Clifton Heights

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documented. Five milligrams of Hydrocodone is equivalent to 1 mg of Hydromorphone. Regarding Resident R1's severe pain ratings, he stated: Pain is subjective, but I can understand based on my knowledge of that medication his report of pain. That makes sense from a clinical perspective.In an interview with the DON on [DATE REDACTED] at 3:39 PM, she stated she could not speak to the specifics of Resident R1's admission as she has only been employed by the facility for approximately two weeks. She reported she has been trying to work together with the NP if the person needs a script before they get here. The NP refers staff to [the Medical Director] if

she cannot write it. Regarding her expectations for the timeliness of admission orders, she stated: You can get medications stat delivered; you can also use the EDK if the med is available [in the EDK], but reported

she was not sure about the actual timeframes for resident admissions, sending orders to the pharmacy, and receiving those orders from the pharmacy. The DON stated she did not consider a 48-hour delay to be timely. Interview with the Administrator on [DATE REDACTED] at 9:25 AM, revealed his statement that Resident R1 was admitted

on [DATE REDACTED] sometime between 9:00 PM and 11:00 PM and he provided no explanation as why or how the staff documented that they had completed an initial admission assessment on [DATE REDACTED] at 6:32 PM.In an additional interview with the Administrator on [DATE REDACTED] at 2:03 PM, he reported resident medications are taken into consideration prior to admission to the facility, stating they consider the availability, the costs, [and] whether it is a rare medication. Regarding the admission process for residents discharging from the hospital, he stated: We have a nurse liaison in the field. They receive referrals from the hospital. At times

they go into the hospital and review the charts, talk to the resident. However, he was uncertain if this had taken place prior to Resident R1's admission to the facility. When asked whether it was his expectation that scheduled medications be available when a new resident arrives to the facility, he stated: I expect us to follow our own policies and CMS guidelines. When asked if, for medications not on hand, the facility attempts to obtain them prior to the resident's arrival, he responded it depends on what the order is and our policies and CMS guidelines.Further interview with the Administrator, on [DATE REDACTED], regarding his expectation for the timely administration of scheduled pain medication, he stated: Whatever our policies state and CMS guidelines. That would be something that a clinician would need to answer, but expressed that his expectation was that the physician orders were followed. When asked whether approximately 48 hours without a resident's scheduled pain medication would be considered timely, he stated: Depends. It is case by case. I would have to speak with the doctor. When asked about his expectation of appropriate pain management, he stated: I cannot answer that as I am not a clinician, then added: I would expect the clinician to address a resident's pain. The Administrator described the Medical Director's role at the facility as the overall clinician. The Administrator stated that it was on a case by case basis as to when in the admission process staff should reach out to the Medical Director to obtain scheduled medications, adding I did not see his referral, I don't know what medications he [Resident R1] was on, I cannot speak to that.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clifton Heights

446 Mt. Holly Avenue Louisville, KY 40206

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 0776 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview with the NP on 11/13/2025 at 10:07 AM, she stated that on 10/29/2025 Resident R1 fell out of bed and was complaining of leg pain, so she ordered a bilateral leg X-ray in response. She stated that she did not order

the X-ray stat (with an expected time frame of four hours.) Instead, it was a routine order, for which she believed that 24 hours is reasonable. Further interview revealed she looked in the computer to see whether orders such as X-rays had been completed and that if something was not done, nursing staff or the UM would usually follow up with her. The NP reported that by the time she would have known there was an issue with not obtaining Resident R1's X-ray, He had gone to the hospital. In a follow-up interview on 11/21/2025 at 12:54 PM, when asked who staff should reach out to at night for provider issues, she stated: It is me.In an

interview with the DON on 11/17/2025 at 4:02 PM, she stated there was a form used for auditing and oversight of orders and believed It is being used during the clinical meeting, which is held daily, adding whoever is leading the meeting that day would fill it out. She stated presently she is the one reviewing charts to make sure there are no pending orders, but that she was not working at the facility at the time of Resident R1's X-ray order and could not identify who was responsible for ensuring his ordered X-ray was completed and followed up during that period, and was unable to provide evidence that the chart had been audited to identify the pending order. In a subsequent interview on 11/21/2025 at 3:44 PM, she stated nurses that have been trained can order X-rays but acknowledged there were recent changes in the process for ordering X-rays and that a lot of staff, including her, were new. She stated a staff member could confirm an X-ray had been ordered correctly by calling [the X-ray company] for confirmation. She stated possible routes for ordering an X-ray included calling it in, placing it in PCC, or going into the X-ray company's system, and that follow-up to ensure X-rays were completed should be passed in report from nurse to nurse. The DON was unable to say whether there was any follow up on Resident R1's X-ray, adding, I was not here

during that time.In an interview with the Administrator on 11/21/2025 at 2:03 PM, he stated practitioners, such as doctors and NPs, and nurses that have been trained have the ability to order X-rays. When asked how staff confirm an X-ray had been ordered correctly, he stated, I do not know that process, then added

The clinicians would know. He stated leadership, the clinical team, and the Interdisciplinary Team [IDT] follow up that X-rays are completed. The Administrator again repeated that he was under the impression that Resident R1 did not want an X-ray and told him he was going out with his family; however, he then acknowledged there was no such documented refusal.

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