Green Acres Healthcare

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documented the notification in a progress note. The LPN further stated she did not have access to the system to enter radiology orders and so, she notified the Director of Nursing (DON) that Resident R1 needed an x-ray order entered. She additionally stated the POA should have been notified as soon as possible.During

interview with the DON on [DATE REDACTED] at 1:50 PM, she stated the wound care nurse rounding with the APRN had been responsible for notifying the resident's family and obtaining and entering any new orders. She reported the nurse should have contacted the physician to obtain the x-ray order and then should have placed the order into the radiology system. The DON said she would have expected to see documentation of notification of the POA in the progress notes. During interview with the Administrator on [DATE REDACTED] at 10:55 AM, she stated staff should follow the facility's policy and procedures when making any notifications.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Acres Healthcare

402 W. Farthing Street Mayfield, KY 42066

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, interview, and facility policy review, the facility failed to develop and implement a baseline care plan with instructions to provide effective and person-centered care for 1 of 6 sampled residents, (Resident (R)1). The findings include: Review of the facility policy titled, Baseline Care Plan, reviewed [DATE REDACTED], revealed the facility was to develop and implement a baseline care plan for each resident that included the instructions needed to provided effective and person-centered care of the resident to meet professional standards of quality of care. Review further revealed the baseline care plan was to be developed within 48 hours of a resident's admission. Review of the closed record revealed the Facesheet noted the facility admitted Resident R1 on [DATE REDACTED], with diagnoses to include: pressure-induced deep tissue damage of sacral region, traumatic subdural hemorrhage, and malnutrition. Review of the closed record further revealed Resident R1 was discharged to the hospital on [DATE REDACTED] and expired on [DATE REDACTED]. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE REDACTED], revealed the facility assessed Resident R1 as having a Brief Interview for Mental Status (BIMS) score of a seven out of 15, indicating severe cognitive impairment. Review of the baseline care plan the facility developed for risk of skin impairment revealed a start date of [DATE REDACTED], seven days after Resident R1's admission. Review of the wound care progress note dated [DATE REDACTED], revealed Resident R1 had been admitted with a Deep Tissue Injury (DTI) to the sacrum. Continued review revealed further assessment of Resident R1 revealed since admission the resident had acquired an additional DTI to the right heel and a Stage 2 pressure injury to the right elbow. In interview on [DATE REDACTED] at 1:36 PM, Licensed Practical Nurse (LPN) 2 stated she had been the admitting nurse for Resident R1 on [DATE REDACTED]. LPN 2 reported she did not know who was typically responsible for developing a resident's baseline care plan. She said she had been new at the time of Resident R1's admission, and the Director of Nursing (DON) assisted her with the resident's admission. The LPN stated she would expect a resident assessed to have a risk for skin breakdown to have a care plan addressing that problem. She further stated the baseline care plan was to be done on a resident's admission, so other nurses would know how to care for that resident. In

interview on [DATE REDACTED] at 1:50 PM, the DON stated the facility process for initiating a new resident's baseline care plan was for the admitting nurse to initiate the care plan upon admission. The DON said she had assisted LPN 2 with Resident R1's admission. The DON reported Resident R1 should have had a baseline care plan developed for being at risk for impaired skin integrity on admission. She stated it was important to have the baseline care plan so staff would know Resident R1 had impaired skin integrity on admission, had an area to watch for worsening. The DON further stated by not having a baseline care plan developed, Resident R1 could have had a delay in care, harm, or staff caring for her might not have been aware of the resident's care needs. She additionally said Resident R1 should have had a baseline care plan developed upon admission. The DON reported

she was not sure what the breakdown had been or why the baseline care plan was not done; however, she or the nurse had been responsible for the baseline care plan. In interview on [DATE REDACTED] at 10:55 AM, the Administrator stated she expected staff to follow the facility policies and procedures. She said if staff did not do that, residents might not get the care they needed. The Administrator reported a baseline care plan should have been implemented within 48 hours of Resident R1's admission. She stated the purpose of the baseline care plan was to dictate the resident's care and what was going on with the resident. The Administrator further stated if the baseline care plan was completed, the resident would not receive the care they needed.

She additionally stated Resident R1's wounds might have been caught sooner if the facility had put a care plan in place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Acres Healthcare

402 W. Farthing Street Mayfield, KY 42066

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

have had something done about them sooner. In interview on [DATE REDACTED] at 1:36 PM, Licensed Practical Nurse (LPN) 2 stated she had been the nurse who admitted Resident R1 on [DATE REDACTED]. LPN 2 reported she had been new at

the time of Resident R1's admission, so the Director of Nursing (DON) assisted her with the admission. She stated

the DON had performed Resident R1's admission skin assessment. LPN 2 said she would expect a resident who was at risk for skin breakdown to have a care plan to address that. She further stated a baseline care plan should be completed on a new resident's admission so other nurses would know how to care for that resident. In interview on [DATE REDACTED] at 1:36PM, LPN 2 stated we do the baseline, care plan; however, I did not do one on Resident R1 because I had not been working at the facility very long at that time. She said she had not finished Resident R1's admission, so the DON completed it for her. In interview on [DATE REDACTED] at 1:50 PM, the DON stated baseline care plans were to be developed and implemented on admission. She said Resident 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. The DON further stated however,

she had not completed one for Resident R1. During interview with LPN 3 on [DATE REDACTED] at 3:55 PM, she stated on [DATE REDACTED], she did wound rounds with the APRN. LPN 3 said she recalled Resident R1 having several wounds that day.

She reported Resident R1 had a wound on her heels, her bottom and maybe a new one on the gluteal fold. The LPN reported she could not recall if she notified Resident R1's POA of the new orders for the resident received that day; however, she should have done that and documented the notification in a progress note. She stated she did not have access to the facility's system to enter radiology orders and so she notified the DON that Resident R1 needed an x-ray order entered. She further stated Resident R1's POA should have been notified as soon as possible. In interview with the DON on [DATE REDACTED] at 1:50 PM, she stated she had performed Resident R1's admission skin assessment. The DON said Resident R1 had an open area to her sacrum/coccyx at that time, with no open areas on the heels at that time. She explained the facility's process for initiating a new resident's baseline care plan was for the admitting nurse to initiate the care plan upon the new resident's admission. The DON stated Resident R1 should have had a baseline care plan developed for being at risk for impaired skin integrity on admission. She said the baseline care plan was important so staff would know Resident R1 had an area to watch for worsening and so they would know the resident was at risk for skin breakdown. The DON reported by not having a baseline care plan developed for Resident 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 Resident R1's care needs. She further stated she was not sure what the breakdown had been with Resident 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. During interview with the Administrator on [DATE REDACTED] at 10:55 AM, she stated her expectations were for staff to follow the facility's policy and procedures when providing resident care. She explained the facility's policies and procedures lined out with how resident's skin or wounds were to be assessed. The Administrator stated she expected staff to report any skin abnormalities to the DON or herself immediately.

She reported Resident R1 should have had a baseline care plan developed within 48 hours of admission. The Administrator said otherwise, Resident R1 could have experienced a delay in care or not receive the care the resident would have needed. She further stated Resident R1's new skin breakdown could potentially have been caught sooner if the resident had a baseline care plan in place. The Administrator additionally stated by staff not following the facility's policy, the resident's wound could have worsened.

Event ID:

Facility ID:

If continuation sheet