Green Acres Healthcare: Notification Failures - KY
The facility's Director of Nursing performed the admission skin assessment and found an open area on the resident's sacrum and coccyx. No wounds existed on her heels at that time. But neither the admitting nurse nor the DON created the required baseline care plan for skin integrity.
"I did not do one on R1 because I had not been working at the facility very long at that time," Licensed Practical Nurse 2 told inspectors. She said the DON completed the admission for her after she couldn't finish it.
The DON acknowledged the failure during her interview. "R1 should have had one for skin integrity on admission, so everyone taking care of her would know she had an area to watch for worsening and that the resident was at risk for skin breakdown," she said. "However, she had not completed one for R1."
Days later, LPN 3 discovered multiple wounds during wound rounds with the nurse practitioner. The resident now had wounds on her heels, bottom, and possibly a new one in the gluteal fold.
"She recalled R1 having several wounds that day," according to the inspection report. The nurse said she notified the DON that the resident needed an x-ray order entered, but couldn't recall whether she notified the resident's power of attorney about the new treatment orders.
The breakdown in communication extended beyond the missing care plan. LPN 3 admitted she should have documented notification of the POA in a progress note. "R1's POA should have been notified as soon as possible," she told inspectors.
The facility's administrator said staff were expected to follow policies requiring immediate reporting of skin abnormalities. Baseline care plans should be developed within 48 hours of admission, she explained.
"Otherwise, R1 could have experienced a delay in care or not receive the care the resident would have needed," the administrator said.
The DON explained why the baseline care plan mattered for this particular resident. Staff caring for the patient "might not be aware of R1's care needs" without it, she said. The plan would ensure everyone knew the resident "had an area to watch for worsening" and was "at risk for skin breakdown."
By not having the plan in place, "the resident could have experienced a delay in care, harm," the DON acknowledged.
The administrator was more direct about the consequences. "R1's new skin breakdown could potentially have been caught sooner if the resident had a baseline care plan in place," she said. "By staff not following the facility's policy, the resident's wound could have worsened."
The DON couldn't explain what went wrong. She said she "was not sure what the breakdown had been with R1 not having a baseline care plan developed for being at risk for skin breakdown and did not know why the baseline care plan had not been done."
The inspection revealed a facility where basic admission procedures weren't followed despite clear policies. A new nurse admitted she wasn't experienced enough to complete the admission properly. The DON stepped in to help but failed to create the very care plan designed to prevent exactly what happened.
The resident arrived with one wound and developed multiple new ones within days. The facility's own staff acknowledged the new breakdown might have been prevented with proper planning and communication.
LPN 2 said she "would expect a resident who was at risk for skin breakdown to have a care plan to address that." She understood that "a baseline care plan should be completed on a new resident's admission so other nurses would know how to care for that resident."
The expectation was clear. The execution failed. And the resident developed new wounds that staff admitted might have been prevented with the care plan that was never written.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Green Acres Healthcare from 2025-11-19 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: June 20, 2026 · Our methodology
Green Acres Healthcare in Mayfield, KY was cited for violations during a health inspection on November 19, 2025.
The facility's Director of Nursing performed the admission skin assessment and found an open area on the resident's sacrum and coccyx.
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.