Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Resorts At Beaufort during CMS and state inspections, most recent first.
Facility failed to keep resident areas in good repair. Observations found loose side rails, rusty toilet seats and handles, a towel bar on the floor, damaged walls, missing cove molding, and AC units with gaps or improper covers. The MD stated some issues were not reported to him, there was no written maintenance reporting policy, and the unit maintenance logbooks had no documentation for the concerns identified.
A resident who had Medicare Part A skilled services and remained in the facility after discharge from skilled care did not receive the required SNF ABN. The policy required use of the CMS SNF ABN form before non-covered care, but the SSD, DOR, and DON gave conflicting responses about who completed the notice, and the DON stated SNF ABNs appeared not to have been done for residents who required them.
Failure to keep a resident’s fingernails clean and trimmed. A resident with DM, diabetic neuropathy, and severe cognitive impairment had fingernails about 3/4 inch long with a black/brown substance underneath them during multiple observations. The resident said he wanted his fingernails cut shorter, and the DON and UM confirmed the nails were dirty and needed trimming; records showed no refusal of care.
A resident with MS, muscular dystrophy, and gastrostomy status had medications administered via G-tube without the nurse verifying tube placement first. During observation, the UM flushed the tube and gave each medication without checking residual or using air insufflation with a stethoscope, and later confirmed she did not know the facility policy. The facility policy required enteral tube placement to be verified before giving any fluids or medications, and the DON stated staff were expected to check placement before administration.
Improper Meal Substitution: The facility failed to provide a lunch alternate with comparable nutritive value when residents were offered kielbasa sausage instead of the posted cheese tortellini with alfredo sauce. The DM stated the residents do not eat tortellini and served sausage instead, while the RD stated pasta would not be an adequate nutritive substitute for meat.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with severe cognitive impairment and a history of frequent falls did not receive required 1:1 supervision as outlined in their care plan. Staff placed a geriatric chair next to the bed as a barrier, despite knowing the resident often tried to climb over it, and did not provide direct supervision during the night. The resident was later found injured, with hospital records indicating a neck fracture and facial contusion likely related to climbing over the chair. The facility also failed to recognize other hazards, such as a rolling computer chair left in the room, and did not document when or how 1:1 supervision was provided.
A resident with severe cognitive impairment and a history of falls was routinely placed in a reclined geriatric chair, which staff positioned as a barrier next to the bed to prevent the resident from getting up without staff's knowledge. Despite the resident's repeated attempts to climb out of or over the chair, no assessment was conducted to determine if this constituted a restraint, and no physician order or consent was obtained. The resident sustained injuries after attempting to climb over the chair, and facility staff and leadership demonstrated inconsistent understanding and application of restraint policies.
A resident with a history of falls and multiple medical conditions experienced two documented falls, one resulting in a cervical fracture and another without injury, but these incidents were not accurately reflected in the MDS assessments. The MDS Coordinator later acknowledged the errors after reviewing the medical record, and both the DON and Administrator confirmed that assessments are expected to be accurate and complete.
A resident with severe cognitive impairment and total incontinence was left in a geriatric chair overnight after an assisted fall, without being checked or changed for incontinence. Staff interviews and documentation confirmed that incontinence care was not provided during routine rounds, contrary to the care plan and facility policy requiring checks every two hours.
A resident with a catheter was observed with her catheter bag on the floor without a privacy cover, violating dignity and infection control standards. Despite the facility's policy and CDC recommendations, the bag was found on the floor during multiple observations. Staff acknowledged the issue, but the deficiency persisted.
The facility failed to update the MDS for two residents experiencing significant changes, including hospice election and a hip fracture, within the required timeframe. Staff interviews revealed a lack of adherence to the policy on timely MDS updates, contributing to the deficiency.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 7.14% during a med pass involving a resident with vitamin deficiency and hypertension. Errors included administering Vitamin D3 instead of the prescribed Vitamin D2 and not adhering to specific instructions for Metoprolol Tartrate, which was given despite the resident's diastolic blood pressure being below the prescribed threshold. The LPN acknowledged the errors, indicating unfamiliarity with the order requirements.
