Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carlyle Place during CMS and state inspections, most recent first.
The facility exhibited deficiencies in food storage and labeling practices, including ice build-up in the walk-in freezer affecting food items, failure to label and date opened food items, and improper drying of steam table pans leading to wet nesting. Despite maintenance notifications, ice accumulation persisted, and dietary staff did not adhere to labeling policies. The facility also lacked a specific policy for air drying pans before storage.
A resident with COPD and other health issues was observed receiving oxygen therapy without the required humidification, contrary to facility policy. An LPN confirmed the absence of a humidifier and acknowledged the oversight, while the DON emphasized the expectation for nurses to adhere to oxygen administration procedures.
The facility administration failed to oversee an abuse prevention program, resulting in a resident being involuntarily secluded and the incident not being reported to the State Agency. The involved LPN continued to provide care without suspension, and the issue was not addressed in the QAPI committee.
The facility failed to identify and address concerns related to abuse prevention systems, including an incident where an LPN secluded and restrained a resident. The QAPI committee did not discuss or investigate the incident, leading to a determination of Immediate Jeopardy.
A resident with cognitive impairments was involuntarily secluded by an LPN who barricaded the resident in bed using a mattress and chairs. The incident was discovered the next morning, but the LPN received only a verbal warning, and no further investigation or staff training was conducted. The facility's failure to address the incident led to a determination of Immediate Jeopardy.
The facility failed to protect a resident's right to be free from physical abuse by not reporting an abuse allegation in a timely manner to the State Agency (SA). A resident with moderate cognitive impairment was found barricaded in his room, and the incident was reported internally but not to the SA as required. Interviews confirmed that the incident was known but not reported, leading to Immediate Jeopardy.
A facility failed to investigate and prevent abuse when an LPN used a mattress and chairs to barricade a resident in bed for over eight hours. The incident was not properly addressed or investigated, and no staff training or corrective actions were taken, leading to an ongoing Immediate Jeopardy situation.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices, leading to potential contamination risks. Observations in the walk-in freezer revealed significant ice build-up on the air condenser, with ice and frost accumulating on food items stored directly beneath it. Despite maintenance being notified, the issue persisted, and dietary staff continued to store food under the condenser, resulting in ice formation on cases of frozen peaches, diced mango, and tart cherries. Interviews with the Dining General Manager (DGM) and Healthcare Dining Manager (HDM) confirmed the presence of ice on food items and acknowledged that dietary staff should have taken measures to prevent this. Additionally, the facility did not adhere to its policy regarding the labeling and dating of opened food items. Numerous food items in the dry storage area and the two-door reach-in refrigerator were found opened without any indication of the date they were opened. This included various types of pasta, sauces, salad dressings, and icing containers. Both the DGM and HDM confirmed the lack of open dates and stated that dietary staff are expected to label and date items upon opening. Furthermore, the facility failed to ensure proper drying of steam table pans before stacking them, leading to wet nesting. Observations of the pot and pan storage rack revealed moisture inside multiple stacks of steam table pans. The HDM confirmed that dietary staff are expected to air dry pans completely before stacking, although the facility lacked a specific policy on this practice. The HDM indicated that staff should follow the manufacturer's recommendations for air drying dishware before storage.
Failure to Provide Humidification with Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident receiving oxygen therapy, as observed during a survey. The facility's policy required the use of a humidifier container or disposable humidifier with oxygen concentrators, which was not adhered to in the case of a resident with multiple diagnoses including chronic obstructive pulmonary disease (COPD), anemia, heart failure, unstable angina, and atherosclerotic heart disease. The resident had a physician's order for continuous oxygen therapy at 2-5 liters per minute via nasal cannula, with oxygen saturation checks every shift. Observations on two consecutive days revealed that the resident was receiving oxygen at 2 liters per minute from a concentrator without a humidifier container or disposable humidifier attached. Interviews with a Licensed Practical Nurse (LPN) confirmed the absence of the humidifier and acknowledged that it should have been attached. The LPN indicated that night shift nurses were responsible for ensuring humidifier bottles were attached when changing oxygen tubing, and all nurses were responsible for replacing them as needed. The Director of Nursing (DON) stated that her expectations were for nurses to follow policy procedures for oxygen administration, which included ensuring humidifier bottles were attached.
Failure to Oversee Abuse Prevention Program
Penalty
Summary
The facility administration failed to effectively oversee an abuse prevention program, resulting in a resident being subjected to involuntary seclusion. Specifically, one resident was found with one side of his bed pushed against the wall and the other side barricaded with a mattress and chairs, preventing him from getting out of bed from approximately 10:30 pm on 10/27/2023 until 7:30 am the next morning. This incident was not reported to the State Agency (SA) and was inadequately addressed internally by the facility's administration, including the Administrator and Director of Nursing (DON). The administration also failed to protect the resident's right to be free from physical abuse by not reporting the abuse allegation in a timely manner to the SA. The incident was reported internally but was not escalated to the appropriate authorities, and no comprehensive investigation was conducted. The involved Licensed Practical Nurse (LPN) continued to provide care to residents, including the affected resident, without suspension or dismissal during the investigation. Furthermore, the administration did not effectively implement Quality Assurance Process Improvement (QAPI) plans related to the abuse prevention system. The incident was not discussed in the QAPI committee, and no facility-wide in-service training was conducted to address the issue. The Medical Director was also not informed of the incident, indicating a significant lapse in communication and procedural adherence within the facility's administration.
Failure to Implement QAPI Plans for Abuse Prevention
Penalty
Summary
The facility failed to identify concerns and effectively implement Quality Assurance Process Improvement (QAPI) plans related to abuse prevention systems, including staff-to-resident abuse allegations and implementing all components of the abuse policies. The facility's QAPI committee did not address an incident where a Licensed Practical Nurse (LPN) placed a mattress on the edge of a resident's bed, resulting in the resident being secluded and restrained. This incident, which occurred on 10/27/2023, was not reported to the QAPI committee or the State Agency, nor was it investigated or discussed in subsequent QAPI meetings. The facility census at the time was 32 residents. The facility's policy titled QAPI Change Process- Work Instruction, revised on 10/24/2023, outlines a systematic approach to performance improvement activities, including identifying potential problems, determining root causes, and developing corrective actions. However, the QAPI committee meetings held on 10/10/2023, 1/9/2024, and 4/9/2024 did not address the abuse allegation or review the abuse prevention program. Interviews with the previous Administrator, Medical Director, and Quality Analysis Registered Nurse revealed that they were unaware of the incident and that it had not been brought to the QAPI committee for corrective action. The failure to address the incident in a timely manner and implement appropriate interventions led to a determination of Immediate Jeopardy on 4/16/2024. The facility administration, including the current Administrator, Director of Nursing, and Hospital Director, were informed of the Immediate Jeopardy, which was identified to have existed since 10/27/2023. As of the exit date on 4/19/2024, an acceptable Immediate Jeopardy Removal Plan had not been received, and the Immediate Jeopardy remained ongoing.
Failure to Prevent Involuntary Seclusion of Resident
Penalty
Summary
The facility failed to ensure that a resident (R4) was free from involuntary seclusion. R4, who had a cognitive communication deficit, psychophysiological insomnia, dementia, and a right femur fracture, was admitted to the facility and had a BIMS score indicating moderate cognitive impairment. On the night in question, an LPN working the evening shift placed R4 in bed and, due to his repeated attempts to get out of bed, barricaded him using a mattress and chairs, effectively confining him to his bed from approximately 10:30 pm until 7:30 am the next morning. This action blocked R4's view of his room and prevented him from getting out of bed, which is considered involuntary seclusion and against facility policy. The incident was discovered the following morning by an RN who removed the barricade and reported the situation to the Administrator. Despite the severity of the incident, the LPN involved received only a verbal warning, and no further investigation or staff in-service training was conducted. Interviews with various staff members, including the DON, Medical Director, and other nurses, confirmed that the use of restraints and involuntary seclusion was against facility policy and that the incident was not reported to the State Agency as required. The facility's failure to address the incident appropriately and ensure that staff were adequately trained on the use of restraints and fall prevention measures led to a determination of Immediate Jeopardy. The Immediate Jeopardy status remained ongoing as an acceptable removal plan had not been received by the time of the survey exit. The facility census at the time was 32 residents.
Failure to Report Abuse Allegation in a Timely Manner
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff by not reporting an allegation of abuse in a timely manner to the State Agency (SA). The incident involved a resident with moderate cognitive impairment who was found barricaded in his room with a mattress and chairs, preventing him from moving. This incident was reported internally to the Administrator but was not reported to the SA as required by the facility's policy. The policy mandates that allegations involving abuse or serious bodily injury be reported immediately, but not later than 2 hours after the allegation is made. In this case, the incident was not reported to the SA, Medical Director, or other required authorities, violating the facility's procedures and state regulations. Interviews with staff, including the Registered Nurse (RN), Director of Nursing (DON), and both Administrators, confirmed that the incident was known but not reported to the SA. The previous Administrator admitted to addressing the situation internally without following the proper reporting channels. The current Administrator also acknowledged that the incident was not reported to the SA, despite being informed about it. This failure to report the abuse allegation in a timely manner led to the determination of Immediate Jeopardy, indicating that the facility's noncompliance had the likelihood to cause serious injury, harm, impairment, or death to residents.
Failure to Investigate and Prevent Abuse
Penalty
Summary
The facility failed to investigate, correct, and prevent allegations of abuse involving a resident who was involuntarily secluded. Specifically, a Licensed Practical Nurse (LPN) used a mattress and chairs to barricade a resident in his bed for more than eight hours. The Director of Nursing (DON) was informed of the incident by the previous Administrator, who had only issued a verbal warning to the LPN without conducting a full investigation or taking further corrective actions. The resident was unable to get out of bed and had his view blocked by the mattress, which constituted a physical restraint against facility policy. Interviews with staff revealed that the incident was not properly addressed or investigated. The DON confirmed that no staff training or further investigation was conducted following the incident. The Executive Director also acknowledged that the proper channels of investigation were not followed. The facility's policy on abuse, neglect, and exploitation requires a thorough investigation and corrective actions, which were not implemented in this case. As a result, the Immediate Jeopardy situation remained ongoing at the time of the survey exit.
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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 Macon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Zebulon Park Health And Rehabilitation | 1.2 mi | — | 2 | 0 |
| Pruitthealth - Peake | 1.4 mi | — | 0 | 0 |
| Bolingreen Health And Rehabilitation | 4.5 mi | — | 1 | 0 |
| Pruitthealth - Macon | 5.2 mi | — | 0 | 0 |
| Medical Management Health And Rehab Center | 5.5 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 August 2026) and official state health department websites.