Greenhaven Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 16, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety for one of three sampled residents (Resident 1) when Resident 1 fell when alone and unsupervised outdoors. This failure resulted in Resident 1's fall and subsequent transfer to the acute care hospital for further evaluation. This evaluation indicated that Resident 1 had widespread bleeding on his head and later died in the hospital.Findings:A review of the admission Record indicated Resident 1 was admitted August of 2016 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness) following nontraumatic subarachnoid hemorrhage (bleeding into the spaces around the brain) affecting left… […]

• No harm, potential for more than minimal, widespreadF850May 5, 2026

  Based on interview and record review, the facility failed to ensure the employed social worker met the minimum qualifications of the position as per federal regulations for a census of 143 residents, when the social worker had no bachelor's degree since hiring to meet the required minimum qualifications of the position for a facility with more than 120 beds.This failure decreased the facility's potential to provide social services that meet the residents' individualized needs.Findings:A review of the Social Service Manager's (SSM) undated Employee Information, indicated SSM was hired on 11/10/25 for the Social Services Director (SSD) position.A review of the SSM's Offer Letter for Social Services Leader at [the facility name], dated 10/21/25, indicated SSM was offered a full-time position… […]

• No harm, potential for more than minimal, widespreadF812Jun 9, 2023

  Based on observation, interview, and record review the facility failed to provide food storage and preparation, and maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 101 residents who ate facility prepared meals when: 1. One out of nine cutting boards was found with stain and deep scratches; 2. One out of two electric wall fans was found with gray particles on its blade edges; 3. A package of turkey in the refrigerator, a package of corn and a package of sausage patties (with ice crystals build-up) in the freezer were all found open and exposed to air; 4. A bag of lettuce and a bag of parsley that had changed its original color were in the refrigerator; 5. […]

• No harm, potential for more than minimal, patternF755Feb 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe and effective medication management, when:1. Two of six randomly selected residents' (Resident 12 and Resident 111) controlled medications (those with high potential for abuse and addiction) were not accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR, an accountability record); and 2. Automated dispensing cabinet (ADC) medication discrepancies, including those involving controlled substances were not identified, reported and resolved in a timely manner for a census of 144 residents.These failures decreased the facility's potential to prevent misuse, loss, or diversion of controlled substances and resulted in three unresolved ADC discrepancies,… […]

• No harm, potential for more than minimal, patternF761Feb 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure medications were properly stored, labeled, and maintained according to the facility's policy and/or manufacturer's specifications for a census of 144 residents, when:1. A treatment cart containing supplies and medications was left unlocked and unsupervised; 2. Resident 74 and Resident 12 had expired medications stored in two of four medication carts;3. Resident 54 had one opened and undated foil pouch containing levalbuterol (a medication to relieve shortness of breath) stored in one of five medication rooms; and 4. […]