A medication room refrigerator was found to be malfunctioning, with a thermometer reading of 48 degrees Fahrenheit, above the recommended storage temperature for insulin. Insulin for three residents was stored improperly, lying in standing water with thawed ice packs. A nurse confirmed the temperature issue, and the administrator stated the refrigerator was being replaced.
A resident with a suprapubic catheter was observed with her catheter bag on the floor without a privacy cover, compromising dignity and infection control. Despite facility protocols to prevent such occurrences, the deficiency was noted during multiple observations. Interviews with the Unit Manager and DON confirmed the issue, highlighting a lapse in adherence to infection control and dignity policies.
Facility Failed to Maintain Resident Areas in Good Repair
Penalty
Summary
The facility failed to maintain resident areas in good repair, with observations showing loose side rails, rusty toilet seats and handles on an over-toilet riser, a towel bar lying on the floor after separating from the wall, walls with gouged or damaged areas, missing cove molding, and gaps or improper fitting around AC units. During an observation and interview on the C hall, the Maintenance Director identified a two-to-three-inch movement in the right side rail in Room C01-D, large gouged areas on the wall in Room C08-W, and a rusty toilet seat with rusty handles on the toilet riser in Room A17-P. In that same room, the towel bar was on the floor, and the Maintenance Director stated he had not been told about the broken towel bar or the rusty equipment. On the A wing, the Maintenance Director observed a room with missing cove molding, markings around the AC, and a gap between the AC and the wall, another room with an AC unit that was unplugged and a cover not fitting properly exposing internal components, and multiple rooms with holes or gouged drywall near beds. The Maintenance Director stated several of these areas needed to be fixed or painted and said there was no written policy and procedure for reporting maintenance issues. Review of the maintenance logbooks on each unit showed no documentation for any of the concerns identified during the tour.
Failure to Issue SNF ABN for Medicare Part A Resident
Penalty
Summary
The facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident, R13, out of three residents reviewed for SNF ABNs. Review of the facility policy titled Advanced Beneficiary Notices stated that for Part A items and services, the facility shall use the SNF ABN, Form CMS-10055, and shall issue an ABN prior to furnishing non-covered care. Review of R13's EMR showed an admission date of 04/01/25 and Medicare Part A services from 10/01/25-11/26/25. Review of the Notice of Medicare Non-Coverage dated 11/24/25 showed the facility did not issue the ABN to the resident or resident representative after the facility initiated discharge from skilled services with Medicare Part A days remaining, and R13 remained in the facility after discharge from Medicare Part A services. During interviews, the SSD stated she does not do SNF ABNs for residents coming off skilled services under Medicare Part A and remaining in the facility and said therapy does them; the DOR stated therapy ABNs are only for residents coming off Medicare Part B services and did not know who completes SNF ABNs for Medicare Part A; the DON stated she was not sure who was responsible for completing SNF ABNs and later stated it appeared SNF ABNs had not been being done for those who require it.
Failure to Keep a Resident’s Fingernails Clean and Trimmed
Penalty
Summary
The facility failed to ensure that Resident 9’s fingernails were kept clean and trimmed. Resident 9 had diagnoses of type 2 diabetes mellitus and diabetic neuropathy, and the care plan identified the resident as at risk for impaired skin integrity with a goal to avoid scratching and keep fingernails short. The resident’s MDS showed severe cognitive impairment with a BIMS score of 4 out of 15 and dependence for personal hygiene. During observations on 03/31/26 and 04/01/26, Resident 9’s fingernails were noted to be approximately 3/4 inch long with a black/brown substance underneath them. The resident stated he wanted his fingernails cut shorter and confirmed he had received a bed bath. Review of records showed no refusals of bathing or personal hygiene care, and the DON and UM both confirmed at the bedside that the fingernails were dirty, needed trimming, and should be completed as needed as the resident allows. The DON also confirmed there was no documentation that the resident refused nail care.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's gastrostomy tube (G-tube) was patent by checking placement before administering medications. The resident, R33, was admitted with diagnoses including multiple sclerosis, muscular dystrophy, and gastrostomy status. During a medication administration observation, the Unit Manager flushed the G-tube with 30 mL of water and administered each medication after each flush, but did not verify tube placement by aspirating for residual or by injecting air and listening with a stethoscope over the left upper abdomen. During interview, the Unit Manager confirmed she did not check G-tube placement before giving the medications and stated she did not know the facility policy on checking placement. The facility policy titled Medication Administration via Enteral Tube required enteral tube placement to be verified prior to administering any fluids or medication. The DON stated nursing staff were expected to check placement before administering medications and identified methods for doing so, while also stating the facility did not have a policy on maintaining patency of the G-tube. The Administrator stated nursing staff were expected to be trained on the procedure for checking placement in the facility's policy.
