Florence Park Care Center

In the surveyor’s words

From the most serious findings on record at Florence Park Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 15, 2026

  Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the glucometer's (used to measure blood glucose values) directions for use, review of the facility's disinfection wipes' directions for use, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases for 3 of 29 sampled residents who required blood glucose monitoring, Resident (R) 67, R70, and R41; for 1 of 31 sampled residents for indwelling catheter collection bag resting on the ground, R8; for 3 of 31 sampled residents where staff did… […]

• Actual harm, isolatedF697Nov 14, 2025

  Based on interview, record review, and review of the facility's policies, the facility failed to ensure residents received necessary pain management as ordered when it did not safeguard and account for controlled substances to prevent diversion by staff. This deficient practice resulted in ordered pain medication not being available for administration causing unmanaged pain and discomfort for 3 of 9 sampled residents reviewed for pain, Resident (R) 1, R3, and R4. On 10/25/2025, a comparison of the medications on hand with the documented controlled substance record sheets revealed the narcotic counts for the C-Hall medication carts were inaccurate. The investigation into the discrepancies showed that residents had not received their scheduled narcotic pain medications. […]

• No harm, potential for more than minimal, widespreadF755Jan 15, 2026

  Based on observation, interview, record review, review of the controlled substance log titled Individual Patient Controlled Substance Administration Records [IPCSAR], and review of the facility's policies, the facility failed to ensure the proper documentation of controlled substances in accordance with professional standards of practice when nursing staff did not accurately complete and reconcile controlled narcotic record sheets at the time of removal for the A, B, and C Hall medication carts. In multiple instances, the IPCSAR sign out time, which should reflect the actual time the narcotic was removed from the narcotic bubble pack, instead reflected the ordered time and did not correlate with the medication administration time documented on the Medication Administration Record [MAR]. […]

• No harm, potential for more than minimal, widespreadF865Jan 15, 2026

  Based on observation, interview, document review, review of the Quality Assurance/Quality Assurance and Performance Improvement (QA/QAPI) Committee minutes, review of the facility's Plan of Correction (PoC), and review of the facility's policy, the facility failed to implement and sustain its Plan of Correction (PoC) related to monitoring of the narcotic sign-out sheets and timely administration of pain medications, as evidenced by the facility not thoroughly performing an audit process, and the QA/QAPI/ Committee failing to provide effective oversight and follow-up of identified concerns. […]

• No harm, potential for more than minimal, widespreadF865Nov 14, 2025

  Based on observation, interview, document review, review of the Quality Assurance/Quality Assurance and Performance Improvement (QA/QAPI) Committee minutes, review of the facility's Plan of Correction (PoC), and review of the facility's policy, the facility failed to implement and sustain its Plan of Correction (PoC) related to monitoring of the narcotic sign-out sheets and timely administration of pain medications, as evidenced by the facility not thoroughly performing an audit process, and the QA/QAPI/ Committee failing to provide effective oversight and follow-up of identified concerns. […]