Ridgeway Manor Healthcare Center

F-F602 Misappropriation disputing this citation. 2. 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

F-F755 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that

an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 425158 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 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. Level of Harm - Immediate jeopardy to resident health or During an interview on 03/02/25 at 5:25 PM, the Administer stated, Pharmacy will typically bring extra cards safety 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 DON and I have the keys. We don't do med reconciliation on Residents Affected - Few them, but they're in there for storage and not accessible to anyone.

Note: The nursing home is During an interview on 03/03/25 at 2:50 PM, the Administer stated, We haven't addressed the pharmacy disputing this citation. reports in QAPI yet. We do talk about them though.

During an interview on 03/03/25 at 3:40 PM, the Director of Nursing (DON) stated, 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.

On 03/04/25 at 7:38 PM, the facility presented an acceptable plan of removal, which included:

The resident's medications were replaced and the MAR show's no doses of the medication were missed.

On 03/03/2025 the facility system for monitoring, identifying, reporting, tracking and investigating adverse events related to pharmacy services after noted discrepancies in narcotic medication reconciliation were reviewed and updated as necessary to ensure the safety and wellbeing of the facility residents receiving narcotic medications.

On 2/26/25 education for all staff was initiated on resident abuse, neglect, and misappropriation of property.

This education includes the need for immediate reporting of suspicious behavior in relation to narcotic medications and is being provided to staff from all shifts and PRN and agency staff as well and will be conducted prior their next shift. This education will be completed on or before 3/5/25. All new hires will receive this education during their orientation, prior to resident contact. Policies and procedures were reviewed by the Admin, DON, RDO, and RNC, on 3/3/25 to identify any necessary revisions to aid in control of narcotic diversion. As a result of the review updates on the narcotic count sheet process and accounting were revised on the policy tilted Controlled Substance Administration and Accountability. These changes included updating of the how the total number of meds is noted on the sheets and it now requires two nurses' signatures to add or remove medications and and for receiving medications from the pharmacy. The controlled substance card count sheet was updated to include a full count of on hand medications. With two nurse's signatures required to add or remove medications from the cart. The DON and/or Admin will audit narcotic counts and medications will be conducted three times weekly until no further instances of non-compliance are found to exist. Once compliance is achieved the audits will be conducted weekly going forward. All audit results will be provided the facility QAPI committee for review. The pharmacy report will also be reviewed monthly by the committee.

The facility QAPI committee will review the narcotic count audits monthly times three months with no issues noted. Pharmacy reports will also be reviewed monthly by the QAPI Committee to ensure timely reporting is accomplished.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 425158