Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Green Hill during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and end stage renal disease reported a fall and arm pain to a COTA, who informed the assigned LPN. The LPN assessed the resident, applied lidocaine cream as ordered, and sent the resident to dialysis without initiating the fall protocol or notifying the physician and resident representative. The dialysis center later reported facial bruising, and the resident was sent to the ER. Facility policy requiring timely notification was not followed.
Multiple environmental deficiencies were observed, including a broken window blind in a family room, damaged door frames in a dining area, torn carpet and a sharp broken plastic piece in a resident room, and loose ceiling tiles in another room. A resident with multiple health conditions reported the ceiling tiles had been loose for months and expressed concern for their safety. Facility staff were either unaware of these issues or unable to provide documentation of maintenance requests, and no policy for maintaining a homelike environment was available.
The facility failed to conduct and document thorough investigations into two separate abuse allegations involving two residents. In one case, a resident with severe cognitive impairment was reported to have a bruise after dialysis, but no investigation or follow-up was documented. In another case, a resident with moderate cognitive impairment was allegedly struck by staff, but the facility's investigation lacked required staff statements and complete documentation, contrary to facility policy.
A resident who was dependent on staff for hygiene was found wearing two saturated incontinent briefs, a practice initiated by staff and not documented as a resident preference in the care plan. The CNA checked the resident by feeling the outside of the briefs and believed the resident was dry if the briefs did not feel heavy. Facility policy required residents to be kept clean and dry and for care plans to reflect resident preferences, but no documentation or education regarding the use of two briefs was found.
A resident with severe cognitive impairment and multiple medical conditions reported a fall and arm pain to a COTA, who informed the assigned LPN. The LPN checked the resident, found no visible injury, and sent the resident to dialysis without initiating the facility's fall protocol or notifying supervisory staff or the physician. Later, the resident was found with facial bruising at the dialysis center and sent to the ER. Staff interviews confirmed that required fall investigation procedures were not followed.
A resident, who was cognitively intact and on a regular diet, did not receive all requested breakfast items as listed on their meal ticket. The resident received only cereal and a biscuit, with pancakes missing, and was not informed in advance about the unavailability or offered substitution options. The ADON confirmed the kitchen did not have pancakes and provided a sandwich as a substitute, but this was not communicated to the resident prior to meal delivery, resulting in the facility not honoring the resident's dietary preferences.
Failure to Notify Physician and Resident Representative After Reported Fall
Penalty
Summary
A deficiency was identified when a resident reported a fall and subsequent pain to a Certified Occupational Therapist Assistant (COTA) during a therapy session. The COTA relayed this information to the assigned LPN, who assessed the resident and found no visible injury or change in condition. The LPN applied lidocaine cream to the resident's left arm dialysis site as per routine orders and sent the resident to their scheduled dialysis session without further action. Later, the dialysis center contacted the facility to report that the resident had facial bruising and was being transferred to the emergency room for evaluation. Review of facility documentation and interviews revealed that the LPN did not initiate the facility's fall protocol, which includes conducting a thorough investigation, notifying the supervisor, the physician, and the resident representative (RR), and updating the care plan. There was no documentation that the physician or RR was informed at the time the fall was reported. The resident involved had severe cognitive impairment, end stage renal disease, and was dependent on hemodialysis. Despite the resident's report of a fall and complaint of pain, the required notifications and protocols were not followed, as confirmed by staff interviews and review of facility policy, which mandates timely notification of the physician and family after such incidents.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple environmental deficiencies observed during a survey. In the family room used by residents, a broken window blind was noted, and the Licensed Nursing Home Administrator (LNHA) was unaware of how long it had been in that condition. In the main resident dining room, the door frame had broken wood on both sides, and in a resident room, the carpet was torn and frayed with a sharp plastic piece broken off the bathroom entrance frame. The Assistant Director of Nursing (ADON) stated she had not noticed these issues, and the LNHA indicated that the facility was transitioning to a new work order system but could not provide documentation of any work orders for the observed problems. The facility also did not have a policy for maintaining a homelike environment. Additionally, in another resident room, two ceiling tiles near the window were loose and out of alignment. The resident occupying the room, who was cognitively intact and had diagnoses including bilateral osteoarthritis of the knee, morbid obesity, anxiety, and depression, reported that the tiles had been loose since February and expressed fear that they might fall. The LPN assigned to the resident confirmed the observation but stated they had not previously noticed the issue. No additional information or documentation regarding maintenance or work orders for these deficiencies was provided to the surveyor.
