RIDGEWAY, SC - Federal inspectors declared an immediate jeopardy situation at Ridgeway Manor Healthcare Center after discovering systemic failures in narcotic medication tracking that placed residents at serious risk of medication diversion and compromised care.
Immediate Jeopardy Declaration Over Narcotic Tracking
On March 3, 2025, federal surveyors notified facility administrators of an immediate jeopardy finding at 8:35 PM, the most serious category of health and safety violations that can be cited during a nursing home inspection. The designation indicated that the facility's medication management practices created a substantial likelihood of serious injury, harm, impairment, or death to residents.
The immediate jeopardy remained in effect until March 5, 2025, at 1:50 PM, when surveyors validated that the facility had implemented sufficient corrective measures to ensure resident safety. However, even after the most urgent concerns were addressed, the deficiency continued at a lower severity level due to documented instances of potential harm to residents.
Months of Unresolved Pharmacy Concerns
The investigation revealed that Ridgeway Manor's pharmacy consultant, Omnicare, had identified narcotic discrepancies in monthly quality improvement reports for multiple consecutive months, yet the facility failed to adequately address these red flags.
In the October 2024 pharmacy report covering 98 resident charts, consultants documented that "quantities on back of MAR [Medication Administration Record] do not always match quantity on Narcotic sheet." The report specifically noted one discrepancy during a sample audit of just four residents and recommended that staff ensure appropriate documentation when controlled substances are administered.
The same issue appeared in the November 2024 report. Again reviewing 97 charts, pharmacy consultants found that narcotic counts on medication administration records did not align with quantities recorded on controlled substance tracking sheets. One discrepancy was identified in a sample of four residents, prompting another recommendation for improved documentation practices.
By January 2025, the problem had escalated. The pharmacy report for that month, which reviewed 98 charts, documented three discrepancies in a sample of four residents. Notably, one of these discrepancies was off by three pills, suggesting a more significant tracking failure than previous months.
Narcotic medications require meticulous documentation because of their high potential for abuse and diversion. Federal regulations mandate that healthcare facilities maintain exact counts of all controlled substances, with two staff members typically required to verify quantities when medications are administered, wasted, or transferred. When counts don't match documentation, it creates opportunities for medication theft, raises questions about whether residents received prescribed doses, and compromises the facility's ability to detect diversion patterns.
Inadequate Storage and Accountability Procedures
The investigation uncovered troubling practices regarding how excess narcotic medications were handled at Ridgeway Manor. During a March 2, 2025 interview at 4:15 PM, the Director of Nursing acknowledged a problematic storage protocol: "I used to keep all the excess narcotics in my office, but we won't be anymore. They're going straight to med cart."
This admission revealed that narcotic medications had been stored outside the standard medication cart system, creating a break in the chain of custody that is essential for controlled substance security. When the Administrator was interviewed later that day at 5:25 PM, additional details emerged about this practice: "Pharmacy will typically bring extra cards and [DON] keeps the narcotics with narcotic sheets in her office, but this process has changed now to storing them in the cart now since this incident."
The Administrator further explained the facility's approach to these stored medications: "The DON and I have the keys. We don't do med reconciliation on them, but they're in there for storage and not accessible to anyone."
This lack of medication reconciliation represents a critical failure in pharmaceutical oversight. Reconciliation is the process of comparing physical medication counts against documentation to identify discrepancies. Without regular reconciliation of stored narcotics, facilities cannot detect diversion, ensure medication availability for residents who need them, or maintain the accountability required by federal and state controlled substance regulations.
The Director of Nursing's statement during the March 2 interview further illustrated the accountability gap: "We don't have any accountability for them because no one touches them. We didn't need to have double verification for the Unit Manager (UM) to keep them in her office because she wasn't supposed to be doing it."
This reasoning contradicts fundamental principles of controlled substance management. Even medications in storage require accountability measures precisely because the lack of routine handling creates opportunities for undetected access. The absence of double verification for an unauthorized storage location compounds the security failure.
