Clifton Heights: X-Ray Delays Harm Residents - KY
The nurse practitioner who ordered the bilateral leg X-ray on October 29, 2025 told inspectors she placed it as a routine order, not a stat order, and considered a 24-hour turnaround reasonable. She said she checked the computer for completed orders and assumed nursing staff or the unit manager would flag anything that slipped through. They didn't. "By the time she would have known there was an issue with not obtaining R1's X-ray," inspectors noted, "he had gone to the hospital."
The director of nursing told inspectors she believed a daily clinical meeting included chart audits to catch pending orders. She was not at the facility during the period in question and could not identify who was responsible for ensuring the X-ray was completed. She could not provide evidence that anyone had audited the chart and found the pending order sitting there. In a follow-up interview, she described a recently changed ordering process involving at least three possible routes: calling the X-ray company directly, entering the order into the facility's electronic system, or going into the X-ray company's own system. Follow-up, she said, was supposed to pass from nurse to nurse at shift change. Whether that happened for this resident, she said, she did not know. "I was not here during that time."
The administrator told inspectors he believed the clinical team and the interdisciplinary team handled X-ray follow-up. When asked how staff confirm an X-ray was ordered correctly, he said, "I do not know that process." He also told inspectors he had been under the impression the resident refused the X-ray and left to spend time with family. Inspectors asked for documentation of that refusal. There was none.
CMS cited the deficiency at the actual harm level. A resident fell, said his leg hurt, and the order that followed went untracked through a system where the nurse practitioner, the director of nursing, and the administrator each described someone else as responsible, and none of them could say what actually happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clifton Heights from 2025-11-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
Clifton Heights in Louisville, KY was cited for violations during a health inspection on November 22, 2025.
She said she checked the computer for completed orders and assumed nursing staff or the unit manager would flag anything that slipped through.
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.