Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clifton Heights during CMS and state inspections, most recent first.
The facility did not maintain a sanitary environment, as evidenced by ongoing pest activity including cockroach carcasses and residue in resident rooms, dining, and common areas. Staff interviews confirmed persistent pest sightings despite a pest control contract and regular treatments. Key staff were aware of the infestation, but pest issues continued to be observed.
A resident requiring tracheostomy care did not receive treatment according to professional standards when an LPN failed to maintain sterile technique and did not properly oxygenate the resident between suction passes. The LPN used a contaminated hand during the procedure and did not provide rest periods or assess respiratory tolerance, resulting in a breach of infection control and care protocols.
A resident with paraplegia, a chronic Stage IV sacral ulcer, and long-term opioid use was admitted with an order for scheduled hydromorphone every 4 hours, but the medication was not obtained or administered for about 2 days. Nursing notes documented severe pain ratings of 8/10 to 10/10, and the resident reported crying, vomiting, withdrawal symptoms, and uncontrolled pain while staff waited for the script to reach the pharmacy. The baseline assessment and care plan did not fully capture the resident’s chronic pain needs or specify the ordered analgesic and pain monitoring interventions.
A resident with paraplegia and muscle weakness fell and was given a verbal order for BLE x-rays after reporting leg pain, but staff did not ensure the imaging was completed or confirmed with the x-ray company. Over the next few days, the resident continued to complain of worsening pain and swelling, and was later sent to the hospital where a displaced tib-fib fracture was found and surgery was required.
Failure to Prevent and Control Pest Infestation in Resident Care Areas
Penalty
Summary
The facility failed to maintain a sanitary and safe physical environment to prevent the presence of pests within resident care areas. Observations during environmental rounds revealed insect carcasses, identified as cockroaches, in a resident room, the dining area, and the common area. Additional evidence of pest residue was found in multiple resident rooms. Interviews with staff confirmed ongoing pest activity, with one CNA reporting daily sightings of roaches in specific rooms over the previous month and noting that residents were aware of the infestation. Another staff member acknowledged pest presence in common areas, though not directly in resident rooms. Record review showed that the facility had a pest control policy in place, with a local contractor providing monthly and as-needed treatments. However, the most recent documented treatment was on 09/19/2025, and pest activity persisted despite these interventions. The Maintenance Director confirmed the existence of a pest control contract but was unaware of pest issues in resident or common areas. The DON acknowledged awareness of pest infestations but stated she was not directly involved in pest control. The Administrator also confirmed the pest control contract and recognized the potential for pests to transmit diseases to residents.
Failure to Provide Safe and Sterile Tracheostomy Care
Penalty
Summary
A resident with a tracheostomy, impaired cognition, and multiple medical diagnoses was observed receiving tracheostomy care that did not adhere to professional standards, the resident's care plan, or facility policy. During the procedure, an LPN failed to maintain sterile technique by using her designated 'dirty' hand to adjust the resident's oxygen and then used the same hand to open a bottle of normal saline, contaminating the sterile field. The LPN then poured the saline into the tracheostomy care kit without recognizing the breach in sterility. Additionally, the LPN did not oxygenate or hyper-oxygenate the resident between suction passes, as required by evidence-based procedures, and performed three consecutive suction passes without providing rest periods or assessing the resident's respiratory tolerance. The LPN acknowledged during an interview that she broke sterile field and did not follow proper oxygenation procedures, attributing her actions to nervousness and lack of experience, having only started three weeks prior. The facility's policy and infection control procedures were not followed during the tracheostomy care, and the LPN did not set up a clean working area or barrier for the sterile procedure. Interviews with other nursing staff confirmed knowledge of the correct procedures and the importance of restarting the process if sterility is compromised.
Failure to Provide Timely Scheduled Pain Medication
Penalty
Summary
The facility failed to provide effective pain management for a resident with chronic pain who was discharged from the hospital on a routine order for hydromorphone 2 mg, two tablets every four hours for pain. The resident had paraplegia from a prior gunshot wound, a chronic Stage IV sacral pressure ulcer with osteomyelitis, and a history of long-term opioid use for pain control. On admission, the nurse documented pain at 8/10 and noted the resident had pain to the coccyx, but the baseline assessment did not identify the resident’s chronic opioid use as ongoing pain management needs, and the care plan did not specify administration of the ordered analgesic or monitoring/reporting of pain complaints as part of the baseline interventions. Although the physician order called for hydromorphone every four hours, the resident did not receive the first dose until two days after admission. Facility records showed that the pharmacy did not receive the hydromorphone order until the medical director first contacted it, and multiple nursing notes documented severe uncontrolled pain during the gap in medication availability, with pain ratings of 8/10, 9/10, and 10/10. Staff documented repeated calls to the NP, APRN, medical director, and pharmacy, and a temporary order for hydrocodone-acetaminophen was later given, but it was only administered three times while the resident continued to wait for the ordered hydromorphone. The resident stated that he arrived without his medications, did not receive hydromorphone until late on the second day, and experienced withdrawal symptoms, crying, vomiting, and severe pain. He reported that the only way the pain was going away was if he died. Interviews with nursing staff, the NP, the medical director, the DON, the administrator, the pharmacy, and the pain clinic confirmed that the resident’s scheduled opioid was not promptly obtained or administered as ordered, and that the resident remained in severe pain during the delay.
Delayed X-ray Follow-Up After Resident Fall
Penalty
Summary
The facility failed to ensure timely diagnostic x-ray services were obtained after a resident sustained a fall and reported leg pain. The resident had diagnoses including paraplegia and muscle weakness. After the fall, a Change in Condition evaluation documented that the nurse practitioner gave a verbal order for bilateral lower extremity x-rays, and the order was noted in the record. However, the clinical record did not show that the ordered x-rays were completed at the facility before the resident was transferred to the hospital approximately 72 hours later. Following the fall, progress notes showed the resident continued to report that both feet looked awkward, but there was no evidence that staff acted on the x-ray order or identified that it had not been completed. One note documented that the resident was encouraged to go to the hospital for evaluation, but he declined at that time. Later, the resident complained of severe right leg pain, rated 9/10, with marked swelling compared with the other extremity, elevated blood pressure, and an elevated pulse. The resident stated that an x-ray had been ordered but the company never came, and staff determined an emergency transfer was needed. Hospital documentation showed the resident was admitted with a displaced tibia and fibula fracture and later required surgery and a 10-day hospitalization. Interviews with nursing staff, the nurse practitioner, the DON, the Administrator, and the x-ray company showed confusion about the ordering process, lack of confirmation that the order had been received, and no documented follow-up to ensure completion of the x-ray. The Administrator also stated he believed the resident had refused the x-ray, but the resident denied refusing it, and there was no documentation of a refusal in the record.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sycamore Heights Health And Rehabilitation | 0.4 mi | ★★★★★ | 9 | 0 |
| Nazareth Home Clifton | 0.6 mi | ★★★★★ | 0 | 0 |
| Home Of The Innocents | 1.6 mi | ★★★★★ | 37 | 0 |
| Kindred Hospital - Louisville | 1.9 mi | ★★★★★ | 3 | 0 |
| Highlands Nursing And Rehabilitation | 2.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.