Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Acres Healthcare during CMS and state inspections, most recent first.
Failure to Notify Resident Representative of Significant Change in Condition: A resident with severe cognitive impairment, pressure injuries, traumatic subdural hemorrhage, and malnutrition developed a new DTI and received new wound care orders from the APRN, including an x-ray to rule out osteomyelitis. There was no documented evidence that the POA was notified of the change in condition or the new orders, and the POA stated the facility had not communicated how serious the wounds were or that the resident had a bone infection and antibiotics.
Failure to develop a baseline care plan within 48 hours of admission. A resident with severe cognitive impairment, malnutrition, traumatic subdural hemorrhage, and a DTI to the sacrum was admitted with skin integrity risks, but the baseline care plan for impaired skin integrity was not started until 7 days later. The resident later developed an additional DTI to the heel and a Stage 2 pressure injury to the elbow. The LPN and DON stated the admitting nurse was responsible for initiating the baseline care plan on admission.
A resident with severe cognitive impairment and existing skin breakdown was admitted with a sacral DTI, but the baseline care plan for skin risk was not started on admission and was delayed for several days. The record showed additional pressure injuries developed, including wounds to the heels and elbow, and the APRN ordered wound treatments, heel offloading, a LAL mattress, and imaging to rule out osteomyelitis. The POA said the facility did not communicate the severity of the wounds or the suspected bone infection, and an LPN stated she could not recall notifying the POA of the new orders.
Call lights were not kept within reach for three dependent residents. One resident’s call light was clipped to a privacy curtain, another resident’s touch pad was at the foot of the bed, and a third resident’s call light was under bed linens. Staff, including RN, LPN, CNA, DON, and the Administrator, stated call lights should be accessible when residents are in bed or in a wheelchair.
Missed Quarterly Care Plan Conferences: The facility failed to conduct and document required quarterly care plan meetings for two residents with severe cognitive impairment. One resident had vascular dementia, psychotic disturbance, mood disturbance, and anxiety, and the other had COPD, Alzheimer's disease, and HTN. Records showed missing quarterly care conferences and overdue care plan reviews, and staff confirmed the SSD was responsible for ensuring the meetings occurred and were documented.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to inform the resident representative when there was a significant change in a resident’s status for 1 of 4 residents sampled for notification. The resident, who had diagnoses including pressure-induced deep tissue damage of the sacral region, traumatic subdural hemorrhage, and malnutrition, was severely cognitively impaired with a BIMS score of 7. The resident was later discharged to the hospital and expired there. Review of the facility policy showed that when a resident had a change in condition requiring notification, the facility was to promptly inform the resident, consult the physician, and notify the resident’s representative. Record review showed that during wound care rounds, the APRN identified a new DTI to the left heel and gave new wound treatment orders, including skin prep to the sacral wound area, medical grade honey to the wound bed, Triad cream to the left gluteal fold, and betadine to the left heel DTI. The APRN also recommended an x-ray to rule out osteomyelitis, but there was no documented evidence that the resident’s POA was notified of the new DTI or the new orders. The x-ray order was entered verbally and was not obtained until seven days later, and the DON stated the x-ray findings were osteomyelitis. The POA stated the facility had not communicated the resident’s condition and was unaware the wounds were as bad as they were or that the resident had a bone infection and antibiotics.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan with instructions for effective and person-centered care within 48 hours of admission for one resident. The facility policy required a baseline care plan for each resident within 48 hours of admission, but the resident's baseline care plan for risk of skin impairment was not started until seven days after admission. The resident's closed record showed admission diagnoses that included pressure-induced deep tissue damage of the sacral region, traumatic subdural hemorrhage, and malnutrition, and the admission MDS showed a BIMS score of 7 out of 15, indicating severe cognitive impairment. The record also showed the resident had a DTI to the sacrum on admission and later developed an additional DTI to the right heel and a Stage 2 pressure injury to the right elbow. In interview, the admitting LPN stated she did not know who was typically responsible for developing the baseline care plan and said she would expect a resident at risk for skin breakdown to have a care plan addressing that problem. The DON stated the admitting nurse was responsible for initiating the baseline care plan on admission and confirmed the resident should have had a baseline care plan for impaired skin integrity upon admission. The Administrator stated the baseline care plan should have been implemented within 48 hours and said the resident's wounds might have been caught sooner if the care plan had been in place.
