Resorts at Beaufort: Lift Malfunction Drops Resident - SC
The incident happened on July 19, 2025, at Resorts at Beaufort. The resident, identified in inspection records as R5, was still inside the sling when she landed. A piece of the mechanical lift came to rest on her stomach.
The nursing aide, CNA3, had been assigned to transfer R5 that morning. R5's care plan designated the transfer as a two-person assist, meaning a second staff member was required to be present. CNA3 did not get one. She told the Director of Nursing that she was aware of the two-person requirement but that everyone was busy and she didn't want to bother anyone.
During a phone interview with inspectors on August 20, CNA3 explained where the habit came from. During COVID, she said, there was a shortage of aides, and she got used to running mechanical lifts by herself. "I knew that was a no, no," she told inspectors. "I do take responsibility for that."
She also said she had not checked the resident's Kardex, the document that would have confirmed the two-person requirement, before beginning the transfer.
As she backed the lift up, CNA3 said, it started to squeak and make what she called a "funky noise." She didn't stop. She told inspectors she didn't pay it any mind, though she acknowledged it was noticeable. Then the bar dislodged from the machine itself, and R5 slipped to the floor while still in the sling.
CNA2 was in the hallway when CNA3 called her into the room. She found R5 lying on the floor with part of the mechanical lift on the resident's stomach. She went to get the charge nurse, RN1, who told her to call 911.
R5 was sent to the hospital. The trauma workup came back negative for acute fracture or traumatic injury. But the imaging identified a lytic lesion that radiologists flagged as concerning for malignancy or metastatic disease.
R5 spoke with inspectors on August 19. She confirmed there had been only one staff member present for the transfer. She said the aide had tried to find a second person but no one was available. She described falling straight down and tipping to the left. She said she believed the lift would have broken even with two people there. She had no fractures.
The Director of Nursing documented that she received a call from RN1 at 12:01 PM on July 19. She came to the facility that day and saw R5 after the resident returned from the hospital. In a follow-up interview with inspectors, she said her expectation was that staff confirm they have two people present, the appropriate sling, and that the lift is functioning, with pins in place and secure. She said if something seemed wrong during a transfer, staff should put the resident back down.
The administrator told inspectors her expectation was that staff use the lift the way they had been trained. If they heard unusual noises, they were to stop and notify a supervisor.
CNA3 did neither. The facility's own post-incident report concluded the fall was caused by poor judgment on her part. She was removed from the facility and told not to return.
The inspection, conducted as a complaint investigation, cited the facility for failing to ensure R5's environment was free from accident hazards. The violation was cited at a level of minimal harm or potential for actual harm.
What the citation does not capture is the sequence of decisions that led to a resident on the floor with a piece of broken equipment on her stomach: a staffing habit formed during a pandemic, a care plan not checked, a noise that registered as noticeable but wasn't enough to stop the transfer, and no second set of hands in the room. R5 went to the hospital and came back without broken bones. The imaging found something else.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Resorts At Beaufort from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
Resorts at Beaufort in Beaufort, SC was cited for violations during a health inspection on August 20, 2025.
The incident happened on July 19, 2025, at Resorts at Beaufort.
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.