Florence, SC

Carlyle Senior Care of Florence

1-star overall rating with 2-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

133 West Clarke Road, Florence, SC

(843) 669-4374

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

88

Certified beds

Average residents

81

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Carlyle Senior Care

Operator or chain grouping

Approved since

1988-06-16

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 2 overall / 3 health / 3 staffing / 2 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.40

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.18

Licensed practical nurse staffing · state 1.01 · national 0.87

Aide hours / resident day

2.42

Nurse aide staffing · state 2.22 · national 2.35

Total nurse hours

4.00

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.58

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.73

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.33

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

4.12

CMS adjusted total nurse staffing hours

Case-mix index

1.33

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

60%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,209

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

17.67

Composite VBP score used to determine payment impact.

Payment multiplier

0.9818

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

0.92

Baseline 5.44% · Performance 7.56% · Measure score 0.92 · Achievement 0.92 · Improvement 0

Total nurse turnover

1.96

Baseline 50.62% · Performance 55.68% · Measure score 1.96 · Achievement 1.96 · Improvement 0

Adjusted total nurse staffing

2.42

Baseline 3.43 hours · Performance 3.77 hours · Measure score 2.42 · Achievement 2.42 · Improvement 0.95

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.06%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 49 · Observed rate 12.24% · Lower 95% interval 7.18%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.04	1.02 About the same
Drug regimen review with follow-up	91.49%	95.27% 3.8 pts worse	Numerator 43 · Denominator 47
Falls with major injury	4.26%	0.77% 3.5 pts worse	Numerator 2 · Denominator 47
Discharge self-care score	26.92%	53.69% 26.8 pts worse	Numerator 7 · Denominator 26
Discharge mobility score	38.46%	50.94% 12.5 pts worse	Numerator 10 · Denominator 26
Pressure ulcers or injuries, new or worsened	6.38%	2.29% 4.1 pts worse	Numerator 3 · Denominator 47 · Adjusted rate 4.16%
Healthcare-associated infections requiring hospitalization	7.56%	7.12% 0.4 pts worse	No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 4.33%
Staff COVID-19 vaccination coverage	13.1%	8.2% 4.9 pts better	Numerator 11 · Denominator 84
Staff flu vaccination coverage	13.1%	42% 28.9 pts worse	Numerator 11 · Denominator 84
Discharge function score	26.92%	56.45% 29.5 pts worse	Numerator 7 · Denominator 26
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 20 · Denominator 20
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	63.33%	25.2% 38.1 pts better	Numerator 19 · Denominator 30

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	4.1	2.0 2.1 pts worse	1.9 2.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.1 · Observed 4.0 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.1	1.9 1.2 pts worse	1.8 1.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	90.5% 9.5 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	90.6% 9.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	4.4%	3.0% 1.4 pts worse	3.3% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.8% · Q3 6.3% · Q4 6.2% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.2%	2.9% 0.7 pts better	11.4% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.5% · Q3 1.4% · Q4 1.4% · 4Q avg 2.2%
Percentage of long-stay residents who lose too much weight	4.5%	6.2% 1.7 pts better	5.4% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 9.7% · Q4 6.7% · 4Q avg 4.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.4%	20.4% 2 pts worse	19.6% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 21.8% · Q3 23.7% · Q4 27.3% · 4Q avg 22.4%
Percentage of long-stay residents who received an antipsychotic medication	23.7%	16.3% 7.4 pts worse	16.7% 7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 27.8% · Q3 21.6% · Q4 23.1% · 4Q avg 23.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	14.0%	14.9% 0.9 pts better	16.3% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 16.5% · Q3 21.9% · Q4 9.8% · 4Q avg 14.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	28.1%	12.4% 15.7 pts worse	14.9% 13.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 43.5% · Q2 27.3% · Q3 19.7% · Q4 21.7% · 4Q avg 28.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	5.6%	0.7% 4.9 pts worse	1.0% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.4% · Q3 4.1% · Q4 5.4% · 4Q avg 5.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.9%	1.6% 2.3 pts worse	1.7% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.1% · Q3 2.7% · Q4 5.1% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.8%	17.2% 3.4 pts better	19.8% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 13.0% · Q3 16.0% · Q4 7.3% · 4Q avg 13.8%
Percentage of long-stay residents with pressure ulcers	8.8%	5.8% 3 pts worse	5.1% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.6% · Q3 10.3% · Q4 7.3% · 4Q avg 8.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	80.8%	79.8% 1 pts better	81.7% 0.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 79.2% · Q3 76.7% · Q4 77.3% · 4Q avg 80.8%
Percentage of short-stay residents who had an outpatient emergency department visit	18.0%	14.1% 3.9 pts worse	12.0% 6 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 21.6% · Expected 13.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	5.3%	1.6% 3.7 pts worse	1.6% 3.7 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 5.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	88.0%	78.0% 10 pts better	79.7% 8.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.3%	24.7% 1.6 pts worse	23.9% 2.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 33.3% · Expected 30.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-27 · Fire 2025-03-27

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 2 Health 2024-02-09 · Fire 2024-02-09

5 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-01-28 · Fire 2022-01-28

5 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-03-27

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-05-28

D · Potential for more than minimal harm 2025-03-27

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-05-28

D · Potential for more than minimal harm 2025-03-27

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2025-05-28

E · Potential for more than minimal harm 2024-02-09

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-09

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-09

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-03-08

D · Potential for more than minimal harm 2022-01-28

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-02-10

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-03-27

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-03-27

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-27

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-27

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-27

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-03-27

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-04-25

F · Potential for more than minimal harm 2024-02-09

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-03-10

F · Potential for more than minimal harm 2024-02-09

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-02-09

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-03-10

D · Potential for more than minimal harm 2024-02-09

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-03-10

D · Potential for more than minimal harm 2024-02-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-10

K · Immediate jeopardy 2022-01-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-02-23

D · Potential for more than minimal harm 2022-01-28

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2022-02-23

D · Potential for more than minimal harm 2022-01-28

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-02-23

D · Potential for more than minimal harm 2022-01-28

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2022-02-23

D · Potential for more than minimal harm 2022-01-28

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2022-02-23

Penalties and ownership