Resorts at Beaufort

Inspectors wroteBased on observations, interviews, and document review, the facility failed to maintain the facility in good repair for resident areas. Specifically, there were side rails loose, rusty toilet seats, towel bar that was separated off the wall, walls in disrepair, cove molding missing, and spacing around air conditioner (AC) units. The facility's failure to repair the residents' environment has the potential to cause injuries to residents in two of three halls (A and C halls).

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident (Resident (R)13) of three residents reviewed for SNF ABNs. This failed practice had the potential to affect all residents receiving Medicare Part A benefits and continued to reside in the facility to make an informed decision on continuing the services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's fingernails were kept clean and trimmed for one of one resident (Resident (R) 9) reviewed for activities of daily living of 33 sample residents. This failure had the potential to affect resident care including personal hygiene in the facility.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure the resident's gastrostomy tube (G-tube) was patent by checking for placement prior to administering medications for one of four residents (Resident (R) 33) observed during medication administration. This failure had the potential to result in the resident not receiving the medication.

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed for one of one meal observation to substitute a lunch meal alternate meal item (tortellini) with another meal item (kielbasa sausage) that has the same comparable nutritive value. The failure had the potential to affects residents at risk of nutritional problems.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff implemented the care plan for 1 (Resident (R)5) of 3 sampled residents reviewed for falls. Specifically, on 07/19/2025, a staff member attempted a bed-to-chair transfer for R5 with a mechanical lift, with only one staff member present. The mechanical lift malfunctioned, and the resident fell to the floor.

Inspectors wroteBased on interview, record review, and review of the owner's manual for Model: F600B Bariatric Full Body Patient Lift, the facility failed to ensure staff safely transferred 1 (Resident (R)5) of 3 sampled residents reviewed for falls. Specifically, on 07/19/25, a staff member failed to follow the resident's care plan and ignored the noises emitted from the mechanical lift when she assisted the resident with a transfer from their bed to their wheelchair. During the transfer, the mechanical lift malfunctioned, and R5 fell to the floor.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to provide one-to-one (1:1) supervision as needed in accordance with Resident (R)1's fall prevention care plan and failed to recognize and address all potential accident hazards in the resident's environment for 1 (R1) of 3 residents reviewed for falls. Specifically, on 01/25/2025, approximately five to ten minutes after the resident was assisted into bed by staff, who placed a reclined geriatric chair along the side of the resident's bed, R1 was seen coming down the hallway yelling that their eye hurt, and the resident's right eye was noted to be redder and more irritated than their left eye. While in the hallway, the resident became too weak to support their weight and was lowered to the floor by a nurse for an assisted fall. [...]

Inspectors wroteBased on observation, record review, interview, and facility document and policy review, the facility failed to ensure staff did not utilize a geriatric chair without assessing whether the use of the geriatric chair was considered a restraint for 1 (Resident (R)1) of 3 residents reviewed for falls. Specifically, despite a known history of climbing out of the side of their geriatric chair and a history of climbing from their bed over their geriatric chair when staff positioned it by the resident's bed, staff placed R1 in a geriatric chair in a reclined position and also utilized the geriatric chair positioned along the side of the resident's bed while the resident was in bed to prevent the resident from getting up without staff's knowledge.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected falls and resulting injuries for 1 (Resident (R)1) of 3 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff checked for incontinence and/or provided incontinence care during routine rounds for 1 (Resident (R)1) of 3 residents reviewed for falls. Specifically, on the evening 01/25/2025, after the resident experienced an assisted fall to the floor, staff placed the resident in a geriatric chair and did not check to see if the resident required incontinence care until sometime between 5:00 AM to 6:00 AM the following morning.

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to maintain the dignity for 1 of 3 residents reviewed for dignity and infection control. Specifically, the facility did not provide a privacy bag for Resident (R)33's catheter bag. Furthermore, the catheter bag was found on the resident's floor during multiple observations. Cross-reference F880.

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to identify and complete a Significant Change in Status Assessment (SCSA) for 2 of 2 residents reviewed for significant change in condition. Specifically Resident (R)42's comprehensive assessment was not updated after the election of hospice services, or a major decline within the fourteen-day status change requirement.

Inspectors wroteBased on observations, record reviews and interview, the facility failed to ensure it is free of medication error rate of 5 % (percent) or greater. The error rate was 7.14 % based on 1 of 5 residents observed during med pass. There were two observed errors related to Resident (R)46, who was admitted to the facility on [DATE] with diagnoses including, but not limited to vitamin deficiency and essential (primary) hypertension.

Inspectors wroteBased on observations, record reviews, interviews and manufacturer package inserts, the facility failed to ensure that 1 of 3 medication room refrigerators, containing refrigerated medications, were operative.

Inspectors wroteBased on observations, interviews, and facility policy, the facility failed to maintain the dignity for 1 of 3 residents reviewed for dignity and infection control. Specifically, the facility did not provide a privacy bag for Resident (R)33's catheter bag. Furthermore, the catheter bag was found on the resident's floor during multiple observations. Cross-reference F880.

Inspectors wroteBased on a review of facility policy, observation, and interview, the facility failed to ensure the removal of expired foods from the cooler in 1 of 1 kitchen.

Inspectors wroteBased on observation, record review, review of the facility policy, and interviews, the facility failed to implement a Care Plan established for Resident (R)41, 1 of 1 resident reviewed for Care Plans, to assist with meals, presenting challenging efforts of using fine motor skills, resulting in decreased will to eat. Findings Include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of March 2022 states, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her care plan, including the right to: g. [...]

Inspectors wroteBased on review of the facility policy, observations, interviews, and record review, the facility failed to label the oxygen tubing for 1 of 1 Resident (R)43 reviewed for respiratory care.

Inspectors wroteBased on review of the facility policy titled, Storage of Medications, observations, and interviews, the facility failed to ensure expired medications were removed and not stored with other medications in use by residents in 2 of 4 medication carts and 1 of 2 medication rooms.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Handwashing/Hand Hygiene, Personal Protective Equipment (PPE)-Using Gloves, and Laundry and Bedding, Soiled, the facility failed to ensure gloves were worn to administer Resident (R)54 eye drops during medication administration by Registered Nurse (RN)1. The facility also failed to ensure hand hygiene/washing was completed after administering eye drops on D Wing. Additionally the facility failed to remove the PPE inside the soiled utility room after collecting soiled linen and wash hands. The PPE was removed at the nurse's desk on A Wing, without the completion of handwashing. The deficient practice was observed on 1 of 2 units where soiled linen was picked up by a laundry worker and 1 of 2 units where eye drops were administered during med pass.

Inspectors wroteBased on observations, interviews and review of the facility policy titled, Fire Safety and Prevention, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers and from the backs of the clothes dryers in the vicinity of the gas flame.