Greencroft Healthcare

In the surveyor’s words

From the most serious findings on record at Greencroft Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 23, 2025

  Based on record review and interview, the facility failed to follow the plan of care for a resident with a history of falls. This deficient practice resulted in a resident falling and sustaining multiple injuries, including bilateral (affecting both sides) small acute subarachnoid hemorrhage along the temporal lobes, a small acute intraventricular hemorrhage in occipital horns, a 0.7 centimeter subdural hematoma and an acute right occipital bone fracture extending into the forearm magnum. (Resident B) Finding includes:Resident B's record review was completed on 12/17/2025 at 11:30 A.M. […]

• Actual harm, isolatedF689Jun 13, 2024

  Based on observation, record review and interviews, the facility failed to ensure 1 of 3 residents reviewed for accidents was provided safe transfer assistance utilizing a mechanical stand lift This deficient practice resulted in a significant injury which required a transfer to an acute care center for treatment, hospice admission and death, (Resident B). Finding includes: A record review for Resident B was completed on [DATE] at 11:00 A.M. Resident B's diagnoses included dementia, deep venous thrombosis, rheumatoid arthritis, anxiety, and history of hip fracture. The resident was admitted to the facility on [DATE], was hospitalized for a fall on [DATE], was readmitted to the facility under hospice care on [DATE], and expired on [DATE]. […]

• Actual harm, isolatedF686Sep 19, 2023

  Based on observation, interview and record review, the facility failed to prevent a pressure ulcer from developing on the heel and buttock, for 1 of 3 residents reviewed for pressure ulcers. (Resident F) Finding includes: On 9/19/23 at 1:35 P.M., a review of the clinical record for Resident F was conducted. The resident's diagnoses included, but were not limited to: diabetes, anemia, arthritis, unsteadiness on feet, and a prosthetic heart valve. A Quarterly Braden Scale for Predicting Pressure Score Risk form, dated 6/16/23, indicated the resident scored a 14. […]

• No harm, potential for more than minimal, widespreadF804Sep 20, 2024

  Based on interviews and record review, the facility failed to ensure hot food temperatures were assessed and logged consistently in the main kitchen to ensure food was served at palatable temperatures. This deficient practice had the potential to affect 155 of 155 residents in nursing care who were served from the main kitchen. Finding includes: During an interview, on 9/16/24 at 12:28 P.M., the Dietary Team Lead staff member indicated food was prepared in the main kitchen and then delivered to the unit servery kitchens, where it was held in steam tables. She indicated she had heard some concerns the food was not always as warm as it should be when served. She indicated hot foods should be held and served at at least 140 degrees Fahrenheit. […]

• No harm, potential for more than minimal, patternF574May 23, 2025

  Based on interview, observation and record review, the facility failed to ensure residents were informed of where the Ombudsman and other state agencies phone numbers were located. This had the potential to affect 145 of 145 residents who resided in the facility. Findings include: During the resident/surveyor meeting, on 5/20/2025 at 10:45 A.M., 11 of 11 residents in attendance indicated they were unaware of where the Ombudsman's contact information or telephone number and where a copy of resident rights was posted. During a random observation, on 5/20/2025 at 11:48 A.M., a poster of the resident rights was hung on a wall in a lounge area past the receptionist desk. […]