Failure to Conduct and Document Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations and maintain complete documentation in response to allegations of abuse for two residents. In the first case, a resident with severe cognitive impairment and multiple medical conditions, including end stage renal disease and metabolic encephalopathy, was reported by a responsible representative at a dialysis center to have a bruise and pain on the left foot. Prior to dialysis, both a physician and a registered nurse assessed the resident and found no bruising or complaints of pain. However, after the report from the dialysis center, there was no evidence that the facility initiated or documented a full investigation into the injury, as required by protocol. The Director of Nursing confirmed that no investigation or follow-up with the dialysis center was conducted, and no incident or fall investigation was found for the date in question. In the second case, a resident with moderate cognitive impairment and multiple diagnoses, including Alzheimer's disease and bipolar disorder, was reported by a representative to have been hit by a staff member, resulting in a scratch and discoloration on the forehead. The resident was assessed, transferred to the hospital, and the incident was reported to the state health department. The facility initiated a 72-hour lookback investigation, suspended two CNAs pending investigation, and collected statements from some staff and residents. However, the investigation file was missing several required staff statements from the relevant shifts during the lookback period. The LNHA acknowledged that not all statements were obtained in writing, despite facility policy requiring thorough documentation and interviews with all involved persons. The facility's policy on abuse, neglect, and exploitation mandates a thorough investigation and complete documentation for all alleged violations. In both cases, the facility did not meet these requirements, as evidenced by the lack of a documented investigation for the first resident's injury and incomplete staff statements for the second resident's abuse allegation. These deficiencies were confirmed by interviews with facility leadership and review of facility records and policies.
Failure to Provide Proper Incontinence Care and Documentation
Penalty
Summary
A deficiency was identified when a resident who was incontinent and dependent on staff for hygiene care was found to be wearing two incontinent briefs, with the inner brief saturated with dark yellow urine. The resident reported waiting for a CNA to return for hygiene care and stated that the use of two briefs was initiated by staff, not by personal request. The resident indicated that the practice was accepted due to infrequent changes and concern about soiling outside the brief. There was no documentation in the care plan or medical record indicating a preference or request for two briefs by the resident. The CNA assigned to the resident confirmed that she checked the resident by feeling the outside of the two briefs and believed the resident was dry if the briefs did not feel heavy. The CNA acknowledged that only one brief should be used unless specifically requested by the resident, but also stated that some residents have special requests. However, the care plan did not reflect any such request or preference for two briefs for this resident. The CNA also reported rounding on residents two to three times per shift to check for incontinence care needs. Facility policy required residents to be kept clean and dry, with incontinence care provided at least every two hours, and care plans to be updated as changes occurred. The Director of Nursing confirmed that more than one brief should not be used unless requested by the resident, and that such preferences should be documented in the care plan along with education on associated risks. The surveyor found no evidence of documentation or education regarding the use of two briefs for this resident, and the facility administration did not provide additional information when informed of the concern.
Failure to Investigate and Report Resident-Reported Fall
Penalty
Summary
The facility failed to comprehensively investigate a reported fall for a resident, as required by its own policy. On the morning in question, a resident with severe cognitive impairment and multiple medical conditions, including end stage renal disease and dependence on dialysis, reported a fall and left arm pain to a Certified Occupational Therapist Assistant (COTA) during a therapy session. The COTA relayed this information to the assigned LPN, who checked the resident and found no visible injury or bruising, then applied lidocaine cream to the resident's dialysis site as ordered. The resident was subsequently sent to a scheduled dialysis appointment. Later that day, the dialysis center contacted the facility to report that the resident had facial bruising and was being transferred to the emergency room for evaluation. Despite the resident's report of a fall and subsequent complaint of pain, the LPN did not initiate the facility's fall protocol, which includes conducting a skin assessment, taking vital signs, notifying the supervisor, DON, physician, and responsible representative, updating the care plan, and starting an incident report. There was also no documentation that the physician or responsible representative was informed at the time the fall was reported. Interviews with facility staff confirmed that the LPN did not follow the required procedures after being informed of the resident's reported fall. The DON acknowledged that the fall investigation protocol was not initiated as required. The facility's policy on assessing falls and their causes was not followed, resulting in a lack of timely investigation and documentation regarding the resident's reported fall and subsequent injury.
Failure to Honor Resident Food Preferences and Communicate Meal Substitutions
Penalty
Summary
A deficiency occurred when a resident did not receive their requested breakfast items as listed on their meal ticket. During incontinence rounds, the resident, who was alert and cognitively intact with a BIMS score of 15, reported receiving only cereal and a biscuit, and stated that pancakes, which were supposed to be included, were missing. The resident indicated this was not the first time they had not received all ordered food items. The Assistant Director of Nursing (ADON) confirmed that after checking with the kitchen, pancakes were not available and a sandwich was provided as a substitute, but this substitution was not communicated to the resident prior to meal delivery. The resident's medical record showed they were on a regular texture and thin liquid diet, with diagnoses including hypertension and generalized muscle weakness. The facility's policy required that alternate meal selections be provided in a timely manner and that individual food preferences be honored. However, the resident was not informed in advance about the unavailability of pancakes or offered substitution options before receiving their tray, resulting in the facility failing to honor the resident's dietary preferences as required.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,476 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Catherine Of Siena | 1.2 mi | ★★★★★ | 0 | 0 |
| Family Of Caring Healthcare At Montclair | 1.6 mi | ★★★★★ | 0 | 0 |
| Montclair Care Center | 1.9 mi | ★★★★★ | 8 | 0 |
| Canterbury At Cedar Grove | 2.2 mi | ★★★★★ | 13 | 0 |
| Alaris Health At Cedar Grove | 2.5 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Green Hill.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.