Inspection Reports for Florence Park Care Center
6975 BURLINGTON PIKE, FLORENCE, KY, 41042
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 14, 2025
Visit Reason
The inspection was conducted due to concerns about failure to provide necessary pain management and potential diversion of controlled substances by staff, resulting in residents not receiving ordered pain medications.
Complaint Details
The investigation was initiated after RN1 observed LPN2 diverting narcotic medications by removing pills from the medication cart and concealing them. Residents R1, R3, and R4 reported not receiving their scheduled pain medications and experiencing severe pain. The facility's narcotic records confirmed missed doses. Interviews with staff and residents corroborated the diversion and missed medication administration.
Findings
The facility failed to ensure residents received ordered pain medications due to inaccurate controlled substance counts and suspected drug diversion by a nurse. Three residents (R1, R3, and R4) missed doses of pain medication, experienced unmanaged pain, and lacked documented pain assessments. Additionally, controlled substance documentation and reconciliation were not properly completed by staff, including agency nurses.
Deficiencies (2)
Failure to provide safe, appropriate pain management resulting in missed doses of narcotic pain medications for residents R1, R3, and R4.
Failure to ensure proper control, accountability, reconciliation, and safeguarding of controlled substances, including failure to sign out controlled medications at the time of administration for residents R10, R11, R12, and R13.
Report Facts
Residents affected by pain medication diversion: 3
Residents affected by controlled substance documentation deficiencies: 4
Missed doses: 3
Medication administration times not signed out: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Observed diverting narcotic medications and responsible for missed medication doses for residents R1, R3, and R4. |
| RN1 | Registered Nurse | Observed LPN2 diverting medications and reported residents' complaints of pain. |
| LPN4 | Licensed Practical Nurse | Agency nurse who failed to sign out controlled medications at time of administration for residents R10, R11, R12, and R13. |
| DON | Director of Nursing | Reviewed narcotic records, confirmed missed doses, and described facility policies and expectations. |
| NP2 | Nurse Practitioner | On-call provider who denied additional pain medication request for R1 and was aware of potential narcotic diversion. |
| NP1 | Nurse Practitioner | Facility provider who commented on communication issues with on-call NP and pain management. |
| Administrator | Facility Administrator | Stated expectations for pain management and controlled substance policy compliance. |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 16, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility standards, including medication management, food safety, infection control, and other care practices.
Findings
The facility was found deficient in multiple areas including improper labeling and storage of medications, serving food at unsafe temperatures, incomplete refrigeration temperature logs, and lapses in infection prevention practices such as hand hygiene and improper handling of used trays. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (4)
Failed to ensure all drugs were labeled according to professional standards and used prior to expiration, including expired insulin and epinephrine pens, and medications without opened dates on medication carts.
Failed to serve hot food at a proper and palatable temperature; scrambled eggs served at 114°F and tasted warm for some residents.
Failed to store food safely; refrigeration storage log was incomplete for 8 out of 14 days.
Failed to identify and correct infection prevention problems; staff did not perform hand hygiene or wear gloves during medication administration and food handling, and used trays were improperly stored in the kitchenette.
Report Facts
Medication carts inspected: 7
Residents sampled for food temperature: 25
Days missing refrigeration temperature logs: 8
Used trays observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 12 | LPN | Named in findings for failure to perform hand hygiene and use gloves during medication administration |
| Assistant Director of Nursing | ADON | Interviewed regarding expectations for medication cart monitoring, infection control, and policy adherence |
| Dietary Manager | Interviewed regarding food temperature issues and tray handling procedures | |
| Dietary Supervisor | Interviewed about refrigeration log omissions and food temperature concerns | |
| Administrator | Interviewed regarding facility policy enforcement and infection control expectations | |
| Activity Assistant 2 | Observed and interviewed for failure to wash hands and use gloves when handling resident food | |
| State Trained Nurse Aide 18 | STNA | Interviewed about tray handling and infection control practices |
| C Unit Supervisor | LPN1 | Interviewed regarding tray cart availability and infection control concerns |
Inspection Report
Routine
Deficiencies: 1
Date: Jul 25, 2019
Visit Reason
The inspection occurred due to a review of the facility's compliance with care plan revisions following an incident where Resident #141 was found outside the building unaccompanied by staff on 05/31/19.