Improper Meal Substitution
Penalty
Summary
The facility failed to ensure that a lunch menu alternate was substituted with another item of comparable nutritive value. The posted lunch menu provided by the Dietary Manager listed beef stew, rice, and green beans, with cheese tortellini with alfredo sauce as the alternate meal. During lunch observation in the main dining room, residents were offered kielbasa sausage as the alternate instead of the listed tortellini. During interviews, the Dietary Manager stated the lunch meal was beef cubes, mashed potatoes, and spinach, and that the alternate meal was smoked sausage. The Dietary Manager later stated the residents do not eat tortellini, so kielbasa sausage was served instead, and also stated substitutions were made in the computer system before tickets went out and that the Registered Dietitian would ensure an equal-value substitute. The Administrator stated the menu substitutions were approved by the RD for nutritional density, while the RD stated she would not substitute pasta for meat as an adequate nutritive substitution.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and individualized resident care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide 1:1 Supervision and Address Environmental Hazards Resulting in Resident Injury
Penalty
Summary
The facility failed to provide required one-to-one (1:1) supervision for a resident with a significant history of falls and severe cognitive impairment, as outlined in the resident's care plan. Despite documented interventions for 1:1 supervision and the use of a geriatric chair for rest periods, staff did not consistently implement or document 1:1 supervision, particularly during the evening and night shifts. The resident, who had multiple risk factors including cauda equina syndrome, muscle weakness, dementia, and a history of frequent falls, was left unsupervised after being placed in bed, with staff relying on the placement of a geriatric chair next to the bed as a barrier rather than direct supervision. On the night in question, the resident was found in the hallway complaining of eye pain and was subsequently lowered to the floor by a nurse after being unable to support their own weight. Hospital records later indicated that the resident had sustained a type II fracture of the odontoid process and a facial contusion, with evidence suggesting the injuries may have occurred while the resident attempted to climb over the geriatric chair placed beside the bed. Staff interviews revealed that the practice of placing the geriatric chair next to the bed was routine, despite knowledge that the resident had a history of attempting to climb over or out of the chair, and that 1:1 supervision was not provided during the night shift due to staffing limitations. The facility's investigation into the incident did not fully consider all potential causal factors, such as the environmental hazards posed by the placement of the geriatric chair and the lack of direct supervision. Additionally, a rolling computer chair was observed in the resident's room when not in use, presenting another accident hazard. There was no documentation of when 1:1 supervision was provided, how its effectiveness was evaluated, or how decisions regarding the initiation or discontinuation of 1:1 supervision were made. The facility's failure to recognize and address these hazards and to follow the resident's care plan for fall prevention directly contributed to the resident's injuries.
