Carlyle Senior Care: Resident Assault Investigation Failures - SC
The incident happened on February 19, 2025, at approximately 7:20 in the evening. The resident identified in inspection records as R12 had a documented history of wandering daily, a BIMS cognitive score so low she rarely or never understood what was communicated to her, and both short-term and long-term memory problems. Her wandering, according to her own assessment records, regularly intruded on the privacy and activities of other residents.
That evening, R12 entered a room occupied by at least two other residents.
The account that emerged from the facility's own investigation documents is specific and consistent across multiple sources. R60, a resident whose cognition tested as fully intact on a December 2024 assessment, described what happened in a written statement: "I yelled at [R12] to get out of my room. [R52] got up and tried to make her [R12] get out of the room. [R12] held onto my bed and would not turn it loose. [R12] slapped [R52] and [R52] slapped her [R12] back."
R52, who had been readmitted to the facility with a dementia diagnosis and whose January 2025 cognitive assessment showed moderate impairment, gave her own account in a written statement the same night: "[R12] was in our room. We told her [R12] to get out. She [R12] would not leave; I pushed her out of the room, and she [R12] slapped me in my face. I slapped her [R12] back in her face."
Staff separated the residents. Law enforcement was notified, according to the facility's initial report.
When a federal inspector interviewed R52 more than a month later, on March 25, her account had shifted slightly in detail but remained consistent in its arc. R12 had come into the room, gone into the bathroom, come out and sat down. R52 opened the bedroom door and told R12 to leave. R12 pushed her. R52 pushed back. A nurse entered the room and removed R52, telling her not to return.
R12 could not give any account at all. When an inspector interviewed her on March 26, she was alert but confused and could not recall the incident. Given her documented cognitive state, that was entirely predictable. The facility knew it. Her assessment records had already established that she rarely understood what was communicated to her, let alone what she herself had done.
The question the inspection raised was not whether R12 could be interviewed. It was whether the facility had documented that fact, and whether it had done anything else to understand what happened from her perspective or on her behalf. The answer, the administrator confirmed, was no.
During an interview on March 26 at 5:23 in the afternoon, the administrator acknowledged that no additional resident interviews had been conducted beyond those with R52 and R60. He described the incident as isolated. That characterization, he said, was the reason only two residents were interviewed. He also confirmed that while the facility was aware R12 had a low BIMS score and could not be interviewed, no one had written a statement documenting that fact or what steps, if any, had been taken in lieu of her account.
The investigative file contained no evidence of interviews with any other residents.
That gap matters for a specific reason. Physical altercations between residents in nursing home settings are not simply interpersonal disputes to be noted and filed. When one of the residents involved has a documented cognitive impairment severe enough that she cannot understand communication directed at her, the facility bears a particular responsibility to account for her experience and her safety, not only through her own words but through the record it keeps. The absence of any documented effort to address that limitation is what federal inspectors flagged.
R12's situation before the incident had been documented in her own assessment records with clinical precision. She wandered every day. Her wandering was described as significantly intruding on the privacy or activities of other residents. Her cognitive score placed her at the lowest end of comprehension. Whether those documented behaviors had any bearing on the February 19 incident, whether her care plan addressed the risk of her entering other residents' rooms, whether staff had identified any pattern before that evening — none of that is addressed in the inspection narrative. The inspection focused narrowly on what happened after the slapping, not on what the facility knew before it.
What the inspection did establish is that the administrator, when asked directly, confirmed the investigation's limits without contest. There were no further interviews. R12's inability to participate had not been written down. The incident was treated as a one-time event between two residents, with the third resident in the room, R60, interviewed only as a witness.
R52 was the one told by the nurse not to return to her own room.
Federal inspectors cited the facility for failing to conduct a thorough investigation of the abuse allegation, finding the deficiency caused minimal harm or the potential for actual harm and affected a small number of residents.
The inspection was completed on March 27, 2025.
What remains is the image of R12 at her interview — alert, confused, unable to recall what had happened to her or what she had done. A woman whose own records described her as someone who wanders daily into spaces where she is not wanted, who rarely understands when she is told to leave, who is assessed as incapable of reliably communicating her own experience. Whatever happened in that room on the evening of February 19, her version of it was never written down. The facility confirmed as much, and called it sufficient.
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 29, 2026 · Our methodology
Carlyle Senior Care of Florence in Florence, SC was cited for violations during a health inspection on March 27, 2025.
The incident happened on February 19, 2025, at approximately 7:20 in the evening.
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.