Cycle 1
Health 2025-02-24 · Fire 2025-02-24
16 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
West Orange, NJ
Green Hill
3-star overall rating with 2-star inspections with 16 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
103 Pleasant Valley Way, West Orange, NJ
(973) 731-2300
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
127
Certified beds
Average residents
95
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,981
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.92% · Performance 22.52% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.27% · Performance 8.25% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.18
Baseline 52.46% · Performance 46.58% · Measure score 4.18 · Achievement 4.18 · Improvement 1.63
Adjusted total nurse staffing
3.19
Baseline 3.59 hours · Performance 3.99 hours · Measure score 3.19 · Achievement 3.19 · Improvement 1.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.1% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 9.14% · Lower 95% interval 7.35% |
| Discharge to community | 58.36% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 217 · Observed rate 51.15% · Lower 95% interval 50.42% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 170 · Denominator 170 |
| Falls with major injury | 0.59% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 170 |
| Discharge self-care score | 62.2% |
53.69%
8.5 pts better
|
Numerator 51 · Denominator 82 |
| Discharge mobility score | 69.51% |
50.94%
18.6 pts better
|
Numerator 57 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 3.53% |
2.29%
1.2 pts worse
|
Numerator 6 · Denominator 170 · Adjusted rate 2.86% |
| Healthcare-associated infections requiring hospitalization | 8.25% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 9.86% · Lower 95% interval 4.71% |
| Staff COVID-19 vaccination coverage | 2.4% |
8.2%
5.8 pts worse
|
Numerator 4 · Denominator 167 |
| Staff flu vaccination coverage | 70.59% |
42%
28.6 pts better
|
Numerator 120 · Denominator 170 |
| Discharge function score | 75.61% |
56.45%
19.2 pts better
|
Numerator 62 · Denominator 82 |
| Transfer of health information to provider | 98.95% |
95.95%
3 pts better
|
Numerator 94 · Denominator 95 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 49 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 4.03% |
25.2%
21.2 pts worse
|
Numerator 5 · Denominator 124 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.1
0.6 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.6% |
93.0%
21.4 pts worse
|
93.4%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 91.3% · Q3 62.5% · Q4 52.2% · 4Q avg 71.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.2% |
97.2%
3 pts worse
|
95.5%
1.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
2.4%
1.4 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
11.4%
3.1 pts better
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 10.5% · Q3 3.8% · Q4 10.3% · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
4.6%
0.8 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 6.1% · Q4 8.2% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.2% |
19.0%
10.8 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.8% · Q3 7.7% · Q4 7.7% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
13.5%
6.6 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.3% · Q3 5.4% · Q4 4.2% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.1% |
9.8%
1.7 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 14.3% · Q3 11.5% · Q4 5.9% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
9.7%
3.9 pts worse
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 15.8% · Q3 23.3% · Q4 5.6% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.8%
0.3 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
15.9%
13.5 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 19.7% · Q3 42.5% · Q4 32.0% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
6.0%
3.1 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 6.4% · Q3 12.2% · Q4 8.1% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.8% |
78.7%
21.9 pts worse
|
81.7%
24.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.2% · Q2 67.5% · Q3 55.7% · Q4 36.0% · 4Q avg 56.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
8.2%
0.3 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.7% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.8% · Q3 1.6% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.9% |
80.1%
8.2 pts worse
|
79.7%
7.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
25.4%
3.1 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 29.9% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-27 · Fire 2023-01-27
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-02-24 · Fire 2021-02-24
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-24
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-02-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-25
F · Potential for more than minimal harm
2025-02-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-02-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-06
D · Potential for more than minimal harm
2025-02-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-25
F · Potential for more than minimal harm
2023-01-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-22
F · Potential for more than minimal harm
2023-01-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-03-22
F · Potential for more than minimal harm
2023-01-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-14
F · Potential for more than minimal harm
2023-01-27
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-03-14
F · Potential for more than minimal harm
2023-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-10-29
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-10-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-10-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-10-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-27
D · Potential for more than minimal harm
2025-10-29
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-11-27
F · Potential for more than minimal harm
2025-02-24
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-02-24
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-02-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-24
G · Actual harm
2023-01-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-27
E · Potential for more than minimal harm
2021-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-23
D · Potential for more than minimal harm
2021-02-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-03-31
D · Potential for more than minimal harm
2021-02-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-03-31
D · Potential for more than minimal harm
2021-02-24
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2021-03-31
Penalties and ownership
What sits behind the stars
Ownership
Braender, Lori
Corporate Director · Individual
Depiro, Valerie
Corporate Director · Individual
Gagliano, Debra
W-2 Managing Employee · Individual
Ganter, Danielle
Corporate Director · Individual
Gardner, Loretta
Corporate Director · Individual
Green Hill Inc
5% Or Greater Direct Ownership Interest · Organization
Lazartic, Donna
Corporate Director · Individual
Lazartic, Donna
W-2 Managing Employee · Individual
Raskulinecz, Jaime
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
St Catherine Of Siena
Caldwell, NJ
2-star overall rating with 3-star inspections with $16,171 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Family of Caring Healthcare at Montclair
Montclair, NJ
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Montclair Care Center
Montclair, NJ
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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