Complete Care at Green Knoll

In the surveyor’s words

From the most serious findings on record at Complete Care at Green Knoll, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Apr 24, 2023

  Complaint#: NJ163545, NJ163595, NJ163682 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 4/20/2023 & 4/24/2023, it was determined that the facility failed to protect residents from significant medication errors on 4/18/2023 at approximately 9:00 p.m. when the Licensed Practical Nurse (LPN) administered subcutaneous insulin injections instead of heparin, to two residents (Resident #1 and Resident #3) who are not Diabetics or had a Physician's Order for Insulin. During the 9:00 p.m. medication pass, the LPN assigned to Residents #1 & #3 did not verify the medication and administered the wrong medication (insulin-Admelog) instead of Heparin 5000 IU [International Unit] as ordered to both residents. […]

• No harm, potential for more than minimal, widespreadF814Feb 11, 2026

  Based on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris.On 02/04/2026 9:21 AM, in the presence of the Food Service Director (FSD), the surveyor toured the kitchen and the designated garbage area and observed the following: There were multiple carboard boxes outside of the dumpster on the ground and surrounding area. The FSD stated that the area should have been cleaned by the maintenance and dietary departments. On 2/5/26 at 9:00 AM, the FSD provided the surveyor with a facility policy titled, Garbage and dumpster area policy with a revised date of 5/8/21. […]

• No harm, potential for more than minimal, patternF558Feb 11, 2026

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep the call bell within residents' reach. This deficient practice was identified for 8 of 30 residents (Resident #6,15, 37, 44, 55, 139, 152 and 155) reviewed for accommodations of needs and was evidenced by the following:1.On [DATE] at 11:56 AM, the surveyor observed Resident #139 in bed wearing glasses with floor mats on both sides of the bed and the call bell on the floor not within the resident's reach. On [DATE] at 7:40 AM, the surveyor observed Resident #139 in bed with floor mats on both sides of the bed and the call bell on the floor not within the resident's reach. The surveyor reviewed the medical record for Resident #139. […]

• No harm, potential for more than minimal, patternF657Feb 11, 2026

  Based on observation, interview, record review and review of facility provided documents, it was determined the facility failed to a.) ensure the timeliness of each resident's person-centered comprehensive care plan (PCCP), that is reviewed and revised by an interdisciplinary care team, (IDCP) during the IDCP meeting with the resident and a resident representative (if applicable) every quarter, and b) updating the care plan to reflect new physician orders. The deficient practice was identified for 2 of 30 residents reviewed for Comprehensive Care Plan (Resident #11 and Resident #168). These deficient practices were evidenced by the followinga. Resident #11 On 02/4/26 at 10:45 AM, the surveyor observed Resident #11 in their room. […]

• No harm, potential for more than minimal, patternF585Sep 26, 2024

  Based on interview, record review, and facility policy review, the facility failed to provide information on how to file an anonymous grievance for six of six residents (Residents (R) 18, R88, R94, R97, R95, and R128) reviewed for the grievance process of 40 sample residents. The failure had the potential to affect residents' ability to safely report concerns without fear of retaliation. Findings include: A resident group interview was conducted on 09/25/24 at 3:00 PM with six residents whom the facility identified as reliable historians. During the meeting, six of the six residents (R18, R88, R94, R97, R95, and R128) expressed that they did not know how to file an anonymous grievance. […]