Inspection Reports for Green Hill
103 Pleasant Valley Way, West Orange, NJ, 07052
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
86 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS and their rights related to this information.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health information, legal duties of NJDHSS, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 17
Date: Feb 24, 2025
Visit Reason
A recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, triggered by multiple complaints including NJ001802194, NJ00181689, NJ00181039, NJ00180085, NJ00177148, NJ00172899, NJ00171613, NJ00168597, and NJ162424.
Complaint Details
The visit was complaint-related with multiple complaint numbers listed including NJ001802194, NJ00181689, NJ00181039, NJ00180085, NJ00177148, NJ00172899, NJ00171613, NJ00168597, and NJ162424. Specific complaints involved staffing deficiencies, care plan issues, medication errors, and life safety code violations. Substantiation status is not explicitly stated.
Findings
Deficiencies were cited related to failure to complete and transmit Minimum Data Set (MDS) assessments timely, accuracy of assessments, baseline care plans, services provided, food service safety, life safety code violations including delayed egress locking and sprinkler system maintenance, and medication administration errors. Corrective actions and plans of correction were documented with completion dates mostly by 03/24/2025.
Deficiencies (17)
Facility failed to complete and transmit Minimum Data Set (MDS) assessments within federal guidelines for 9 of 18 system-selected residents.
Facility failed to accurately reflect residents' status in assessments for 2 of 18 residents.
Facility failed to initiate baseline care plans within required timeframe for 2 of 22 residents.
Facility failed to develop and implement comprehensive person-centered care plans for 1 of 22 residents.
Facility failed to maintain proper kitchen sanitation practices, including food storage and preparation.
Facility failed to provide meals and snacks according to regulatory requirements, including serving nourishing snacks at bedtime.
Facility failed to follow physician orders for medication administration for 1 resident, resulting in medication errors.
Facility failed to ensure doors in exit stairway enclosures were equipped with delayed egress locking devices in accordance with NFPA 101.
Facility failed to ensure doors with self-closing devices in corridors were properly maintained and closed.
Facility failed to ensure sprinkler systems were properly maintained and operational.
Facility failed to ensure elevators were inspected, tested, and maintained in accordance with NFPA 101.
Facility failed to ensure fire alarm system was properly maintained and monitored.
Facility failed to ensure hazardous areas were protected by fire barriers and doors in accordance with NFPA 101.
Facility failed to ensure elevators were inspected and maintained, and elevator service contracts were current.
Facility failed to ensure emergency generator batteries were tested and maintained.
Facility failed to ensure adequate staffing ratios for certified nurse aides on multiple shifts.
Facility failed to ensure newly hired employees completed required health screenings and documentation.
Report Facts
Census: 86
Sample size: 19
Closed records: 3
Deficiencies cited: 16
Certified Nurse Aide staffing deficiencies: 5
Certified Nurse Aide staffing deficiencies: 3
Medication administration errors: 1
Fire safety deficiencies: 7
Inspection Report
Original Licensing
Census: 57
Capacity: 77
Deficiencies: 4
Date: Jul 16, 2024
Visit Reason
A survey was conducted by the New Jersey Department of Health to add an additional 50 beds to the facility's license.
Findings
The facility was found to be non-compliant with NJAC 8:39 standards for licensure of long-term care facilities due to occupying beds prior to inspection approval. Additionally, the facility was non-compliant with NFPA 101:2012 edition life safety code requirements including exit discharge surface, exit discharge lighting, and HVAC exhaust fan maintenance.
Deficiencies (4)
Facility failed to meet conditions of approval for addition of 50 licensed beds by occupying beds prior to inspection approval.
Failed to maintain a level walking surface at exit discharge, posing a trip hazard.
Failed to provide exit discharge lighting in accordance with NFPA 101:2012 edition.
Failed to ensure all residents bathroom exhaust fans were maintained in operational condition.
