Green Hill

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

facilitate the plan of care, dated 4/27/25 revealed the resident's cognition using a Brief Interview of Mental Status (BIMS) test. Resident #1 scored a 6 out of 15 which indicated the resident had severe cognitive impairment. On 10/28/25 at 2:40 PM, the surveyor interviewed the Registered Nurse (RN) Supervisor who stated if a resident had a new injury or a fall was reported, a skin assessment and vital signs were completed. The RN Supervisor explained the supervisor, the DON, the physician, and the RR were to be notified of the incident; and the resident's care plan would be updated; and an incident report started.On 10/29/25 at 12:09 PM, the surveyor interviewed the LPN, who was assigned to care for the resident on 4/30/25 for the 7AM to 3PM shift. The LPN stated she recalled the COTA informed her that Resident #1 stated that they fell, and she went to check on the resident. The LPN stated that there was no change or injury with the resident. The LPN further explained that she applied lidocaine topical cream to the resident's left arm dialysis access site as ordered and the resident was sent to dialysis in good condition. The LPN stated that the dialysis center called the facility and reported that the resident had a bruise on their face and was going to the ER for evaluation. The LPN confirmed that she did not report to the supervisor, the resident's physician and the RR that Resident #1 reported having a fall incident to a staff member. The LPN also confirmed that she did not initiate the facility's fall incident protocol. On 10/29/25 at 2:00 PM, the surveyor interviewed the COTA who confirmed that he treated Resident #1 in their room for a therapy session that day and the resident reported they had a fall. The COTA further explained Resident #1 couldn't say when the fall occurred or what happened. The COTA stated that the resident complained of left arm pain by the dialysis access site and observed no visible injury. On 10/29/25 at 3:10 PM, the surveyor informed the LNHA and the current DON regarding the concern that the physician and the RR were not informed at the time that the resident reported having a fall to the staff. The current DON acknowledged that

the LPN did not follow the facility's fall protocol. On 10/29/25 at 3:59 PM, the DON and the LNHA met with

the surveyor. There was no additional information provided to the surveyor. A review of the undated facility policy titled, Assessing Falls and Their Causes which revealed under Steps in the Procedure After a Fall: #5 Notify the resident's attending physician and family in an appropriate time frame.NJAC 8:39-13.1(c)(d)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Hill

103 Pleasant Valley Way West Orange, NJ 07052

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #2622045Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 1 of 9 residents reviewed, (Resident #3). The deficient practice was evidenced by

the following:On 10/28/25 at 12:25 PM, the surveyor conducted the initial tour in the presence of the License Nursing Home Administrator (LNHA) and observed the following:1. In the family room, used by residents, near the first-floor unit, the surveyor observed one broken window blind on the window. The LNHA stated, I don't know how long it's been like that, but I will have maintenance look at it. The LNHA further stated that he made rounds every day. The surveyor requested from the LNHA for the Homelike Environment policy.2. At 12:32 PM, on the second floor, in the main resident dining room entrance, the door's frame had areas with broken wood on both of its sides. The LNHA confirmed observation of the damaged door frame and stated he would put in a maintenance work order. 3. In room [ROOM NUMBER], by the bathroom entrance, the carpet was observed torn and frayed; and a sharp plastic piece was broken off the frame of the bathroom entrance. The surveyor and the LNHA were joined by the Assistant Director of Nursing (ADON) who stated, she did not notice the environmental concerns. The ADON explained that the process for work orders was to let the receptionist know and they would contact maintenance staff. The LNHA added that they previously submitted work orders through an electronic system and were currently transitioning to a new system. The LNHA was not able to provide the surveyor documentation of any work orders entered for the issues observed in the main dining room and room [ROOM NUMBER].On 10/28/25 at 3:42 PM, the LNHA stated that they do not have a facility policy for Homelike Environment.4. On 10/29/25 at 11:00 AM, the surveyor observed room [ROOM NUMBER] on the first floor. The surveyor observed two ceiling tiles near the window loose and out of alignment. The surveyor observed Resident #3 lying in the bed and the resident stated that the tiles on the ceiling were loose and have been like that since February 2025. The resident stated that they're afraid it may fall down. On 10/29/25 at 11:15 AM, the License Practical Nurse (LPN) assigned to Resident #3 accompanied the surveyor to the room to observe

the ceiling tiles. The LPN confirmed the observation of the broken ceiling tiles and stated, I've never noticed that. I will let maintenance know.The surveyor reviewed the Resident #3's medical records which revealed diagnoses which included but were not limited to bilateral osteoarthritis of knee, morbid obesity, anxiety and depression. A review of a Quarterly Minimum Data Set (MDS), a facility assessment tool that facilitates the plan of care, dated 9/30/25, revealed the resident's cognition was assessed using a Brief Interview Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. At 3:10 PM, the surveyor informed the LNHA and the DON of the observed concerns regarding homelike environment.

