Sprenger Health Care of Port Royal

In the surveyor’s words

From the most serious findings on record at Sprenger Health Care of Port Royal, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 25, 2025

  Based on a review of facility policy, resident records, and interviews, the facility failed to provide adequate supervision to prevent Resident (R)1 from eloping. Specifically, R1 had a successful elopement from the facility on 11/22/25. This failure to adequately supervise has the potential to cause serious injury or death to residents.On 11/25/25 at 6:57 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template informing the facility IJ existed as of 11/22/25. The IJ was related to 42 CFR 483.25 - Quality of Care.On 11/25/25 at 8:32 PM, the facility provided an acceptable IJ Removal Plan, indicating compliance as of 11/24/25. […]

• No harm, potential for more than minimal, widespreadF755Mar 12, 2026

  Based on review of facility policy, observation, interview, record review, pharmacy contract and manufacturer's package inserts (see USP (United States Pharmacopeia)), the facility failed to ensure that medications were safely stored at the correct manufacturer/USP temperatures in 1 of 1 automated dispensing cabinet.Findings include: Review of the facility policy titled Medication Storage Policy revised/reviewed 08/2021, stated, It is the policy of [NAME] Health Care Systems to ensure that all medications are maintained behind locked door that cannot be accessed by any unlicensed personnel. The Policy did not address additional aspects of medication storage. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based on observation, interview, and review of facility policy, the facility failed to ensure food was labeled and stored appropriately in 1 of 1 kitchen.Findings include: Review of the facility policy titled Food and Storage Time Policy stated, . To maintain food quality and prevent foodborne illness, food should be stored for limited amount of time. During an observation and interview on 03/10/26 at 10:18 AM, with the Kitchen Manager, revealed the following items not dated/labeled/or stored appropriately: - 1 bottle of BBQ Sauce - labeled and dated, but in dry storage and should have been refrigerated after opening.- 1 bottle of Chives opened and not dated,- 1 bottle of baking soda opened and not dated. […]

• No harm, potential for more than minimal, patternF689Mar 12, 2026

  Based on review of facility policy, observation, and interview, the facility failed to ensure in-room sharps containers were locked securely to prevent residents from accessing used sharps, needles, and syringes in 3 of 4 halls observed. Findings include:Review of the facility policy titled, Sharps Disposal Protocol with a date of 04/2022 revealed, Policy: It is the policy of [NAME] Health Care Systems to ensure that all sharps are properly disposed of after use . Protocol: . Staff will monitor the sharps containers .1. Review of R32's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to, Parkinson's disease, dementia, anxiety, depression, difficulty in walking, repeated falls, and Type 2 diabetes. […]

• No harm, potential for more than minimal, patternF761Aug 20, 2021

  Based on observation, interview and facility policy review, the facility failed to provide safe and effective medication administration by allowing expired medications to be available for resident use in two (2) of two (2) medication storage rooms. Findings include: The facility provided policy titled Medication Storage Guidance dated 2021 directed, [MEDICATION(S)] Tests: [MEDICATION(S)] Injection: [MEDICATION(S)] Injection. Store in the refrigerator at 36 degrees to 46 degrees F [Fahrenheit] (two (2) degrees to eight (8) degrees C [Celsius]). Protect from light. Do not freeze. Date when opened and discard unused portion after 30 days. Observation of the Front Medication Room on 8/18/21 at 12:20 p.m. […]