Resorts At Beaufort

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the statement, when CNA2 entered the room, Resident R5 was lying on the floor with part of the mechanical lift on

the resident's stomach. The statement indicated CNA2 got RN1, and RN1 directed the CNA to call 911.

Review of a document titled [Facility name] Witness Interview/Statement Form signed by CNA3 on 07/19/25 revealed that on 07/19/25 at approximately 10:30 AM, CNA3 was assisting Resident R5 with a transfer using the mechanical lift. The statement indicated, During the transfer process, I noticed that the lift appeared to malfunction (the bar dislodged). As a result of the malfunction, the resident slipped to the floor while still inside the sling. During an interview on 08/19/25 at 9:11 AM, Resident R5 stated there was only one staff member present for the transfer on 07/19/25. Resident R5 stated the aide knew how to use the mechanical lift, and she tried to get another person to assist, but no one was available. Resident R5 stated the resident fell straight down and tipped to the left and had no fractures from the incident. During an interview on 08/19/25 at 1:18 PM, the Director of Nursing (DON) stated she was notified of Resident R5's fall during a transfer with a mechanical lift. She stated she came to the facility the day of the incident and saw the resident when the resident returned from

the hospital. CNA3 told her she was aware Resident R5 was a two-person assist for transferring, but everyone was busy, and she did not want to bother anyone. During an interview on 08/19/25 at 3:24 PM, RN1 stated the CNAs had access to the Kardex to determine the care needs for a resident. During a phone interview on 08/20/25 at 1:46 PM, CNA3 stated she did not look at the resident's Kardex. CNA3 stated that during Coronavirus disease (COVID) they had a lack of CNAs, and she got accustomed to doing a mechanical lift by herself, and she knew that was a no, no. CNA3 stated, I do take responsibility for that. She stated Resident R5 wanted to get up out of bed, and she looked in the hallway and did not see anyone to assist her, so 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 the resident. During a follow-up interview on 08/20/25 at 2:44 PM, the DON stated the care plan was patient-focused, and she expected the care plan to be followed. During an interview on 08/20/25 at 3:11 PM, the Administrator stated her expectation was for staff to have two people per the care plan and per the Kardex for a mechanical lift. During an interview on 08/20/25 at 4:10 PM, the MDS Director stated care plan interventions were updated quarterly and as needed. She stated care plan interventions were included on the Kardex for staff to reference

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Resorts at Beaufort

11 Todd Drive Beaufort, SC 29901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

being transferred by a mechanical lift. The section titled Activity Restrictions or Additional Instructions revealed the resident's trauma workup was negative for acute fracture or traumatic injury, and a lytic lesion was identified that was concerning for malignancy versus metastatic disease.Review of a typed document, dated 07/19/25 and signed by the Director of Nursing (DON), revealed they received a phone call from RN1 at 12:01 PM. The document indicated RN1 reported Resident R5 fell from a mechanical lift, and the RN was sending

the resident to the hospital. Per the document, RN1 reported the mechanical lift malfunctioned, causing the fall. The document further revealed that CNA3 reported that when she was lifting the resident up from the bed, she noticed the mechanical lift was making a funny noise but did not think anything about it because mechanical lifts make noises (which was normal). The document revealed the facility concluded the incident was attributed to poor judgement made by CNA3. The report revealed CNA3 was removed from the facility, not to return.Review of a document titled [Facility name] Witness Interview/Statement Form, signed by CNA2 on 07/19/25, revealed that CNA2 was in the hall when CNA3 asked her to come to Resident R5's room. Per

the statement, when CNA2 entered the room, Resident R5 was lying on the floor with part of the mechanical lift on

the resident's stomach. The statement indicated CNA2 got RN1, and RN1 directed the CNA to call 911.Review of a document titled [Facility name] Witness Interview/Statement Form, signed by CNA3 on 07/19/25, revealed that on 07/19/25 at approximately 10:30 AM, CNA3 was assisting Resident R5 with a transfer using the mechanical lift. The statement indicated, During the transfer process, I noticed that the lift appeared to malfunction (the bar dislodged). As a result of the malfunction, the resident slipped to the floor while still inside sling.During an interview on 08/19/25 at 9:11 AM, Resident R5 stated there was only one staff member present for the transfer on 07/19/25. Resident R5 stated the aide knew how to use the mechanical lift, and

she tried to get another person to assist, but no one was available. Resident R5 stated the resident fell straight down and tipped to the left and had no fractures from the incident. Resident R5 stated the mechanical lift broke, and if they had two staff on that day assisting, the resident thought it still would have happened.During an interview on 08/19/25 at 1:18 PM, the DON stated she was notified of Resident R5's fall during a transfer with a mechanical lift.

She stated she came to the facility the day of the incident and saw the resident when the resident returned from the hospital. CNA3 told her she was aware Resident R5 was a two-person assist for transferring, but everyone was busy, and she did not want to bother anyone.During a phone interview on 08/20/25 at 1:46 PM, CNA3 stated that during Coronavirus disease (COVID) they had a lack of CNAs, and she got accustomed to doing

a mechanical lift by herself, and she knew that was a no, no. She stated, I do take responsibility for that.

She stated she did not look at the resident's Kardex. She stated that when she was lifting Resident R5 up, she did not notice anything. Then, she stated, when she was backing up the mechanical lift, it started to squeak and made a funky noise, and she did not pay it any mind, but it was noticeable. She stated she thought a piece fell out or dislodged because the bar dislodged from the machine itself, and the resident slipped to

the floor.During a follow-up interview on 08/20/25 at 2:44 PM, the DON stated she expected the staff to make sure they had two people with them, the appropriate sling, and make sure the mechanical lift was functioning and pins were in place and sturdy. She stated if something seemed wrong with the mechanical lift during the transfer, staff should put the resident back down.During an interview on 08/20/25 at 3:11 PM,

the Administrator stated her expectation was for staff to use the lift per protocol and how they had been taught. She stated if the staff heard the mechanical lift making noises, they were to stop what they were doing and notify a supervisor.

Event ID:

Facility ID:

If continuation sheet