that there had been no schedule for food being checked for dates or expired food.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide written documentation of a hospital transfer to Resident 5 and to the resident’s representative. The facility policy titled, Transfers and Discharges, dated March 2024, required written notification to include the specific reason for the transfer or discharge, the effective date, the specific location, an explanation of the resident’s rights to appeal, bed hold notification, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Resident 5’s admission record showed diagnoses including acute and chronic respiratory failure, paroxysmal atrial fibrillation, dysphagia, vascular dementia, and a stage II pressure ulcer of the left heel. Nursing progress notes documented that the resident was transferred to the hospital related to altered mental status and increased confusion, and later returned to the facility. There was no documented evidence that a written transfer/discharge notice was provided to the resident or the resident’s representative at the time of transfer or shortly thereafter. During interview, the Administrator stated the notices were generally not scanned into the EMR and were kept in the Admissions Coordinator’s office, but after searching that office, she could not find a discharge/transfer notification for Resident 5.
Failure to Manage Resident's Pain Due to Delayed Medication Reorder
Penalty
Summary
The facility failed to effectively manage pain for a resident, identified as R58, who was reliant on Morphine for pain management. R58, who was cognitively intact, had a history of significant medical conditions including an above-the-knee amputation and peripheral vascular disease, which contributed to chronic pain. The facility's policy required that Schedule II controlled substances, such as Morphine, be reordered seven days in advance. However, the facility did not adhere to this policy, resulting in a delay in ordering R58's Morphine, which led to the resident experiencing uncontrolled pain. The deficiency was further compounded by the facility's failure to administer eight doses of Morphine to R58 over several days. During this period, R58 reported severe pain, rated 10 out of 10, and was unable to move or get out of bed. The resident's oral intake decreased significantly as a result of the pain, with R58 refusing meals and consuming less than usual. Despite the availability of Tylenol as an alternative, it was ineffective in managing R58's pain. Interviews with facility staff, including an LPN and the DON, revealed a lack of timely communication and action to address the medication shortage. The LPN acknowledged that the prescription was not sent in a timely manner, and the DON was unaware of the issue until after the fact. The NP confirmed that the medication was supposed to be filled and sent to the facility, but there was no notification of the issue over the weekend. This lack of coordination and adherence to policy resulted in a significant lapse in pain management for R58.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for four residents, leading to deficiencies in wound assessment and documentation. The facility's policy required licensed nurses to conduct full body skin assessments upon admission and weekly, with findings documented in the medical record. However, for Resident 12, there was no initial wound assessment documentation, including the start date, wound size, and conditions. The Treatment Administration Record (TAR) also lacked documentation that the wound doctor's care recommendations were implemented. The Director of Nursing (DON) confirmed that the Infection Preventionist/Wound Nurse (IP/WN) did not document the initial measurements and conditions of the pressure wounds. Resident 27 was admitted with a diagnosis of diabetes and developed a stage II pressure ulcer on the right buttock. The nurse's note documented the open area and treatment, but there was no initial wound assessment, including the size and conditions of the pressure ulcer. The DON stated that the wound was verbally reported to the IP/WN, but the initial measurements and conditions were not documented. Similarly, Resident 30, with a history of chronic obstructive pulmonary disease and pressure-induced deep tissue damage, had no documentation of the wound doctor's care recommendations being implemented. Resident 47, admitted with diabetes and a stage III pressure ulcer of the sacral region, also lacked initial wound assessment documentation. The progress notes indicated a progression to a stage IV pressure wound, but there was no documentation of the treatment order or implementation of the care plan recommendations. The DON acknowledged the lack of documentation and stated that the facility's air mattresses were in group two, with pressure settings adjusted based on the resident's weight. The deficiencies in documentation and implementation of care plans placed the residents at risk of worsening pressure ulcers.
Failure to Document Bruising in Resident on Antiplatelet Medication
Penalty
Summary
The facility failed to document bruising for a resident, identified as R11, which could have led to a missed opportunity to distinguish between accidents and inflicted injuries. R11, who had a moderately impaired cognition with a BIMS score of 11 out of 15, was on antiplatelet medications, Clopidogrel Bisulfate and Aspirin, with instructions to monitor and document any side effects such as bruising. Despite these instructions, the March 2025 Medication Administration Record (MAR) indicated no side effects were present, and there was no documentation of bruising in R11's progress notes from January to March 2025. Observations on March 25, 2025, revealed several purple bruises on R11's forearms, neck, and shoulder, which R11 could not explain. Interviews with facility staff revealed a lack of awareness and documentation regarding R11's bruises. LPN1 was aware of the bruises but incorrectly believed R11 was not on anticoagulant medication. The Director of Nursing (DON) was also unaware of the bruises and confirmed the lack of documentation in the MAR and skin assessments. The Nurse Practitioner (NP) noted the bruises on March 24, 2025, and identified them as purpura but did not consistently communicate this to the staff. This lack of documentation and communication among the staff contributed to the deficiency in providing appropriate treatment and care according to orders and resident preferences and goals.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident within the required 2-hour timeframe. According to facility policy, any alleged abuse must be reported immediately, but not later than 2 hours after the allegation is made, to the Administrator and appropriate state agencies. In this incident, a resident with diagnoses including dementia with behavioral disturbance, Alzheimer's Disease, and major depressive disorder, alleged that a CNA dragged her from her bed and beat her to force her to take a bath. The allegation was made when the CNA reported the incident to the nurse at the end of her shift, but the nurses did not report the incident to the Administrator or state agency within the required timeframe. Documentation shows that the resident's son later reported the incident, and a body assessment revealed no signs of injury or bruising. Interviews with staff confirmed that the allegation was not reported as required by policy. The Administrator acknowledged that the incident should have been reported within 2 hours, and the RN Unit Manager confirmed awareness of the reporting requirement. The failure to report the allegation promptly constitutes a deficiency in following abuse reporting protocols.
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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 Kingstree
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dr Ronald E Mcnair Nursing & Rehabilitation Center | 12.5 mi | ★★★★★ | 8 | 0 |
| Lake City Scranton Healthcare Center | 18.3 mi | ★★★★★ | 0 | 0 |
| Lake Moultrie Nursing Home | 19.1 mi | ★★★★★ | 2 | 0 |
| Pocotaligo River Health And Rehab | 23.9 mi | ★★★★★ | 4 | 0 |
| Lake Marion Nursing Facility | 31.3 mi | ★★★★★ | 1 | 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.