Carlyle Senior Care: Consent Violation for Psych Meds - SC
Federal inspectors documented the violation during a March 27, 2025 survey at the facility on West Clarke Road. The finding centered on a single resident, identified in inspection records as Resident 72, whose case exposed a gap between what the facility knew about him and what its own nursing director knew.
Resident 72 had been admitted with diagnoses that included strange and inexplicable behavior. His most recent cognitive assessment, completed in February 2025, gave him a score of 13 out of 15 on the Brief Interview for Mental Status, a result that placed him in the cognitively intact range. That number was apparently what the Director of Nursing relied on.
What she did not check was a separate document sitting in a different section of the same electronic medical record. A Certification of Inability to Make Healthcare Decisions, signed by two physicians and dated July 27, 2023, established that Resident 72 was legally incapable of making healthcare decisions for himself. The document was nearly two years old by the time the consent form was signed.
On March 20, 2025, one week before inspectors arrived, the Director of Nursing completed an informed consent form for psychoactive medication use with Resident 72 directly. He signed it. She signed it as the completing nurse.
When inspectors interviewed her the morning of March 27, she said she had been unaware of the incapacity certification. She said she looked at his BIMS score, spoke with him about the medication, and he said okay. She took that as understanding.
"She agreed that if a physician had deemed him incapable it was inappropriate to discuss the risk and benefits of the medications with him and have him sign the document," the inspection report states.
She also agreed that his legal representative, not the resident himself, should have been the one to receive that information and sign the form.
The resident's representative was never contacted. There is no indication in the inspection findings that the representative was informed of the medication, its risks, or its benefits at any point before the consent was obtained from a man two physicians had already said could not consent.
The tension at the center of this case is not complicated. A cognitive screening tool showed a score that looked fine. A legal document in the same record said something different. The Director of Nursing used one and missed the other, then signed her own name to a consent form that should never have gone to the resident at all.
CMS rated the violation at the minimal harm level, meaning inspectors determined no actual harm occurred or was likely. The deficiency applied to Resident 72 specifically, though inspectors noted the failure had the potential to affect any resident at the facility receiving psychotropic medications.
Carlyle Senior Care of Florence is a licensed nursing facility in Florence, South Carolina. The inspection was completed March 27, 2025.
Resident 72's legal representative still does not appear in the record as having been told anything about the medication their family member was placed on, or asked to weigh in on whether the risks were worth taking.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carlyle Senior Care of Florence from 2025-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 30, 2026 · Our methodology
Carlyle Senior Care of Florence in Florence, SC was cited for violations during a health inspection on March 27, 2025.
Federal inspectors documented the violation during a March 27, 2025 survey at the facility on West Clarke Road.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.