Failure to Assess and Prevent Use of Geriatric Chair as Restraint
Penalty
Summary
The facility failed to ensure that staff did not utilize a geriatric chair as a restraint without proper assessment for one resident with a history of falls and severe cognitive impairment. Staff routinely placed the resident in a reclined geriatric chair and positioned the chair along the side of the resident's bed to prevent the resident from getting up without staff's knowledge. This practice was carried out despite the resident's known history of attempting to climb out of the geriatric chair and over it from the bed, and without conducting a pre-restraining assessment or obtaining a physician's order or consent, as required by facility policy. The resident had multiple medical conditions, including cauda equina syndrome, vertebral complications, dementia, bipolar disorder, and a history of falls. The care plan indicated the use of a geriatric recliner for rest periods but did not authorize the use of any type of restraint. Staff interviews revealed that the geriatric chair was intentionally used as a barrier to restrict the resident's mobility, with the wheels locked and the chair placed in a way to alert staff if the resident attempted to get up. Staff and nursing leadership demonstrated inconsistent understanding of when the use of the geriatric chair constituted a restraint, and no assessments were completed to evaluate its use as a restraint for any resident, including this one. An incident occurred in which the resident was found with a facial bruise and later diagnosed with a cervical spine fracture after attempting to climb over the geriatric chair placed beside the bed. The medical director was not informed of the use of the geriatric chair as a barrier and stated that such use was at least an attempt at a restraint. Facility leadership, including the administrator and DON, acknowledged a lack of assessment and monitoring regarding the use of the geriatric chair as a restraint, and the facility's own policy was not followed in this case.
Inaccurate MDS Coding of Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected falls and resulting injuries for a resident with a complex medical history, including cauda equina syndrome, vertebral complications, a history of falls, dementia, and other neurological and psychiatric conditions. Despite documented incidents, including an assisted fall resulting in a cervical neck fracture and another witnessed fall without injury, the MDS assessments were coded to indicate that the resident had not experienced any falls since admission or their prior assessment. These inaccuracies were identified during interviews and record reviews, where the MDS Coordinator acknowledged that the assessments should have reflected the actual fall events and their outcomes. The deficiency was further substantiated by facility policy, which requires comprehensive and accurate assessments, and by statements from both the Director of Nursing and the Administrator, who confirmed that MDS assessments are expected to be complete and accurate. The failure to review the medical record and accurately code the MDS assessments led to the omission of significant fall events and injuries in the resident's official assessment documentation.
Failure to Provide Timely Incontinence Care After Fall
Penalty
Summary
The facility failed to ensure that staff checked for incontinence and provided incontinence care during routine rounds for a resident with severe cognitive impairment and a history of incontinence. After experiencing an assisted fall, the resident was placed in a geriatric chair and remained there overnight without being checked for incontinence or provided with incontinence care. Documentation and staff interviews confirmed that no toileting or incontinence care was provided from the time of the fall until the following morning, despite the resident's care plan and facility policy requiring checks every two hours. The resident involved had multiple medical conditions, including cauda equina syndrome, dementia, muscle weakness, and a history of falls, and was always incontinent of bowel and bladder. Staff interviews revealed that the resident was left in the day room in a geriatric chair after the fall and was not checked or changed during the night because staff did not want to wake the resident, even though the expectation was to provide care every two hours. The lack of incontinence care was corroborated by both nursing aides and an LPN, as well as by the absence of documentation for toileting or hygiene activities during the relevant shifts.
Failure to Maintain Dignity and Infection Control for Resident with Catheter
Penalty
Summary
The facility failed to maintain the dignity and infection control for a resident with a catheter. The resident, who has a history of cerebral palsy, neuromuscular dysfunction of the bladder, and urinary retention, was observed with her catheter bag lying on the floor without a privacy cover on multiple occasions. This is contrary to the facility's policy on resident rights, which emphasizes treating residents with respect and dignity, and the CDC's infection control recommendations, which state that catheter bags should not rest on the floor. During observations, the resident's catheter bag was found on the floor both when she was in bed and in her wheelchair, without a privacy cover. Interviews with the Unit Manager and the Director of Nursing confirmed awareness of the issue, acknowledging that the catheter bag should not be on the floor and should have a privacy cover to maintain dignity and prevent infection. Despite these acknowledgments, the deficiency was observed multiple times, indicating a lapse in adherence to the facility's policies and infection control practices.
