Louisville, KY

Clifton Heights

1-star overall rating with 1-star inspections with Special Focus status with $369,780 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

446 Mt. Holly Avenue, Louisville, KY

(502) 897-1646

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

110

Certified beds

Average residents

100

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Journey Healthcare

Operator or chain grouping

Approved since

1984-12-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

20 facilities

Chain averages 2 overall / 2 health / 1 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.41

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.79

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

2.11

Nurse aide staffing · state 2.43 · national 2.35

Total nurse hours

3.31

All reported nurse hours · state 4.01 · national 3.89

Licensed hours

1.20

RN + LPN hours · state 1.58 · national 1.54

Weekend hours

3.01

Weekend nurse staffing · state 3.50 · national 3.43

Weekend RN hours

0.28

Weekend registered nurse coverage · state 0.52 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.40

CMS adjusted RN staffing hours

Adjusted total hours

3.21

CMS adjusted total nurse staffing hours

Case-mix index

1.41

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.33%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 47 · Observed rate 17.02% · Lower 95% interval 7.83%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.17	1.02 0.1 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 24 · Denominator 24
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 24
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	8.33%	2.29% 6 pts worse	Numerator 2 · Denominator 24 · Adjusted rate 6.63%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	29.73%	8.2% 21.5 pts better	Numerator 33 · Denominator 111
Staff flu vaccination coverage	52.63%	42% 10.6 pts better	Numerator 90 · Denominator 171
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.5	1.9 0.6 pts worse	1.9 0.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.4	2.2 0.8 pts better	1.8 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.0%	94.3% 1.7 pts better	93.4% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 100.0% · Q4 86.5% · 4Q avg 96.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	96.2% 3.8 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.6%	3.8% 3.2 pts better	3.3% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	11.5%	15.2% 3.7 pts better	11.4% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 9.9% · Q3 7.8% · Q4 12.9% · 4Q avg 11.5%
Percentage of long-stay residents who lose too much weight	4.9%	6.7% 1.8 pts better	5.4% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 1.4% · Q3 4.9% · Q4 7.4% · 4Q avg 4.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.6%	29.6% 13 pts better	19.6% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 20.8% · Q3 15.7% · Q4 15.5% · 4Q avg 16.6%
Percentage of long-stay residents who received an antipsychotic medication	16.4%	17.6% 1.2 pts better	16.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 15.8% · Q3 20.0% · Q4 12.5% · 4Q avg 16.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	20.1%	17.3% 2.8 pts worse	16.3% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q4 25.3% · 4Q avg 20.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	18.2%	15.6% 2.6 pts worse	14.9% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 15.9% · Q3 17.1% · Q4 25.3% · 4Q avg 18.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.7% 0.7 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.6%	1.7% 1.1 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.5%	19.8% 6.7 pts worse	19.8% 6.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 34.1% · Q3 18.4% · Q4 25.9% · 4Q avg 26.5%
Percentage of long-stay residents with pressure ulcers	6.8%	5.5% 1.3 pts worse	5.1% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 10.5% · Q3 7.3% · Q4 5.8% · 4Q avg 6.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	82.9%	83.8% 0.9 pts worse	81.7% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 86.6% · Q3 91.6% · Q4 70.2% · 4Q avg 82.9%
Percentage of short-stay residents who had an outpatient emergency department visit	4.0%	13.9% 9.9 pts better	12.0% 8 pts better	Short Stay · 20240701-20250630 · Adjusted 4.0% · Observed 4.8% · Expected 13.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.6%	1.8% 0.2 pts better	1.6% About the same	Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	90.1%	83.6% 6.5 pts better	79.7% 10.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 90.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	13.9%	24.5% 10.6 pts better	23.9% 10 pts better	Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 19.0% · Expected 32.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-06-11 · Fire 2023-06-11

18 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2019-03-01 · Fire 2019-03-01

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2017-12-22 · Fire 2017-12-22

10 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-06-11

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-06-11

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-06-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-06-11

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2023-07-07

E · Potential for more than minimal harm 2023-06-11

K532 · Services Deficiencies

Fire Safety

Have a properly installed and maintained dumbwaiter or escalator.

Corrected 2023-07-07

F · Potential for more than minimal harm 2019-03-01

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-04-16

D · Potential for more than minimal harm 2019-03-01

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2019-04-16

F · Potential for more than minimal harm 2017-12-22

K322 · Smoke Deficiencies

Fire Safety

Ensure that laboratories employing quantities of flammable, combustible, or hazardous materials have fire resistant walls and automatic sprinkler system.

Corrected 2018-01-16

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-04

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-12-17

D · Potential for more than minimal harm 2025-12-04

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-12-17

J · Immediate jeopardy 2025-11-22

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-12-17

G · Actual harm 2025-11-22

F776 · Administration Deficiencies

Health

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

Corrected 2025-12-17

K · Immediate jeopardy 2023-08-11

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-09-23

K · Immediate jeopardy 2023-08-11

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2023-09-23

K · Immediate jeopardy 2023-08-11

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2023-09-23

J · Immediate jeopardy 2023-08-11

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-09-23

J · Immediate jeopardy 2023-08-11

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-09-23

J · Immediate jeopardy 2023-08-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-09-23

E · Potential for more than minimal harm 2023-08-11

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-09-23

D · Potential for more than minimal harm 2023-08-11

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-09-23

D · Potential for more than minimal harm 2023-08-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-09-23

J · Immediate jeopardy 2023-06-11

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-09-23

J · Immediate jeopardy 2023-06-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-09-23

E · Potential for more than minimal harm 2023-06-11

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-09-23

E · Potential for more than minimal harm 2023-06-11

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-09-23