Carlyle Senior Care: Resident Abuse Finding - Florence, SC
That delay, and the incident itself, is what federal inspectors classified as resident-to-resident abuse when they arrived at the facility at 133 West Clarke Road in late March 2025.
The sequence began when Resident 12, identified in inspection records only by number, wandered into the room occupied by Resident 52. A licensed practical nurse, identified in the report as LPN4, said she was in the middle of giving report to the oncoming shift when she was called down to the room. By the time she arrived, the two residents had already been separated.
What she found when she got there: redness on one side of Resident 12's neck. No redness on Resident 52.
Both Resident 52 and a third resident, Resident 60, told staff that Resident 12 had struck first.
The facility's own administrator confirmed to inspectors that a skin assessment should have been completed immediately after the incident. It was not. The assessment wasn't done until February 20, 2025, weeks after the altercation occurred.
The administrator also confirmed what inspectors had already concluded: this was resident-to-resident abuse.
LPN4 told inspectors there had been no further incidents between the residents since that night. That may be true. But the inspection record raises a harder question, one the report does not fully answer: what was done, and when, to make sure there wouldn't be.
A wandering resident reaching another resident's room is not a freak occurrence in memory care or long-term care settings. It is a known risk. Residents with dementia or cognitive impairment can move through hallways and into rooms they don't belong in, and the consequences range from confusion and distress to physical confrontation. What facilities are supposed to have in place, and what they are supposed to do when something goes wrong, is a matter of established protocol. At Carlyle Senior Care of Florence, the protocol for documenting physical injury after such an incident was not followed on the night it mattered.
The redness to Resident 12's neck was visible. LPN4 saw it. The separation of the residents happened. The incident was known to staff. And still, the skin assessment, the basic clinical documentation of what happened to a person's body, sat undone for weeks.
Inspectors rated the level of harm as minimal harm or potential for actual harm, the lower end of the federal harm scale. A small number of residents were affected. The deficiency did not rise to the level of immediate jeopardy, which CMS reserves for situations where inspectors find a pattern or practice likely to cause serious injury or death if not corrected immediately.
But the harm rating describes the outcome, not the gap. What the inspection record shows is a facility where a resident was struck, where the physical evidence of that strike was visible the same night, and where nobody completed the clinical paperwork documenting that evidence for nearly three weeks.
The facility's plan of correction was not included in the inspection narrative provided. For information on how Carlyle Senior Care of Florence intends to address the deficiency, CMS directs the public to contact the facility or the South Carolina state survey agency directly.
What the record does not show is whether anyone told Resident 12's family what happened the night of the incident. It does not show whether the wandering that led to the confrontation prompted any change to how Resident 12 moved through the facility at night. It does not show what, if anything, was said to Resident 52, who was in their own room when another resident came in and a physical altercation followed.
LPN4's account is the only staff account in the inspection narrative. She was giving report, she went to the room, she saw the redness, she confirmed the residents had been separated. She said there had been no further incidents. That is the full extent of what the record captures from the staff who were present that night.
Resident 52 and Resident 60 both gave the same account: Resident 12 hit first. The inspection record does not describe what Resident 12 said, or whether Resident 12 was able to say anything at all.
The inspection was completed on March 27, 2025. The incident itself occurred before February 20, the date the skin assessment was finally completed. The exact date of the altercation is not specified in the inspection narrative.
What is specified is the gap. The assessment was not completed until February 20. The facility's administrator confirmed it should have been completed immediately after the incident. Those two facts, placed next to each other, are what the deficiency finding rests on.
Carlyle Senior Care of Florence is a licensed nursing facility operating under CMS provider number 425163. The inspection was conducted by the South Carolina Department of Health and Environmental Control on behalf of the Centers for Medicare and Medicaid Services.
The facility received a deficiency citation under the resident abuse provisions of federal nursing home regulations. The citation covered a small number of residents. The harm level was rated at the minimal end of the scale.
Somewhere in that facility, Resident 12 is still a resident. So, as far as the inspection record indicates, is Resident 52, who was in their own room on a night that ended with another person's hands on them, and who then waited, as the weeks passed, for someone to write down what had happened to the person who was hit.
The paperwork came eventually. It took until February 20.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 30, 2026 · Our methodology
Carlyle Senior Care of Florence in Florence, SC was cited for abuse-related violations during a health inspection on March 27, 2025.
The sequence began when Resident 12, identified in inspection records only by number, wandered into the room occupied by Resident 52.
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.