Report Facts
Licensed beds: 77
Current census: 57
Additional beds requested: 50
Resident rooms with double occupancy: 7
Deficiency correction completion dates: K0271 corrected 07/17/2024, K0281 corrected 07/18/2024, K0521 corrected 07/19/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Present during inspection and interview regarding bed occupancy and plan of correction | |
| Maintenance Director | Present during inspection and interview regarding physical environment and life safety deficiencies | |
| Director of Maintenance | Involved in corrective actions for exit discharge lighting and audits | |
| HVAC Service Technician | Repaired exhaust fans on 07/17/2024 | |
| Electrician | Installed and tested exit discharge lighting on 07/17/2024 |
Inspection Report
Routine
Census: 66
Capacity: 77
Deficiencies: 7
Date: Jan 27, 2023
Visit Reason
Standard survey conducted on 01/27/2023 to assess compliance with long term care facility regulations.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, with deficiencies cited related to accuracy of assessments, services meeting professional standards, treatment to prevent pressure ulcers, labeling and storage of drugs, and food safety. Deficiencies were corrected as documented in the plan of correction.
Deficiencies (7)
Failure to accurately complete the Minimum Data Set (MDS) for residents, including incorrect coding of language and assessment data.
Failure to accurately follow physician's orders for medication administration for residents.
Failure to provide care to prevent and treat pressure ulcers consistent with professional standards.
Failure to ensure expired and unidentified medications were removed from medication carts in a timely manner.
Failure to maintain proper kitchen sanitation practices, including disinfecting food thermometers prior to use.
Failure to maintain fire alarm system and sprinkler system in accordance with NFPA standards, including sensitivity testing and monitoring of valves.
Failure to protect vertical openings with proper fire resistance rating and enclosure.
Report Facts
Residents present: 66
Licensed beds: 77
Deficiencies cited: 7
Medication carts inspected: 4
Medication carts with deficiencies: 2
Smoke detectors failed sensitivity test: 10
Residents audited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to findings on MDS accuracy, medication administration, and fire safety compliance |
| Licensed Practical Nurse 2 | Licensed Practical Nurse (LPN2) | Named in medication administration deficiency and training |
| Certified Nurse's Assistant | Certified Nurse's Assistant (CNA) | Named in relation to medication administration and resident care |
| Maintenance Director | Maintenance Director | Named in relation to fire safety deficiencies and inspections |
| Food Service Director | Food Service Director (FSD) | Named in relation to food safety deficiencies and kitchen sanitation |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
The inspection visit was conducted in response to a complaint (Complaint #: NJ160404) to assess compliance with regulatory requirements.
Complaint Details
Complaint #: NJ160404; The facility was found to be in substantial compliance based on this complaint visit.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Oct 21, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # NJ 149346.
Complaint Details
Complaint # NJ 149346 was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42CFR Part 483, Subpart B, for Long Term Care facilities based on this complaint visit.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Aug 10, 2021
Visit Reason
The inspection was conducted as a complaint survey to investigate allegations related to failure to follow physician's orders and facility policies on charting and medication administration for a resident.
Complaint Details
The complaint survey found the facility failed to follow physician's orders and facility policies for medication administration and documentation for one resident, including missed medication doses without physician notification and lack of documentation for treatments and bathing care.
Findings
The facility was found not in substantial compliance with professional standards as it failed to follow physician's orders and facility policies regarding medication administration and documentation for one resident. There were omissions in medication administration, treatment administration, and bathing care documentation.
Deficiencies (1)
Failure to follow physician's order and facility policies on charting and documentation of medication administration for one resident.
Report Facts
Census: 48
Sample size: 3
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 24, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on mandatory infection control and sanitation requirements related to new employee physical examinations.
Findings
The facility was found not in compliance with the requirement that all newly hired employees must have a physical examination by a physician within two weeks prior to or upon employment. Four of five new hires reviewed had physical exams conducted more than two weeks before their hire dates.
Deficiencies (1)
Failure to ensure that all newly hired employees had required physical examination by a physician within two weeks prior to or upon employment.
Report Facts
Newly hired employees reviewed: 5
New hires with deficient physical exam timing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Provided new hire employee records and discussed findings with survey team |
| Chief Human Resource Officer | CHRO | Completed audit to ensure new hire paperwork was timely and will audit new employee files weekly |
| Director of Nursing | DON | Participated in discussion with survey team regarding findings |
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with Appendix Z-Emergency Preparedness and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Report
Oct 29, 2025
Report
Feb 24, 2025
Report
Feb 24, 2025
Report
Jan 27, 2023
Report
Feb 24, 2021
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