Green Acres Healthcare: Care Plan Failures - KY
The resident, identified as R1 in inspection records, later developed additional wounds on both heels and possibly her gluteal fold. Licensed Practical Nurse 2, who admitted the resident, told inspectors she had been new at the time and the Director of Nursing assisted with the admission.
"I did not do one on R1 because I had not been working at the facility very long at that time," LPN 2 said during her interview. She explained she had not finished the admission process, so the Director of Nursing completed it for her.
The Director of Nursing acknowledged she performed the resident's admission skin assessment and found "an open area to her sacrum/coccyx at that time, with no open areas on the heels at that time." Despite identifying the existing wound and the resident's risk for further skin breakdown, she failed to create the required baseline care plan.
"R1 should have had a baseline care plan developed for being at risk for impaired skin integrity on admission," the Director of Nursing told inspectors. She explained the plan was crucial "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."
The Director of Nursing admitted she was "not sure what the breakdown had been" and "did not know why the baseline care plan had not been done."
LPN 3 discovered the extent of the resident's deteriorating condition during wound rounds. She recalled the resident "having several wounds that day" including "a wound on her heels, her bottom and maybe a new one on the gluteal fold."
The nurse said she should have immediately notified the resident's power of attorney about new treatment orders but could not recall whether she had done so. She also lacked system access to enter a needed radiology order and had to notify the Director of Nursing to handle it.
"R1's POA should have been notified as soon as possible," LPN 3 acknowledged.
The facility's administrator explained that staff were expected to follow policies requiring immediate reporting of skin abnormalities. She confirmed that baseline care plans should be developed within 48 hours of admission.
Without the care plan, "R1 could have experienced a delay in care or not receive the care the resident would have needed," the administrator said. She added that the resident's new skin breakdown "could potentially have been caught sooner if the resident had a baseline care plan in place."
The Director of Nursing described the potential consequences of the missing care plan: "By not having a baseline care plan developed for R1's risk for skin breakdown, the resident could have experienced a delay in care, harm, or staff caring for her might not be aware of R1's care needs."
LPN 2 acknowledged that a resident at risk for skin breakdown should have had a care plan to address that risk. "I would expect a resident who was at risk for skin breakdown to have a care plan to address that," she said. She explained that baseline care plans help other nurses "know how to care for that resident."
The administrator warned that failing to follow facility policies could lead to worsening wounds. "By staff not following the facility's policy, the resident's wound could have worsened," she told inspectors.
The inspection revealed a breakdown in the facility's admission process that left a vulnerable resident without essential protections. Despite arriving with an existing wound and clear risk factors, the resident received no formal care plan to guide staff in preventing additional skin breakdown.
The resident's condition deteriorated from a single sacrum wound at admission to multiple wounds across different body areas, illustrating the consequences when basic care planning fails.
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 resident, identified as R1 in inspection records, later developed additional wounds on both heels and possibly her gluteal fold.
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.