RIDGEWAY, SC - Ridgeway Manor Healthcare Center received an immediate jeopardy citation from federal inspectors in March after serious violations were discovered in the facility's handling and tracking of narcotic medications, according to a Centers for Medicare & Medicaid Services inspection report.
Immediate Jeopardy Citation Issued
The facility was notified of the immediate jeopardy violation on March 3, 2025, at 8:35 PM during a complaint investigation. Immediate jeopardy represents the most serious level of violation, indicating that residents faced immediate risk of serious injury, harm, impairment, or death due to the facility's failures.
The violation was successfully removed on March 5, 2025, at 1:50 PM after inspectors validated the facility's corrective actions, though the deficiency remained at a lower severity level for an isolated incident of potential harm.
Pattern of Narcotic Tracking Discrepancies
Federal inspectors uncovered a concerning pattern of medication tracking failures spanning several months. Pharmacy quality improvement reports from the facility's consultant pharmacist Omnicare revealed consistent problems with narcotic documentation:
October 2024: One discrepancy noted between Medication Administration Record (MAR) quantities and narcotic sheet documentation among four residents audited out of 98 charts reviewed.
November 2024: One discrepancy again found among four residents audited out of 97 charts reviewed.
January 2025: Three discrepancies discovered among four residents audited, with one discrepancy showing a deficit of three pills out of 98 charts reviewed.
The escalating pattern of discrepancies - from one error in October to three errors by January, including a significant three-pill shortage - indicated deteriorating medication management systems at the facility.
Improper Storage and Oversight Procedures
During interviews with facility leadership, inspectors discovered significant gaps in narcotic medication oversight. The Director of Nursing (DON) revealed that excess narcotic medications had been stored improperly in her office rather than secured in medication carts with appropriate accountability measures.
"I used to keep all the excess narcotics in my office, but we won't be anymore. They're going straight to med cart," the DON told inspectors on March 2, 2025.
The facility's Administrator acknowledged the storage problems, explaining that pharmacy deliveries typically included extra medication cards that were kept in the DON's office without proper verification procedures. "We don't do med reconciliation on them, but they're in there for storage and not accessible to anyone," the Administrator stated.
Quality Assurance Program Failures
Inspectors found that the facility's Quality Assurance and Performance Improvement (QAPI) committee had failed to adequately address the recurring pharmacy reports documenting medication discrepancies. Despite receiving monthly reports showing consistent problems, facility leadership admitted they discussed the issues but failed to document corrective actions or implement systematic improvements.
The Administrator acknowledged during interviews that "We haven't addressed the pharmacy reports in QAPI yet. We do talk about them though." The DON similarly confirmed that while pharmacy reports were reviewed, "We discuss them only in QAPI, but we don't document anything on them. We haven't addressed January's pharmacy report yet."
Medical and Safety Implications
Narcotic medication discrepancies in nursing homes pose serious risks to resident care and safety. Controlled substances require strict tracking protocols because they are frequently prescribed for pain management in elderly residents with complex medical conditions. When tracking systems fail, several critical problems can emerge:
Pain Management Disruption: Missing or unaccounted-for medications can result in residents experiencing inadequate pain relief, potentially affecting their quality of life and recovery outcomes.
Diversion Risk: Improper storage and tracking create opportunities for medication diversion, where controlled substances may be taken for unauthorized use rather than administered to residents as prescribed.
Dosing Errors: Inaccurate medication counts can lead to incorrect dosing, either through double-administration when staff believe medications are missing or under-dosing when medications are actually unavailable.
Regulatory Compliance: Federal and state regulations mandate strict controlled substance tracking to prevent diversion and ensure appropriate medical use.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive systems for tracking controlled substances. Standard protocols include:
Dual Verification: Two qualified staff members must verify controlled substance counts during shift changes and when medications are added or removed from secure storage.
Secure Storage: All narcotic medications must be stored in locked, secure locations with restricted access limited to authorized personnel.
Complete Documentation: Every controlled substance transaction must be documented on both the MAR and narcotic tracking sheets, with quantities reconciled regularly.
Regular Auditing: Facilities should conduct frequent internal audits of controlled substance inventory to identify and address discrepancies promptly.
Facility Response and Corrective Measures
Following the immediate jeopardy citation, Ridgeway Manor implemented comprehensive corrective actions to address the medication management failures. The facility's removal plan, accepted by inspectors on March 4, 2025, included several key components:
Enhanced Training Program: All staff received education on resident abuse, neglect, and misappropriation of property, with specific focus on recognizing and reporting suspicious behavior related to narcotic medications.
Updated Policies: The facility revised its "Controlled Substance Administration and Accountability" policy to require two nurses' signatures for adding or removing medications and for receiving pharmacy deliveries.
Improved Documentation: New controlled substance count sheets were implemented requiring complete medication inventories with dual nurse verification for all transactions.
Increased Oversight: The DON and Administrator committed to conducting narcotic count audits three times weekly until compliance is achieved, followed by weekly audits ongoing.
QAPI Integration: Monthly review of narcotic audits and pharmacy reports was incorporated into the facility's Quality Assurance committee process to ensure systematic monitoring and rapid response to identified problems.
Ongoing Monitoring Requirements
The facility's corrective action plan includes a three-month intensive monitoring period during which the QAPI committee will review narcotic count audits monthly. Pharmacy reports will also receive monthly committee review to ensure timely identification and resolution of any future discrepancies.
These enhanced oversight measures represent a significant improvement over the previous informal discussion approach that allowed medication tracking problems to persist for multiple months without documented corrective action.
The immediate jeopardy citation and subsequent corrective actions highlight the critical importance of robust medication management systems in nursing home settings, where vulnerable residents depend on accurate, secure handling of their prescribed treatments.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.