There was no additional information provided to the surveyor. NJAC 8:39-31.4(a)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Hill

103 Pleasant Valley Way West Orange, NJ 07052

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm

persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.and providing complete and thorough documentation of the investigation.

NJAC 8:39-4.1(a)(5)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Hill

103 Pleasant Valley Way West Orange, NJ 07052

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm

titled Incontinence Care revealed: Take all incontinent residents to the bathroom or put on the bedpan

before and after meals and at least every two hours between meals. The policy did not address use of incontinent brief. NJAC 8:39- 27.2 (h)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Hill

103 Pleasant Valley Way West Orange, NJ 07052

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

report started.On 10/29/25 at 11:52 AM, the surveyor interviewed the CNA, who was assigned to Resident #1 on 4/30/25, 7AM to 3PM shift. The CNA confirmed that she was assigned to care for the resident and stated that the resident had no bruising before they left for their appointment.On 10/29/25 at 12:09 PM, the surveyor interviewed the LPN, who was assigned to care for the resident on 4/30/25 for the 7AM to 3PM shift. The LPN stated she recalled the COTA informed her that Resident #1 stated that they fell, and she went to check on the resident. The LPN stated that there was no change or injury with the resident. The LPN further explained that she applied lidocaine topical cream to the resident's left arm dialysis access site as ordered and the resident was sent to dialysis in good condition. The LPN stated that the dialysis center called the facility and reported that the resident had a bruise on their face and was going to the ER for evaluation. The LPN confirmed that she did not report to the supervisor, the resident's physician and the RR that Resident #1 reported having a fall incident to a staff member. The LPN also confirmed that she did not initiate the facility's fall incident protocol. On 10/29/25 at 2:00 PM, the surveyor interviewed the COTA who confirmed that he treated Resident #1 in their room for therapy session that day and the resident reported they had a fall. The COTA further explained Resident #1 couldn't say when the fall occurred or what happened. The COTA stated that the resident complained of left arm pain by the dialysis access site and observed no visible injury. On 10/29/25 at 3:10 PM, the surveyor informed the LNHA and the current DON regarding the concern that the LPN did not initiate an investigation as per facility fall protocol when

the COTA informed her that the resident said they fell. The current DON acknowledged that the LPN did not follow the facility's fall investigation protocol.On 10/29/25 at 3:59 PM, the DON and the LNHA met with the surveyor. There was no additional information provided to the surveyor. A review of the undated facility policy titled, Assessing Falls and Their Causes revealed under Purpose, The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.NJAC 8:39-27.1(a)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Hill

103 Pleasant Valley Way West Orange, NJ 07052

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Repeat DeficiencyBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident's dietary preferences were honored for 1 of 4 residents (Resident #4) reviewed for food concerns. This deficient practice was evidenced by the following:On 10/28/25 at 10:40 AM, the surveyor accompanied by the Assistant Director of Nursing (ADON) were conducting incontinence rounds. Resident #4 was observed lying in their bed with the head of the bed elevated. The resident was alert, and verbally responsive. Resident #4 had a meal tray on their overbed table positioned in front of them. Resident #4 stated they only received cereal and biscuit on their tray and nothing else. The resident further explained that they were also supposed to receive pancakes on their tray and another staff already went to follow up with the kitchen. Resident #4 stated that this was not the first time that they did not receive food items ordered on their meal tray. The ADON informed the resident she would follow up with the staff regarding their pancakes. On 10/28/25 at 12:56 PM, the surveyor reviewed

the electronic medical record (EMR) of Resident #4.The admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to hypertension and generalized muscle weakness. A quarterly Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated 9/23/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored a 15 out of 15, which indicated the resident was cognitively intact. A physician's order dated 9/11/25 revealed the resident was on

a regular texture, and regular (thin) liquid diet. On 10/29/25 at 10:19 AM, the surveyor interviewed the ADON to follow up on the resident's breakfast yesterday. The ADON stated after following up with the kitchen, the resident did not receive pancakes. The ADON further explained that the kitchen did not have it, and the resident was given a sandwich as a substitute. The ADON acknowledged the resident should have received what was listed on the meal ticket for their meal.On 10/29/25 at 2:18 PM, the surveyor informed

the Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON) of the above concern for Resident #4 not receiving the food ordered and what was listed on their meal ticket for their breakfast meal. The LNHA stated the resident's food was substituted. The surveyor asked if prior to receiving their breakfast tray, was the resident informed that their pancakes were not available and provided substitution options as the resident had received their meal tray without pancakes or its substitute. There was no further verbal response from the facility at this time.On 10/29/25 at 3:59 PM, the LNHA and the DON met with the survey team. There was no additional information provided to the surveyor. The surveyor reviewed the facility provided policy titled, Dining and Food Preferences with a last review date of October 2022. Under Policy Statement revealed: Individual dining, food, and beverage preferences are identified for all residents/patients. Under Procedures revealed: .The alternate meal and/or beverage selection will be provided in a timely manner.NJAC 8:39-17.4 (e); 27.1 (a)

Event ID:

Facility ID:

If continuation sheet