Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Sprenger Health Care Of Port Royal during CMS and state inspections, most recent first.
The facility failed to keep medications in an Omnicell ADC at proper manufacturer/USP temperatures. Staff told the surveyor the Data Storage Room was always very hot, and measured temperatures were 87.8 degrees F, 86.2 degrees F, 86.0 degrees F, and 86.4 degrees F, with no AC and no thermometer in the room. The cabinet contained about 173 medication line items, and the DON provided a transaction log showing about 79 medication removals for multiple residents.
Improper food labeling and storage were observed in the kitchen. The Kitchen Manager was present when surveyors found an opened bottle of BBQ sauce and two bottles of grape jelly stored in dry storage even though they should have been refrigerated after opening, along with opened chives and baking soda that were not dated. Surveyors also observed a box of mushrooms in the walk-in cooler with mold.
Unsecured Sharps Containers in Resident Rooms: The facility failed to keep in-room sharps containers securely locked in 3 of 4 halls observed. One resident with severe cognitive impairment had an open container with no lock, another resident’s container would not latch even though a lock was present, and a third resident’s container was held shut with duct tape and had no lock. Staff interviews confirmed broken or missing locks and inconsistent reporting to maintenance.
Surveyors found an opened bottle of trazodone labeled for discard after the expiration date, an opened container of thickened water left at room temperature instead of refrigerated and dated when opened, and an opened PPD vial still in active storage beyond the manufacturer’s 30-day limit. RN and leadership confirmed the findings and stated medications should be stored per manufacturer specifications.
A resident with moderate cognitive impairment and a history of alcohol dependence, withdrawal delirium, and other conditions eloped from the facility after staff failed to reassess and update the elopement risk despite observed changes in mobility and wandering behavior. The resident exited through automatic doors in a wheelchair and was found unsupervised across the street, highlighting a lapse in supervision and risk assessment procedures.
Improper Medication Storage Temperature in Omnicell Cabinet
Penalty
Summary
The facility failed to ensure medications were safely stored at the correct manufacturer and USP temperatures in 1 of 1 automated dispensing cabinet. Review of the facility’s medication storage policy showed it addressed only keeping medications behind locked doors and did not address additional storage requirements. The pharmacy services agreement stated the consultant would assist the facility in reviewing safe and secure storage of medications in locked compartments under proper temperature controls in accordance with manufacturers’ specifications. USP storage guidance identified controlled room temperature as 68 degrees F to 77 degrees F. During observation and interview, the surveyor found the Omnicell automated dispensing cabinet containing emergency drug supplies in the Data Storage Room on Hall 300. RN1 stated the room was always very hot and kept the door open. The surveyor measured the room temperature at 87.8 degrees F, then 86.2 degrees F after the door was closed. RN2 stated the room was always hot and contacted the Maintenance Director, who measured temperatures of 86.0 degrees F and 86.4 degrees F and stated there was no air conditioning in the room and no thermometer in the Data Storage Room. The Omnicell inventory showed approximately 173 medication line items, including oral medications, injectable antibiotics, IV fluids, enoxaparin, epinephrine, inhalers, nasal spray, and ophthalmic drops and ointments. The DON later provided an Omnicell transaction log showing approximately 79 medication removal transactions for multiple residents during the reviewed period.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
Food was not labeled and stored appropriately in the kitchen, based on observation, interview, and review of the facility's Food and Storage Time Policy. During an observation and interview with the Kitchen Manager on 03/10/26 at 10:18 AM, several items were found not dated, not labeled, or not stored according to the facility policy. In dry storage, a bottle of BBQ sauce was labeled and dated but was stored in dry storage and should have been refrigerated after opening. A bottle of chives was opened and not dated, and a bottle of baking soda was opened and not dated. In the Walk-In Cooler, a box of mushrooms received on 02/12/26 was observed with mold. In the Main Kitchen on a storage shelf, two bottles of grape jelly were opened and dated but were stored in the dry storage area and should have been refrigerated after opening.
Unsecured Sharps Containers in Resident Rooms
Penalty
Summary
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. Review of the facility’s Sharps Disposal Protocol stated that all sharps are to be properly disposed of after use and that staff will monitor the sharps containers. During observations, the sharps container in one resident’s room was open with no lock present, and the interior box was about one-quarter full with used sharps, needles, and syringes. In another resident’s room, the sharps container was open and later remained unlocked even though a lock was present, because the lock was not securing the door closed. In a third resident’s room, the sharps container was held closed with duct tape and had no lock in the door. The residents whose rooms contained the unsecured sharps containers had significant cognitive or physical impairments. One resident had diagnoses including Parkinson’s disease, dementia, anxiety, depression, difficulty walking, repeated falls, and type 2 diabetes, and had a BIMS score of 6, indicating severe cognitive impairment. Another resident had dementia, major depressive disorder, encephalopathy, heart failure, and a history of falling, with a BIMS score of 7, also indicating severe cognitive impairment. The third resident had hemiplegia and hemiparesis due to stroke, anxiety, depression, seizures, viral infection, and muscle weakness, with a BIMS score of 10, indicating moderate cognitive impairment. Staff interviews confirmed the condition of the sharps containers and showed inconsistent awareness of the problem. A housekeeper stated housekeeping was responsible for changing sharps containers and that broken locks should be reported to maintenance, while another housekeeper said the lock on one container was broken and did not know what to do. The unit manager verified one container was open and stated the inner sharps box would be removed and maintenance notified. The maintenance director stated no formal requests had been received for some of the broken containers and acknowledged that one had been replaced only after he noticed it during a room check. The administrator stated housekeeping was responsible for the sharps containers and that staff could enter maintenance requests in TELS.