Failure to Provide Timely Pressure Injury Care and Baseline Skin Plan
Penalty
Summary
The facility failed to ensure a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. The resident was admitted with diagnoses including malnutrition, pressure-induced deep tissue damage of the sacral region, and traumatic subdural hemorrhage, and the admission MDS showed severe cognitive impairment with a BIMS score of 7 out of 15. The record also showed early knowledge of skin integrity problems, including an observation report noting an ulcer with an open area to the buttocks and the DON’s statement that the resident had an open area on the sacrum/coccyx at admission. The baseline care plan for risk of skin impairment was not started until seven days after admission, despite the facility’s expectation that it be developed on admission or within 48 hours. The DON and LPN both stated the resident should have had a baseline care plan for skin integrity so staff would know the resident was at risk for skin breakdown and had an area to monitor for worsening. The DON acknowledged she had not completed the baseline care plan and stated she did not know why it had not been done. The wound record showed the resident later had additional pressure injuries, including a DTI to the right heel and a Stage 2 pressure injury to the right elbow. On wound rounds, the APRN issued new orders for the sacrum, left gluteal fold, left heel, and right heel, including topical treatments, heel offloading, a low air loss mattress, and an x-ray to rule out osteomyelitis. The x-ray order was entered seven days after the APRN recommended it, and the result was suspicious for calcaneal osteomyelitis. The POA stated the facility had not communicated the severity of the wounds or the bone infection, and an LPN stated she could not recall notifying the POA of the new orders and should have documented that notification.
Call lights not kept within reach of dependent residents
Penalty
Summary
The facility failed to ensure that residents had their call lights within reach and accessible while in their rooms. The deficiency involved three sampled residents: one resident admitted with COPD, Alzheimer’s disease, and hypertension who had a BIMS score of 3 and was dependent on staff for all ADLs, toileting, and mobility; a second resident admitted with unspecified dementia, convulsions, and intellectual disabilities who was rarely or never understood and dependent on staff for ADLs, toileting, and mobility; and a third resident admitted with acute pulmonary edema, type 2 diabetes, and heart failure who had a BIMS score of 8 and was dependent on staff for ADLs and wheelchair use. During observation, the first resident was sitting in a wheelchair with the call light clipped to the privacy curtain and not within reach. The second resident was lying in bed asleep with a touch pad call light placed at the foot of the bed and not within reach. The third resident was observed sitting in a wheelchair with the call light under the bed linens and not within reach, and on a later observation was again in the wheelchair facing the television with the call light cord and button still under the bedding. The report also noted that the third resident stated he did not know where his call light was and was not able to roll himself in his wheelchair. Staff interviews confirmed expectations that call lights should be within reach before leaving a resident’s room. RN2, LPN1, CNA4, CNA5, the DON, and the Administrator all stated that if a resident was in bed or in a wheelchair, the call light should be positioned so the resident could reach it. Staff also stated that a call light at the foot of the bed, clipped to a privacy curtain, or placed under bed linens would not be considered within reach.
Missed Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to ensure that required quarterly care plan meetings were conducted and that the interdisciplinary team reviewed and revised care plans after quarterly MDS assessments for two sampled residents. Facility policy stated that comprehensive person-centered care plans were to be developed and implemented for each resident and reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The Social Services Director job description also identified responsibility for timely completion of the social services portion of the MDS, resident care plan, and progress notes. Resident R33 was admitted with diagnoses including vascular dementia, psychotic disturbance, mood disturbance, and anxiety, and had a BIMS score of 05 indicating severe impairment. The last documented care plan meeting for R33 was on 02/13/2025, although a quarterly meeting should have occurred in 05/2025; the care conference record also showed missing quarterly assessments in 09/2024 and 05/2025. Resident R11 was admitted with diagnoses including COPD, Alzheimer's disease, and essential hypertension, and had a BIMS score of 3 out of 15 indicating severe cognitive impairment. The last documented care plan meeting for R11 was on 10/22/2024, although quarterly meetings should have occurred in 01/2025, 04/2025, and 07/2025. Interviews with family members and facility staff confirmed that quarterly care conferences were expected, that the SSD was responsible for ensuring they occurred and were documented, and that the facility could not provide a specific reason for the missing meetings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mayfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mills Nursing & Rehabilitation | 1.7 mi | ★★★★★ | 0 | 0 |
| Lake Way Rehabilitation And Healthcare Center | 17.6 mi | ★★★★★ | 0 | 0 |
| Spring Creek Post-acute Rehabilitation Center | 20.1 mi | ★★★★★ | 1 | 0 |
| Clinton-hickman County Nursing Facility | 20.1 mi | ★★★★★ | 0 | 0 |
| Fulton Nursing And Rehabilitation, Llc | 20.2 mi | ★★★★★ | 0 | 0 |
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