LOUISVILLE, KY- CLIFTON HEIGHTS

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey, that can be found by clicking on “Full State Report” at the bottom.

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Based on record review, interview, and review of the facility’s policies, it was determined the facility failed to ensure that 1 of 11 (Resident (R)1) sampled residents received diagnostic x-ray services in a timely manner, which created a delay in reporting any abnormal results to the physician and/or Nurse Practitioner, who had ordered the x-ray. After R1 sustained a fall, the facility failed to ensure that the resident received necessary follow-up, including implementation of physician orders for bilateral lower extremity (BLE) X-rays. R1 reported having severe leg pain and displayed swelling, changes in condition, and was eventually found to have a displaced tibia and fibula fracture that remained undiagnosed for approximately three days after his fall.

R1 ultimately required surgery and 10 days of hospitalization in response.

The findings include:

Review of the facility’s policy titled Verbal Orders, revised 02/14/2024, revealed that Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so. Per the policy, staff are to enter the order into the medical record electronically or manually, if needed, and follow through with orders by making appropriate notifications to the required provider.

Review of R1’s admission Record revealed the facility admitted the resident from the hospital on
[DATE], with diagnoses including paraplegia and muscle weakness.

Review of a Change in Condition (CIC) evaluation, dated 10/29/2025 at 11:37 PM and documented by Licensed Practical Nurse (LPN) 3, revealed that R1 sustained a fall. Under Nursing observations, evaluation, and recommendations, the note documented the resident stated his feet were awkward in position. In response, the Nurse Practitioner (NP) provided a new, verbal order for X-rays to the bilateral lower extremities (BLE), with orders received and noted. The provider feedback section of this form documented new testing orders for an X-ray to the BLE and to continue to monitor.

Review of R1’s progress notes for the remainder of 10/2025 revealed no further information regarding the need for X-rays. An entry dated 10/31/2025 at 3:53 AM by Registered Nurse (RN) 4 documented the resident told the nurse he had fallen two days ago, and RN4 instructed the incoming nurse to follow up and report to the NP in the morning; however, the note failed to address that X-rays were ordered but had not been obtained.

A progress note dated 11/01/2025 by LPN3 documented the resident complained that both feet appeared awkward and that the nurse encouraged the resident to go to the hospital for evaluation; however, the resident declined at that time, stating: I’m ok, I’ll be ok until I get back. There was no evidence that the order for the X-rays was acted upon, or that staff identified that it had not yet
been completed. Further review of the record revealed a CIC evaluation, dated 11/01/2025 at 11:15 PM, and documented by the Infection Preventionist/Staff Development Coordinator (IP/SDC). The note documented the resident complained of severe [right] leg pain from the thigh down to the foot. Per the note, the resident’s pain was rated at 9/10 (with 0 meaning no pain, and 10 being worst pain imaginable), and that after receiving his bedtime medication pass, he was still inconsolable. The nurse assessed the leg and noted it was notably more swollen than [the] other extremity. The note documented the resident requested to go to the hospital and approached the nurse fully dressed with face flushed and red, grimacing, holding onto leg. The entry further reflected the resident stated, An X-ray was ordered but company never came, and the nurse was extremely concerned about [the] patient’s disposition, not being at baseline and the possibility of a deep vein
thrombosis (DVT) worsening and dislodging into his blood stream due to patient history. The note
documented the resident stated the pain was getting worse and worse over the course of the past few days, and the nurse decided based upon the findings that an emergency send was warranted based upon [the] patient’s [resident’s] request. Vital signs obtained at that time included elevated blood pressure (186/95) and pulse (105).

The entry documented the resident’s change in condition included uncontrolled pain and
elevated vital signs, that the NP and Director of Nursing (DON) were notified, the emergency contact was notified, and report was called to the hospital.

