Green Hill

Inspectors wroteCOMPLAINT # 423030Refer to F0689Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to notify the physician and the resident representative (RR) about an alleged fall reported by the resident. This deficient practice was identified for 1 of 2 residents, Resident #1, reviewed for incidents and accidents. This deficient practice was evidenced by the following:On 10/28/25 at 9:30 AM, the surveyor requested from the License Nursing Home Administration (LNHA) and the Director of Nursing (DON) all Facility Reported Event (FRE) investigations and a list of residents with falls and injuries in the last six months. On 10/28/25 at 11:20 AM, the DON provided the FRE investigations for the last six months. Resident #1 had one FRE investigation dated 5/2/25. [...]

Inspectors wroteComplaint #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. [...]

Inspectors wroteCOMPLAINT #423030 and #2620240Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a) conduct a thorough investigation to address an allegation of abuse; and b) maintain documentation that a thorough investigation was conducted for an allegation of abuse. This deficient practice was identified for 2 of 2 residents (Resident #1 and Resident #2), reviewed for abuse. This deficient practice was evidenced by the following: 1. On 10/28/25 at 9:30 AM, the surveyor requested from the License Nursing Home Administration (LNHA) and the Director of Nursing (DON) all Facility Reported Event (FRE) investigations and a list of residents with falls and injuries in the last six months. On 10/28/25 at 11:20 AM, the surveyor reviewed the resident's electronic medical record (EMR) which revealed the following: [...]

Inspectors wroteComplaint #423030, and #2622045Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that proper incontinence care was provided to 1 of 3 residents (Resident #5) reviewed for incontinence care. This deficient practice was evidenced by the following:On 10/28/25 at 10:46 AM, the surveyor conducted incontinence (loss of bladder/bowel control) rounds with the Assistant Director of Nursing (ADON) on randomly selected residents who were incontinent. Resident #5 was observed resting in their bed covered with blankets. The resident was alert, verbally responsive, and agreeable to speak with the surveyor. Resident #5 stated that they were waiting for their assigned Certified Nursing Aide (CNA) to return to provide hygiene care. [...]

Inspectors wroteCOMPLAINT # 423030Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to comprehensively investigate a resident reported fall to ensure resident safety according to the facility's policy. This deficient practice was identified for 1 of 1 resident (Resident #1) reviewed for falls and accidents. This deficient practice was evidenced by the following:On 10/28/25 at 9:30 AM, the surveyor requested from the License Nursing Home Administration (LNHA) and the Director of Nursing (DON) all Facility Reported Event (FRE) investigations and a list of residents with falls and injuries in the last six months. On 10/28/25 at 11:20 AM, the DON provided the FRE investigations for the last six months. Resident #1 had one FRE investigation dated 5/2/25 for an injury of unknown origin which occurred on 4/30/25. [...]

Inspectors wroteRepeat 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. [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 4 of 4 residents (Resident #104, #105, #1 and #3) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows: 1. On 2/18/25 at 11:55 AM, the surveyor was observing the lunch meal on first floor unit. The surveyor observed Resident #104's tray, per the tray ticket, Resident #104 was supposed to receive 4 ounce (oz) assorted ice cream and a 6oz Coffee, both items were missing from the tray. On 2/20/25 at 10:00 AM, the surveyor reviewed the electronic medical record (E-mar) for Resident #104. [...]

Inspectors wroteBased on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 6 of 6 (Resident's #9, #34, #41, #53, #60, and #78) residents during the resident council meeting and was evidenced by the following: On 02/18/25 at 11:08 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to participate. Six out of six residents stated they were not offered nor receive snacks in the evening. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 2/14/25 at 10:23 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. Upon entering the kitchen, the surveyor observed the Regional FSD (RFSD) and three dietary aides (DA) all wearing large earrings. FSD alerted staff and earrings were removed. 2. In the cooking area of the kitchen the surveyor observed on top of the 2-door standing oven, burnt-on debris and a large build up of a greyish dust like substance. The FSD stated all kitchen equipment would be cleaned immediately. 3. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 9 of 18 system-selected residents, Resident #3, #10, #16, #21, #35, #39, #153, #157, and #162 ) and was evidenced by the following: On 2/14/25 at 1:11 PM, the surveyor reviewed the facility assessment task, including the Resident's MDS assessment. The MDS is a comprehensive tool federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. [...]

Inspectors wroteREPEAT DEFICIENCY Based on interviews and record reviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 18 residents (Residents #39, and #157) reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 2/14/25 at 11:10 AM, the surveyor observed Resident #39 in bed watching television, unable to answer the surveyor's inquiry. On 2/18/25 at 11:51 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #39, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to initiate a baseline care plan (CP) for a resident who had a fall and was a fall risk. This deficient practice was identified for 2 of 22 residents (Resident #155 and #153) and was evidenced by the following: 1. On 2/19/25 at 9:03 AM, the surveyor reviewed Resident #155's medical records, which revealed the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to cerebral infarction (blood flow to the brain is blocked), thrombocytopenia(low platelet levels) and dysphagia(difficulty swallowing). Resident #155 was discharged to the hospital on 1/26/24. A review of the 12/29/23 Morse Fall Scale revealed a score of 10 indicating that the resident was a fall risk. [...]

Inspectors wroteComplaint #: NJ00180085 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to failed to develop and implement a comprehensive person-centered care plan (CP) that include the use continuous Oxygen (O2). The deficient practice was identified for 1 of 22 residents (Resident #158) reviewed for Care Plans. This deficient practice was evidenced by the following: 1. On 2/18/25 at 9:27 AM, the surveyor reviewed closed electronic medical record (E-mar) with Resident #158. A review of Resident #158's E-mar revealed the following: A review of Resident #158's Face sheet (FS) (an admission summary) was admitted to the facility with diagnoses that included but were not limited to pneumonia, Covid-19 and type 2 diabetes mellitus. [...]

