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Complaint Investigation

Greencroft Healthcare

December 23, 2025 · Goshen, IN · 1225 Greencroft Dr
Citations 2
CMS Rating 2/5
Beds 214
Provider ID 155205
Healthcare Facility
Greencroft Healthcare
Goshen, IN  ·  View full profile →
Inspection Summary

GREENCROFT HEALTHCARE in GOSHEN, IN — inspection on December 23, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0677
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Based on interview and record review, the facility failed to provide showers timely for a dependent resident for 1 of 4 residents who were reviewed for showers. (Resident D)

During an interview on 12/16/2025 at 2:40 P.M., Resident D could not recall the last time he had had a shower.

Resident D's record review was completed on 12/18/2025 at 2:45 P.M.

Diagnoses included, but were not limited to: displaced fracture of cervical vertebra, Lewy Bodies dementia, Parkinson's disease and right foot drop. An admission Minimum Data Set (MDS) assessment, dated 9/19/2025, indicated Resident D had intact cognition and was dependent on staff for showering.

Resident D's record lacked the documentation that he had been given a shower on 11/17, 11/20, 11/27, 12/1 and 12/15/2025 as scheduled.

There was no documentation to indicate the resident had been showered on different dates or he had refused a shower on his scheduled dates. A current Care Plan, initiated on 9/16/2025, indicated Resident B had self-care deficit related to bathing. An intervention, initiated 9/16/2025, indicated staff was to help the resident with activities of daily living.

During an interview on 12/18/2025 at 3:30 P.M., the Director of Nursing (DON) indicated there was not any more shower sheets or documentation indicating Resident D had received two showers a week.

The DON indicated all residents should have been offered two showers or bed baths per week and if the resident refused, the refusal should have been documented in the resident's record. On 12/18/2025 at 3:330 P.M., the DON provided a policy, dated 11/15/2025 and titled, Activities of Daily Living.

The DON identified the policy as the one currently used by the facility.

The policy indicated, .Care and services will be provided for the following activities of daily living: 1.

Bathing, dressing, grooming and oral care This citation relates to Intake 2643464.3.1-38(a)(3)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Greencroft Healthcare

1225 Greencroft Dr Goshen, IN 46527

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 12/18/2025 at 1:40 P.M., the ADON indicated she had not been aware Resident B's Care Plan regarding fall risk had not been updated with any new intervention or why the IDT had not reviewed the fall from 10/10/2025.

The ADON indicated if a resident refused an intervention, the refusal should have been documented in the Electronic Medical Record.

During an interview on 12/18/2025 at 1:45 P.M., the Director of Nursing (DON) indicated the facility did not have a policy for following the Care Plan interventions.On 12/18/2025 at 3:00 P.M. the ADON provided a policy, dated 11/15/2025 and titled, Post Fall Assessment Policy and identified it as the policy currently used by the facility.

The policy indicated, .9.

Update the resident's care plan based on findings from the post-fall assessment and probable root cause of the fall The past noncompliance began on 10/10/2025 when staff failed to implement fall interventions for Resident B.

The harm level citation was corrected on 12/4/2025 when the facility implemented a systemic plan that included a review of all residents at risk for falls, review of the care plan interventions for all residents at risk for falls, education of all front line staff regarding fall interventions and care plan implementation and weekly auditing of all falls to ensure the plan had been implemented correctly.

This citation relates to Intakes 2643464 and 2677313. 3.1-45 (a)(2)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GOSHEN, IN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GREENCROFT HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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