Resorts at Beaufort: Lift Transfer Fall Violation - SC
On the morning of July 19, 2025, a certified nursing assistant at Resorts at Beaufort attempted to transfer a resident using a mechanical lift without a second staff member present, despite the resident's care plan explicitly requiring two-person assistance. The lift bar dislodged mid-transfer. The resident slipped to the floor, still inside the sling, with part of the mechanical lift landing on their stomach.
A second nursing assistant entered the room and found the resident on the floor. She got a nurse, who directed her to call 911. The resident was taken to the hospital. They returned with no fractures.
The resident, identified in inspection records as R5, told inspectors on August 19 that there had been only one staff member present during the transfer. "The aide knew how to use the mechanical lift," the resident said, "and she tried to get another person to assist, but no one was available." The resident said they fell straight down and tipped to the left.
The nursing assistant who performed the transfer, identified as CNA3, described her sequence of actions in a written statement. She gave the resident a bed bath, got the resident dressed, placed the mechanical lift pad under the resident, positioned the resident onto the machine, and lifted them. All of it alone. She told inspectors she had looked into the hallway first and saw no one available to help.
When the Director of Nursing spoke with CNA3 after the incident, the aide told her she was aware the resident required two-person assistance for transfers. Her explanation: everyone was busy, and she didn't want to bother anyone.
CNA3 was more direct with inspectors when they interviewed her by phone the following day. She said that during the COVID pandemic, the facility had a shortage of nursing assistants, and she had grown accustomed to operating the mechanical lift by herself. "I do take responsibility for that," she said. She acknowledged she knew working alone was, in her words, "a no, no."
The care plan requirement was not obscure. The facility maintained a document called a Kardex, accessible to all CNAs, that listed each resident's care needs including transfer requirements. A registered nurse told inspectors the CNAs had access to it. CNA3 told inspectors she did not look at it that morning.
The Director of Nursing, who came to the facility the day of the incident and saw the resident after they returned from the hospital, told inspectors her expectation was that care plans be followed. The administrator said the same: two staff for a mechanical lift, per the care plan and the Kardex. The MDS Director explained that care plan interventions were updated quarterly and as needed, and that those interventions were included on the Kardex for staff to reference.
What inspectors found was a gap between what the documents required and what happened in the room. The care plan said two people. The Kardex said two people. CNA3 knew it said two people. She proceeded alone because she couldn't find anyone and didn't want to interrupt colleagues she assumed were occupied.
Federal inspectors cited the facility under F0656, which covers the development and implementation of resident care plans. The citation was rated as minimal harm or potential for actual harm, affecting few residents. The resident's lack of fractures kept the severity level low. But the resident went to the hospital. The lift bar came off. Part of the machine landed on their body.
CNA3 said the habit of solo transfers had formed during a staffing crisis years earlier and had never been corrected. She carried it forward into a morning when a resident wanted to get out of bed, and no one was visible in the hallway, and she made the same choice she had apparently made before, until the machine gave way.
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 lift bar dislodged mid-transfer.
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.