Findings
The facility failed to revise the Comprehensive Care Plan (CCP) for Resident #141 to reflect the incident of exiting the building and the subsequent intervention of placing a Wander Guard. Interviews and record reviews confirmed the CCP was not updated as required by policy.
Deficiencies (1)
Failure to revise the Comprehensive Care Plan (CCP) for Resident #141 to reflect the incident of exiting the building and the placement of a Wander Guard intervention.
Report Facts
Residents sampled: 47
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Resident #141's exiting behavior and care plan revision |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for care plan revision and findings |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 14, 2018
Visit Reason
The inspection was conducted to investigate complaints related to failure to notify the Ombudsman of resident transfers to acute care, failure to develop and implement a comprehensive care plan for prosthetic management, improper application of a prosthesis causing injury, improper use and renewal of psychotropic medication orders, and improper labeling and storage of medications.
Complaint Details
The complaint investigation focused on failure to notify the Ombudsman of resident transfers, inadequate care planning and prosthetic management, improper medication orders and labeling, and staff training deficiencies. The Ombudsman confirmed no notifications were received for transfers of Residents #3 and #98. Interviews revealed lack of training for staff applying prostheses and failure to follow medication order policies.
Findings
The facility failed to notify the Ombudsman of resident transfers to acute care for two residents, failed to develop and implement a comprehensive care plan for prosthetic management for Resident #3, resulting in a wound caused by incorrect prosthesis application by an untrained staff member. The facility also failed to limit PRN psychotropic medication orders to 14 days without renewal documentation and failed to properly label opened medications with dates. Several interviews confirmed these deficiencies and lack of training or policy adherence.
Deficiencies (5)
Failure to notify the Ombudsman of transfers from the facility to acute care settings for two residents.
Failure to develop and implement a comprehensive care plan including prosthetic management interventions for Resident #3.
Failure to provide appropriate care and assistance for Resident #3 with a prosthesis, resulting in a wound due to incorrect application by an untrained nursing assistant.
Failure to ensure PRN psychotropic medication orders were limited to fourteen days unless renewed with documented rationale for Resident #54.
Failure to label opened medications with the date opened and failure to store medications in locked compartments properly.
Report Facts
Residents sampled: 30
Residents affected: 2
Residents affected: 1
Residents affected: 1
Skin tear size: 2
Skin tear size: 0.5
PRN Ativan administrations: 14
PRN Ativan administrations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #4 | State Tested Nurse Assistant | Untrained staff member who incorrectly applied Resident #3's prosthesis causing a wound |
| LPN #3 | Licensed Practical Nurse | Provided wound care and notification for Resident #3's prosthetic injury |
| LPN #8 | Licensed Practical Nurse | Reported Resident #3's prosthesis wound and care progress |
| SRNA #3 | State Registered Nursing Assistant | Preceptor who observed incorrect prosthesis application by STNA #4 |
| Director of Nursing | Director of Nursing | Provided interviews regarding care plan deficiencies and staff training |
| Administrator | Facility Administrator | Provided interviews regarding facility policies and expectations |
| Physician #1 | Primary Care Physician | Prescribed PRN Ativan for Resident #54 |
| APRN #1 | Advanced Registered Nurse Practitioner | Provided psychiatric care and medication orders for Resident #54 |
| LPN #5 | Licensed Practical Nurse | Interviewed about medication labeling and storage policies |
| LPN #6 | Licensed Practical Nurse | Interviewed about medication labeling and storage responsibilities |
| LPN #7 | Licensed Practical Nurse | Interviewed about medication expiration and labeling |
| Registered Pharmacist | Pharmacist | Reviewed medication storage and labeling practices |
| Unit Manager | Unit Manager | Responsible for monthly order reviews and medication cart audits |
Viewing
Loading inspection reports...