Inspectors wroteREPEAT DEFCIENCY Complaint # NJ181689 Based on observation, interview, record review and policy review it was determined the facility failed to a. record urinary catheter (UC) output every shift in accordance with the physician's order (PO) and b. the primary physician (MD) failed to accurately document the resident's wound assessment. This deficient practice was observed for 2 of 7 residents, (resident #160 and resident #153) was evidenced by the following: 1. On 2/14/25 11:52 AM, the surveyor reviewed closed electronic medical record (E-mar) with Resident #160. A review of Resident #160's E-mar revealed the following: A review of Resident #160's Face sheet (FS) (an admission summary) was admitted to the facility with diagnoses that included but were not limited to chronic osteomyelitis, Covid-19, tinea, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's primary physician (MD) accurately dated their physician progress notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 3 of 18 residents (Resident #39, #153, and # 157,). This deficient practice was evidenced by the following: 1. On 2/18/25 at 10:11 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #153, which revealed the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to follow a Physician Orders (PO) for the administration of blood pressure medication for 1 of 1 resident's (Resident #22) reviewed for blood pressure management. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to a. provide effective preventative treatment to a known high risk resident who was admitted to the facility with a Stage 1 (redness) pressure ulcer that progressed and developed into an open pressure ulcer (Stage 2) and, b. accurately monitor and document weekly skin assessments resulting in the development of an open pressure ulcer that had a delay in being identified and treated, for a resident who was found in pain. This deficient practice resulted in the development, progression delaying the identification and treatment of an open pressure ulcer. This deficient practice was identified for 1 of 5 resident, Resident #3 reviewed for pressure ulcers. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately complete the Minimum Data Set, (an assessment of all residents for Medicare and Medicaid) (MDS) for 2 of 18 residents reviewed for accurate MDS completion, Resident #43 and Resident #21. The MDS is a federally mandated process for the clinical assessment of all residents to facilitate the management of care. This deficient practice was evidenced by the following: 1. On 1/20/23 at 10:56 AM, the surveyor in the presence of the Director of Nursing (DON), observed Resident #43 in their room, awake and alert, seated in their wheelchair. The surveyor introduced self to the resident who responded in Spanish. The DON stated that the resident speaks and understands only Spanish. The surveyor reviewed Resident #43's hybrid medical record: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately follow physician's orders (POs), obtain a PO for a device utilized daily by a resident and obtain daily weights in accordance with the PO. This deficient practice was identified for 2 of 18 residents reviewed for POs, Resident #48 and Resident #8. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that expired, unidentified bottle and discontinued medications were removed from the medication cart in a timely manner. This deficient practice was identified in 2 of 4 medication carts inspected. The deficient practice was evidenced by the following: 1. On [DATE] at 1:12 PM, the surveyor inspected [NAME] first floor unit medication cart 1 in the presence of the Licensed Practical Nurse (LPN). The inspection of [NAME] first floor unit medication cart 1, presented an unopened bottle of One Daily Multivitamin (MVI) with minerals 100 tablets which expired 12/2022 and an unlabeled bottle of liquid that was found on the top drawer. The LPN could not identify the liquid found in the bottle and could not explain why the bottle was there without a label. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined that the facility failed to maintain proper kitchen sanitation practices by not disinfecting a food thermometer prior to taking food temperatures during the lunch service. This deficient practice was evidenced by the following: On 1/23/23 at 11:35 AM, while in the presence of the Food Service Director (FSD), the surveyor observed the chef test the temperature of the roasted potatoes on the steam table without disinfecting the food thermometer prior to use. Upon interview with the chef and FSD, the chef stated that he disinfected the food thermometer two hours ago. When asked how long prior to testing any food items should a food thermometer be disinfected, the chef was unable to answer. The FSD stated that the food thermometer needs to be disinfected just prior to testing any food temperatures. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) ensure proper use of personal protective equipment (PPE) for 1 of 3 staff; b) perform handwashing appropriately for 1 of 10; c) ensure that workers are knowledgeable of the cleaning chemical used in the workplace for 2 of 3 staff; and, d) maintain 6 feet of social distancing in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19 and other transmission-based precaution infection. This deficient practice was evidenced by the following: According to the U.S. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of practice by not following a physician's order for 1 of 12 residents (Resident #8) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the safe and appetizing temperatures of food and drink were served to the residents. This deficient practice was identified for 2 of 3 residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 2/22/21 for 1 of 1 nursing units tested for food temperatures and was evidenced by the following: On 2/22/21 at 10:00 AM, the surveyor interviewed three residents for the Resident Council meeting. Two of the three residents stated that the hot foods were not hot enough, and the quality of the food was poor. On 2/23/21 at 10:30 AM, the surveyors calibrated their thermometers in the presence of the team coordinator. On 2/23/21 at 12:31 PM, the surveyors observed one food truck arrive at the low side of the [NAME] unit. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility staff failed to ensure a resident received and consumed liquids in the appropriate amount according to physician orders for 1 of 1 resident (Resident #2) who was on a fluid restricted diet. This deficient practice was evidenced by the following: On 2/17/21 at 12:41 PM, the surveyor observed Resident #2 seated in a wheelchair in the doorway of their room eating lunch with the tray on an overbed table. The resident consumed a four-ounce apple juice and an eight-ounce mug of hot tea. The Food Service Director (FSD) and the Registered Dietitian (RD) approached the resident during this observation, looked at the tray contents, and then proceeded down the hall. [...]