Failure to Timely Update MDS for Significant Changes
Penalty
Summary
The facility failed to identify and complete a Significant Change in Status Assessment (SCSA) for two residents who experienced significant changes in their conditions. Specifically, one resident's comprehensive assessment was not updated after the election of hospice services or a major decline within the fourteen-day status change requirement. The facility policy requires that a SCSA be completed within fourteen days of identifying a status change that impacts more than one area of the resident's health status and requires interdisciplinary review and/or revision of the care plan. The resident in question was admitted to hospice on November 20, 2024, and experienced a hip fracture on December 6, 2024, but the MDS was not updated to reflect these significant changes in a timely manner. Interviews with facility staff, including the MDS coordinators, Administrator, Director of Nursing, and Risk Manager, revealed a lack of adherence to the facility's policy on timely MDS updates. The MDS coordinators acknowledged that the significant change for the resident should have been updated when the hip fracture occurred and when hospice services were elected. The Administrator emphasized the importance of timely documentation in the MDS, while the Director of Nursing and Risk Manager highlighted the role of the MDS in updating residents' health conditions. Despite these acknowledgments, the MDS was not updated within the required timeframe, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 7.14% during a medication pass involving one of five residents. The errors were identified in the administration of medications to a resident with diagnoses including vitamin deficiency and essential hypertension. The facility's policy on medication administration, revised in 2015, requires medications to be administered as prescribed and in accordance with good nursing principles. However, during an observation on January 7, 2025, an LPN administered Vitamin D3 instead of the prescribed Vitamin D2 and failed to adhere to the specific instructions for Metoprolol Tartrate, which included holding the medication if the resident's diastolic blood pressure was below 80. Further review of the resident's medication administration record revealed that Metoprolol Tartrate was administered on two occasions when the diastolic blood pressure was below the prescribed threshold. During an interview, the LPN acknowledged the errors, indicating a lack of familiarity with the specific order requirements. These actions contributed to the facility's failure to comply with the medication administration policy, resulting in a medication error rate exceeding the acceptable limit.
Medication Refrigerator Malfunction
Penalty
Summary
The facility failed to ensure that one of three medication room refrigerators, which contained refrigerated medications, was operative. During an inspection, it was observed that the refrigerator thermometer in the Hall A Medication Room read 48 degrees Fahrenheit, which is above the recommended storage temperature for insulin. Insulin for approximately three residents was found lying on shelves in standing water with thawed ice packs in the freezer compartment. The temperature log on the refrigerator door showed a recorded temperature of 38 degrees on the previous day, with numerous prior entries also reading 38 degrees. A registered nurse confirmed the current temperature reading and began cleaning the water from the refrigerator, noting that the third shift was responsible for checking and recording refrigerator temperatures. The facility administrator later stated that maintenance had determined the refrigerator was not working and was in the process of being replaced.
Failure to Maintain Dignity and Infection Control for Resident with Catheter
Penalty
Summary
The facility failed to maintain the dignity and infection control for a resident with a catheter. The resident, who has a moderate cognitive impairment and a suprapubic catheter due to urinary retention and neurogenic bladder, was observed multiple times with her catheter bag lying on the floor without a privacy cover. This was noted during observations on two separate occasions, where the resident was either in bed or sitting in her wheelchair, and the catheter bag was not appropriately positioned or covered. Interviews with the Unit Manager and the Director of Nursing confirmed the deficiency. The Unit Manager acknowledged the absence of a privacy cover and the improper placement of the catheter bag, recognizing the potential for infection and the dignity issue. The Director of Nursing stated that the staff uses stat locks to prevent kinking and visually checks the catheters, emphasizing that the catheter bag should never be on the floor and should always have a privacy cover. Despite these protocols, the deficiency was observed, indicating a lapse in adherence to the facility's infection control and dignity policies.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beaufort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sprenger Health Care Of Port Royal | 1.6 mi | ★★★★★ | 5 | 1 |
| The Preston Health Center | 12.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Hilton Head | 12.7 mi | ★★★★★ | 0 | 0 |
| Sprenger Healthcare Of Bluffton | 17 mi | ★★★★★ | 0 | 0 |
| Broad Creek Care Center | 17 mi | ★★★★★ | 1 | 1 |
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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 July 2026) and official state health department websites.