Expired and Improperly Stored Medications Found in Active Use
Penalty
Summary
Medications and biologicals were not consistently labeled and stored according to accepted professional principles. During an observation of the 400 Hall medication cart, surveyors found an opened bottle of Trazodone 150 mg belonging to a resident that was labeled by the VA pharmacy to be discarded after 08/07/2025, and an opened container of Ready Care Thickened Lemon-Flavored Water sitting on top of the cart at room temperature even though the manufacturer label stated it was good for 7 days after opening and should be stored in the refrigerator. RN1 verified both findings and stated the thickened water should have been dated when opened and kept refrigerated. Surveyors also observed the Hall 400 medication refrigerator and found an opened vial of PPD, Aplisol 5 TU/0.1 ml, approximately three-quarters full, dated by the facility as opened on 1/1/2026 and still in active storage. The manufacturer label stated that vials in use more than 30 days should be discarded due to possible oxidation and degradation that may affect potency. RN1 verified the vial had been opened on 1/1/2026 and remained in the refrigerator. The Administrator and DON later stated that medications should be stored according to manufacturer specifications and expired medications should not be left in active storage.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including alcohol dependence, withdrawal delirium, anxiety disorder, depression, liver disease, and spinal stenosis, successfully eloped from the facility. The resident had a BIMS score indicating moderate cognitive impairment and was initially assessed as non-ambulatory and not at risk for elopement. However, staff observations and interviews revealed that the resident had become more alert and mobile over time, with some staff noting increased awareness and wandering tendencies prior to the incident. On the day of the incident, the resident was last seen in a common area before being discovered missing. Staff initiated a search, and the resident was found across the street in a parking lot, having exited the facility unsupervised in a wheelchair. The facility's automatic doors likely enabled the resident's exit. Staff interviews indicated that the resident had previously attempted to approach exits and expressed desires to leave, but these behaviors were not reflected in the most recent elopement risk assessment prior to the incident. The facility's policy required elopement risk assessments on admission and after any change in condition, with care plans to be updated accordingly. Despite these requirements, the resident's increased mobility and wandering behavior were not promptly reassessed or addressed in the care plan before the elopement occurred. Staff responses and documentation did not reflect timely recognition of the resident's change in status, resulting in inadequate supervision and failure to prevent the elopement.
Removal Plan
- DON conducted a whole house audit to ensure that elopement risk assessments were complete, and all at risk residents were in the secured unit, with wander guard orders. No concerns were noted.
- DON/designee conducted a whole house audit of elopement assessments completed and accuracy ensured. Any discrepancies corrected and appropriate parties notified. All notifications and any changes to plan of care to be documented. No concerns were noted.
- An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, Regional Quality Assurance Nurse, Director of Clinical Services, Regional Administrator, COO, CEO, Executive Director of QA via telephone. The meeting discussed requirements of physician visits, elopement risk, notifications, communication, current orders, conditions, and corresponding policies.
- DON educated all Nursing staff on elopement policies and procedures, such as frequency of assessment, appropriate intervention (secured unit, wander guards), tools used to communicate any issues (elopement assessments, behavior charting, nurses' notes).
- DON completed education for all nurses on notification of change in condition policy and recognizing signs and symptoms of a change in condition.
- Dr. [NAME], Medical Director, was notified of QAPI meeting discussion and the corrective action plan.
- Administrator and DON/Regional Quality Assurance Nurse completed verbal education to all facility physicians and nurse practitioners regarding facility elopement policy and procedures, elopement risk, change of condition including elopement risk changes.
- DON/designee would audit all admissions for elopement assessments, notifications and documentation every business day for four weeks then randomly thereafter for a total of two months. Quality Assurance (QA) would review the results of the audits weekly.
- DON/designee would audit all nurses' notes for significant change and proper notification and documentation each business day for four weeks, then randomly thereafter for a total of two months. QA would review the results of the audits weekly.
- DON/designee would audit four residents elopement risk each week to check for any changes in elopement risk, if new risk identified, MD and RP notification completed, orders for secured unit and wander guard implemented as well as any needed follow up was completed for four weeks, then randomly thereafter for a total of two months. QA would review the results weekly.
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Illustrative
What surveyors actually found near you
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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.
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Nursing homes near Port Royal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Resorts At Beaufort | 1.6 mi | ★★★★★ | 7 | 0 |
| The Preston Health Center | 10.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Hilton Head | 11.2 mi | ★★★★★ | 0 | 0 |
| Broad Creek Care Center | 15.5 mi | ★★★★★ | 1 | 1 |
| Sprenger Healthcare Of Bluffton | 16 mi | ★★★★★ | 0 | 0 |
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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.