A progress note dated 11/01/2025 at 11:26 PM documented the IP/SDC spoke with an RN at the hospital’s emergency room, who reported the resident would likely be admitted and that imaging had identified a displaced fracture of the tibia and fibula, with the bone having shifted. The note documented that the DON and Medical Director were notified of these findings. There was no evidence in the clinical record that the ordered BLE X-rays were completed at the facility prior to the resident’s transfer on 11/01/2025, approximately 72 hours after the need for the X-ray was first identified.

Review of the hospital Final Report, dated 11/11/2025, revealed the hospital admitted R1 on 11/01/2025 and discharged him back to the facility 10 days later, on 11/11/2025.

Provide safe, appropriate pain management for a resident who requires such services.

Based on record review, interview, and review of the facility’s policies, it was determined the facility failed to ensure an effective pain management regimen, based on a thorough assessment and a person-centered care plan, was implemented for 1 of 11 sampled residents receiving scheduled pain medications (Resident (R) 1). The facility failed to administer pain medication as ordered to R1, who had a history of chronic pain and required multiple daily doses of a potent opioid analgesic. The failure created ongoing, severe pain, and R1 also experienced withdrawal symptoms which he described as, The only way the pain was going away was if I died.

The findings include: Review of the facility’s policy titled Pain Management, dated [DATE], revealed the facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. The policy states that, in order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and prevent or manage pain, the facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated, evaluate the resident for pain and the cause(s) upon admission and with changes in condition, and manage or prevent pain, consistent with the comprehensive assessment and plan of care. and the resident’s goals and preferences. The policy, dated [DATE], further revealed that, based on professional standards of practice, an assessment or evaluation of pain by the interdisciplinary team may include obtaining the resident’s history of pain and its treatment, identifying key characteristics of the pain such as
duration of pain, timing, pattern, and radiation, determining the impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood), and reviewing current prescribed pain medications, dosage and frequency.

In the section on pain management and treatment, the policy stated that, based upon the evaluation, the facility, in collaboration with the attending prescriber and other health care professionals and the resident and/or representative, will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident’s pain beginning at admission, and that the interventions for pain management will be incorporated into the components of the comprehensive care plan.

The policy further indicates that pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain, and that the interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain, including evaluating the resident’s medical condition and current medication regimen and using the most effective and least invasive route for analgesic administration.

Review of the facility’s policy titled Controlled Substance Administration and Accountability, revised [DATE], revealed that non-stock controlled substances are dispensed from the pharmacy according to physician orders for a specific patient. Review of the facility’s policy titled, Medication Reconciliation, revised [DATE] revealed that, prior to admission, staff are to obtain the current medication list from the referral source (e.g., hospital, home health, hospice, or primary care
provider), obtain current medication and admission orders, verify resident identifiers, and forward the information to the nursing unit accepting the resident. The same policy further specifies that upon admission staff are to verify resident identifiers on the information received, compare admission orders to hospital records and obtain clarification orders as needed, transcribe orders in accordance with procedures for admission orders, have a second nurse review the transcribed orders for accuracy and cosign to indicate the review, and order medications from the pharmacy in accordance with facility procedures for ordering medications.1.

Review of R1’s hospital History and Physical [H and P] revealed the hospital admitted R1 on [DATE]. Per the H and P, R1 had a history of a gunshot wound with residual paraplegia (paralysis of the lower limbs). The resident also had a chronic Stage IV pressure ulcer with osteomyelitis growing multiple drug-resistant organisms (MDRO.) This pressure ulcer was described as enlarging, with progressed loss of bone mineral density of the sacrum. The H and P noted that the resident had chronic pain and had orders for hydromorphone (Dilaudid – a potent opioid analgesic used to treat moderate to severe pain) both prior to admission, as well as during his hospitalization.

Review of the facility’s Discharge summary dated [DATE] at 1:53 PM revealed that R1 was discharged from the hospital to a nursing facility on [DATE]. R1, who was followed by a pain clinician (both prior to and during hospitalization), had medication orders at the time of discharge for Hydromorphone HCl oral table 2 milligrams (mg), two tablets every four hours for pain