Kindred Hospital Louisville: Fentanyl Patches Discarded - KY
The incident came to light on October 7, 2025, when LPN3 went to administer a scheduled morning dose for the patient, identified in inspection records as R5, and found the patches missing. The Director of Nursing told inspectors that LPN3 had thrown away the pharmacy delivery bag at the nurse's station, and after checking the narcotic addition and deletion log, confirmed the medication had never been signed in at all.
The Assistant Director of Nursing offered an explanation for how the patches disappeared: they were delivered in a sealed bag inside a small plastic bag, and sometimes the patches would stick to the inside of the pharmacy bag. LPN3 had also taken another medication from the same delivery to a different nurse, LPN8, before discarding the bag.
The problem wasn't just the discarded patches. It was that no verification happened at all. The Director of Nursing told inspectors she expected narcotics to be verified upon delivery and immediately signed in by two nurses. The Executive Director said he expected a secure handoff process, with both the receiving nurses and the pharmacy delivery staff monitoring what came through the door.
Neither of those expectations was met on October 7.
The Medical Director was notified after the patches were discovered missing, and an order was obtained to administer a patch once a replacement arrived from the pharmacy. Inspectors rated the harm as minimal.
R5 waited for pain medication that had already been delivered, thrown away, and replaced before anyone knew it was gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kindred Hospital - Louisville from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Kindred Hospital - Louisville in Louisville, KY was cited for violations during a health inspection on December 31, 2025.
LPN3 had also taken another medication from the same delivery to a different nurse, LPN8, before discarding the bag.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.