Ridgeway Manor Healthcare Center
Ridgeway Manor Healthcare Center in Ridgeway, SC — inspection on March 5, 2025.
Found 2 citations. 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
The facility failed to provide and maintain pharmaceutical services for the receipt, disposition, reconciliation, and control of narcotic medication for one of three residents (Resident (R)8) reviewed for medications out of a total sample of 21 residents.
This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion.
The facility's failure to ensure pharmaceutical services were provided to meet the needs of each resident had the potential to cause serious harm.
Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25, in the area of S483.45 Pharmacy Services
The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the Immediate Jeopardy was removed on 03/05/25 at 1:50 PM.
After removal of the Immediate Jeopardy, the deficiency remained at a D scope and severity for an isolated incident of potential harm.
Cross Reference: Pharmacy Services
3.
Review of the facility's pharmacy Omnicare Quality Improvement: Consultant Pharmacist Summary, dated 10/01/24 to 10/31/24, revealed, .
Quantities on back of MAR [Medication Administration Record] do not always match quantity on Narcotic sheet (one discrepancy noted on sample audit of four residents).
Please ensure staff is documenting appropriately on MAR and on narcotic sheet when controlled substances are administered for 98 charts reviewed.
Review of the facility's pharmacy Omnicare Quality Improvement: Consultant Pharmacist Summary, dated 11/01/24 to 11/30/24, revealed, Quantities on back of MAR do not always match quantity on Narcotic sheet (one discrepancy noted on sample audit of four residents, please ensure staff is documenting appropriately on MAR and narcotic sheet when controlled substances are administered for 97 charts reviewed.
Review of the facility's pharmacy Omnicare Quality Improvement: Consultant Pharmacist Summary, dated 01/01/25 through 01/31/25, revealed, Quantities on back of MAR do not always match quantity on Narcotic sheet (three discrepancies noted on sample audit of four residents and one discrepancy was off by three pills) for 98 charts reviewed.
During an interview on 03/02/25 at 4:15 PM, the DON stated, I used to keep all the excess narcotics in my office, but we won't be anymore.
They're going straight to med cart.
425158
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 425158 B.
Wing 03/05/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ridgeway Manor Healthcare Center 117 Bellfield Road Ridgeway, SC 29130