Quality Assurance System Failures
Beyond the specific medication handling issues, the investigation revealed that Ridgeway Manor's quality assurance process failed to effectively address identified problems. During a March 3, 2025 interview at 2:50 PM, the Administrator acknowledged: "We haven't addressed the pharmacy reports in QAPI yet. We do talk about them though."
The Director of Nursing provided additional context during an interview at 3:40 PM that same day: "We go over all the pharmacy quality assurance reports. We discuss them only in QAPI, but we don't document anything on them. We haven't addressed January's pharmacy report yet."
Quality Assurance and Performance Improvement (QAPI) programs are required in nursing homes to systematically identify problems, implement solutions, and track outcomes. When pharmacy consultants identify the same issue in consecutive monthly reports, an effective QAPI process should trigger investigation, corrective action, and monitoring to ensure the problem is resolved. The fact that narcotic discrepancies persisted from October 2024 through January 2025 without documented intervention suggests the facility's quality assurance system was not functioning as intended.
The absence of documentation is particularly concerning. In healthcare quality improvement, if corrective actions aren't documented, there is no way to demonstrate that problems were taken seriously, track whether interventions were effective, or ensure accountability for follow-through. Informal discussions without documentation create no institutional memory and no way to verify that identified risks to resident safety were adequately addressed.
Medical and Regulatory Implications
Narcotic medications, which include opioids for pain management, are among the most tightly regulated substances in healthcare facilities. These medications serve critical functions for residents experiencing acute or chronic pain, but they also carry significant risks including potential for addiction, respiratory depression, and dangerous interactions with other medications.
When narcotic tracking systems fail, several serious consequences can occur. Residents may not receive prescribed pain medications, leading to unnecessary suffering and potential complications from untreated pain. Conversely, if medications are diverted and documentation is falsified, residents might receive incorrect doses or no medication while records indicate they were medicated. This documentation falsification can mask serious medical deterioration and prevent appropriate clinical responses.
From a regulatory standpoint, controlled substance violations can trigger investigations by state pharmacy boards, the Drug Enforcement Administration, and state health departments. Facilities found to have inadequate controls may face restrictions on their ability to maintain controlled substance registrations, which would fundamentally compromise their ability to provide necessary medical care.
Additional Issues Identified
The inspection narrative indicates that the narcotic control failures were cited under Tag F755 (Pharmacy Services) and also cross-referenced pharmacy service concerns. The facility was found to have inadequate systems for monitoring, identifying, reporting, tracking, and investigating adverse events related to pharmacy services.
Facility Response and Corrective Actions
Following the immediate jeopardy declaration, Ridgeway Manor implemented an extensive corrective action plan that was accepted by surveyors on March 4, 2025, at 7:38 PM. The facility verified that the affected resident's medications were replaced and that no doses were missed according to medication administration records.
The corrective measures included comprehensive staff education on abuse, neglect, and misappropriation of property, with specific emphasis on immediate reporting of suspicious behavior related to narcotic medications. This training was mandated for all staff across all shifts, including PRN and agency personnel, with completion required before their next shift and no later than March 5, 2025.
The facility revised its Controlled Substance Administration and Accountability policy on March 3, 2025, implementing several key changes. The new procedures require two nurses' signatures when adding or removing medications from carts and when receiving medications from the pharmacy. The controlled substance card count sheet was updated to require full counts of on-hand medications with dual verification for any changes.
To ensure ongoing compliance, the facility established an auditing protocol requiring the Director of Nursing or Administrator to conduct narcotic counts and medication audits three times weekly until no further instances of non-compliance are identified. Once compliance is achieved, audits will continue on a weekly basis. All audit results are now submitted to the facility's QAPI committee for review, and pharmacy reports will be reviewed monthly by the committee.
The QAPI committee will review narcotic count audits monthly for three consecutive months, ensuring no issues are noted, while also maintaining monthly review of pharmacy consultant reports to ensure timely identification and resolution of any emerging concerns.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeway Manor Healthcare Center from 2025-03-05 including all violations, facility responses, and corrective action plans.
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