Green Acres Healthcare: Pressure Ulcer Failures - KY
The resident, identified as R1 in inspection documents, was admitted to Green Acres Healthcare with an open area on her sacrum and coccyx. Despite facility policy requiring baseline care plans within 48 hours of admission, none was ever created for her skin integrity risks.
Licensed Practical Nurse 2, who handled the admission, told inspectors she was new at the time and the Director of Nursing assisted her. "I did not do one on R1 because I had not been working at the facility very long at that time," she said. The DON completed the admission for her, but no care plan was established.
The Director of Nursing acknowledged the failure during interviews. "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."
Weeks later, during wound rounds with an Advanced Practice Registered Nurse, Licensed Practical Nurse 3 discovered R1 had developed several new wounds. "She recalled R1 having several wounds that day," according to the inspection report. "She reported R1 had a wound on her heels, her bottom and maybe a new one on the gluteal fold."
The nurse could not recall whether she notified R1's power of attorney about the new treatment orders, though she acknowledged she should have documented such notification in a progress note. She also lacked system access to enter radiology orders and had to notify the DON that R1 needed an x-ray order entered.
"R1's POA should have been notified as soon as possible," LPN 3 told inspectors.
The Director of Nursing explained that baseline care plans were critical for resident safety. "The baseline care plan was important so staff would know R1 had an area to watch for worsening and so they would know the resident was at risk for skin breakdown."
Without the care plan, she said, "the resident could have experienced a delay in care, harm, or staff caring for her might not be aware of R1's care needs." The DON admitted she was "not sure what the breakdown had been with R1 not having a baseline care plan developed" and "did not know why the baseline care plan had not been done."
The facility Administrator told inspectors her expectations were for staff to follow policies and procedures when providing resident care. She said the facility's policies outlined how residents' skin and wounds should be assessed, and she expected staff to report skin abnormalities to the DON or herself immediately.
"R1 should have had a baseline care plan developed within 48 hours of admission," the Administrator said. "Otherwise, R1 could have experienced a delay in care or not receive the care the resident would have needed."
The Administrator suggested the missing care plan could have prevented the resident's deterioration. "R1's new skin breakdown could potentially have been caught sooner if the resident had a baseline care plan in place," she said.
She warned that the policy violation could have led to worse outcomes. "By staff not following the facility's policy, the resident's wound could have worsened."
The inspection found that despite R1 having an open wound at admission, no baseline care plan was ever established to guide staff in monitoring her condition or preventing additional breakdown. The failure meant nurses caring for R1 had no formal guidance about her skin integrity risks or specific areas requiring attention.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. The citation fell under federal regulations requiring nursing homes to provide necessary care and services to maintain each resident's highest practicable physical, mental and psychosocial well-being.
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 documents, was admitted to Green Acres Healthcare with an open area on her 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.