Sprenger Health Care Of Port Royal
Sprenger Health Care of Port Royal in Port Royal, SC — inspection on November 25, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
down his arm.
His arm was bruised, and he had 2 significant scrapes on his arms.
The nurse said he had just fallen. So here, my Dad had just left the building unsupervised, and now, he falls for the umpteenth time . On 11/25/25, the facility provided a removal plan, which included:1. On 11/22/25 by approximately 6:00 P.M., 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.2. On 11/22/25 by approximately 6:00 P.M., 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.3. On 11/22/25 at approximately 6:30 P.M., 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.4. On 11/22/25 by approximately 8:30 P.M., the 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).5. On 11/22/25 by approximately 8:30 P.M., the DON completed education for all nurses on notification of change in condition policy and recognizing s/s of a change in condition.6. On 11/22/25 at approximately 8:45 P.M., Dr. [NAME], Medical Director, was notified of QAPI meeting discussion and the corrective action plan.7. On 11/24/25 by approximately 8:00 P.M., the 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.8.
Beginning on 11/24/25, the 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.9.
Beginning on 11/24/25, the 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.10.
Beginning on 11/24/25, the 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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