Green Acres Healthcare

Review of the closed record revealed the Facesheet noted the facility admitted R1 on [DATE], with diagnoses to include: pressure-induced deep tissue damage of sacral region, traumatic subdural hemorrhage, and malnutrition.

Review of the closed record further revealed R1 was discharged to the hospital on [DATE] and expired on [DATE].

Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed 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], seven days after R1's admission.

Review of the wound care progress note dated [DATE], revealed R1 had been admitted with a Deep Tissue Injury (DTI) to the sacrum.

Continued review revealed further assessment of 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] at 1:36 PM, Licensed Practical Nurse (LPN) 2 stated she had been the admitting nurse for R1 on [DATE]. 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 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] 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 R1's admission.

The DON reported 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 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, 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 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] 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 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 R1's wounds might have been caught sooner if the facility had put a care plan in place.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Acres Healthcare

402 W.

Farthing Street Mayfield, KY 42066

SUMMARY STATEMENT OF DEFICIENCIES

During interview with LPN 3 on [DATE] at 3:55 PM, she stated on [DATE], she did wound rounds with the APRN. LPN 3 said she recalled R1 having several wounds that day.

She reported 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 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 R1 needed an x-ray order entered.

She further stated R1's POA should have been notified as soon as possible. In interview with the DON on [DATE] at 1:50 PM, she stated she had performed R1's admission skin assessment.

The DON said 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 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 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 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.

She further stated 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.

During interview with the Administrator on [DATE] 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 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.

She further stated 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.

Facility ID: