Inspection Reports for Little Brook Nursing And Convalescent Home
78 Sliker Road, NJ, 07830
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Named as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 32
Capacity: 36
Deficiencies: 11
Oct 30, 2024
Visit Reason
A recertification/LSC survey was conducted from 10/23/2024 through 10/30/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The survey identified multiple deficiencies including failure to ensure physician's orders were followed, inadequate resident care related to feeding and diet consistency, failure to maintain accurate Minimum Data Set (MDS) assessments, and deficiencies in infection control and life safety code compliance. Corrective actions and plans of correction were documented for these deficiencies.
Deficiencies (11)
| Description |
|---|
| Failure to follow physician's orders for resident care including diet and medication administration. |
| Inadequate feeding assistance and failure to provide appropriate diet consistency for residents. |
| Failure to complete and transmit accurate Minimum Data Set (MDS) assessments in a timely manner. |
| Failure to maintain adequate infection control practices including improper handling of sharps and PPE. |
| Failure to maintain fire safety equipment and life safety code compliance including self-closing doors and emergency lighting. |
| Failure to maintain emergency preparedness plan and subsistence needs for staff and patients. |
| Failure to maintain accurate and complete medical records and documentation. |
| Failure to maintain adequate staffing levels as required by state regulations. |
| Failure to maintain proper storage and labeling of medications and controlled substances. |
| Failure to maintain proper sanitation and food safety practices in the kitchen and food storage areas. |
| Failure to maintain proper maintenance and testing of fire safety and electrical equipment. |
Report Facts
Census: 32
Total Capacity: 36
Sample Size: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in findings related to resident feeding and medication administration. | |
| Resident #19 | Referenced in multiple deficiencies related to feeding, medication, and care. | |
| Resident #15 | Referenced in deficiencies related to investigation reports and care planning. | |
| Resident #20 | Referenced in medication administration deficiency. | |
| Director of Nursing | Director of Nursing | Named in relation to corrective actions and staff education. |
| Maintenance Director | Maintenance Director | Named in relation to fire safety and equipment maintenance deficiencies. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Dec 12, 2023
Visit Reason
The inspection was conducted based on a complaint visit regarding allegations of resident-to-resident abuse and failure to report such incidents according to state and federal regulations.
Findings
The facility was found not in compliance with requirements related to reporting alleged violations of abuse, neglect, exploitation, or mistreatment. The investigation revealed failures to report multiple allegations of resident-to-resident abuse, incomplete investigations, and failure to revise care plans accordingly for affected residents.
Complaint Details
The complaint investigation was substantiated. The facility failed to report and investigate multiple resident-to-resident abuse incidents and failed to update care plans accordingly. The facility was also found to have inadequate staff education and monitoring related to abuse prevention and reporting.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report four allegations of resident-to-resident abuse to the New Jersey Department of Health and follow facility policy on abuse, neglect, exploitation, mistreatment, and misappropriation of property. | SS=E |
| Failure to thoroughly investigate all alleged violations of abuse, neglect, exploitation, or mistreatment according to facility policies. | SS=E |
| Failure to revise residents' care plans timely and appropriately to reflect incidents of abuse and to include interventions to prevent recurrence. | SS=E |
Report Facts
Census: 33
Sample Size: 6
Deficiencies cited: 3
Plan of Correction Completion Date: Jan 31, 2024
Post-Certification Revisit Date: Feb 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Witnessed and reported resident incidents, confirmed separation of residents after abuse incidents | |
| Administrator | Aware of incidents but failed to ensure reporting to NJDOH and proper investigation | |
| Acting Director of Nursing (ADON) | Informed about incidents and involved in investigation and corrective actions | |
| Activity Director (AD) | Witnessed resident interactions related to abuse incidents | |
| Director of Nursing (DON) | Responsible for follow-up investigations and monitoring corrective actions | |
| Social Worker | Involved in updating care plans for affected residents |
Inspection Report
Re-Inspection
Census: 29
Capacity: 36
Deficiencies: 22
Jun 15, 2023
Visit Reason
Recertification survey conducted to determine compliance with 42 CFR Part 483, including complaint investigations.
Findings
The facility was found not in compliance with multiple regulatory requirements including emergency preparedness, medication management, staffing, and life safety code. Immediate Jeopardy was identified for medication errors, staffing shortages, and failure to act on consultant pharmacist recommendations. A plan of correction was submitted and verified during a revisit.
Complaint Details
Complaint investigations were conducted during the survey. Multiple complaint numbers were referenced including NJ00159306, NJ00155172, NJ00161276, NJ00160806, NJ00155489.
Severity Breakdown
SS=F: 13
SS=K: 3
SS=D: 5
SS=L: 1
SS=E: 2
Deficiencies (22)
| Description | Severity |
|---|---|
| Failed to annually review and update Emergency Preparedness Plan and Program, including cooperation with local, state, and federal emergency preparedness officials, transfer agreements with other facilities, emergency contact information, and emergency preparedness testing requirements. | SS=F |
| Failed to treat residents with dignity during meal assistance; one resident was left waiting with covered tray while others were fed. | SS=D |
| Failed to obtain current and past-employer reference checks prior to hiring for 3 of 5 newly hired employees reviewed. | SS=D |
| Failed to document resident transfers and readmissions properly in medical records for 2 of 5 residents reviewed. | SS=D |
| Failed to assess weight change and follow physician's order for medication to raise weight for 1 of 1 resident reviewed. | SS=D |
| Failed to ensure medication administration and documentation without errors for 13 of 13 residents reviewed, including failure to sign eMAR and administer medications per physician orders. | SS=K |
| Failed to ensure residents were free of significant medication errors; medication administration error rate of 13.5% observed during medication pass. | SS=K |
| Failed to ensure licensed nurses had competencies to assess nursing care for residents' needs; no competencies found for 3 LPNs. | SS=D |
| Failed to complete annual nurse aide performance appraisals for 4 of 4 CNAs reviewed. | SS=F |
| Failed to provide pharmaceutical services ensuring accurate acquiring, receiving, dispensing, and administering of medications; multiple residents had medications not documented as administered in eMAR. | SS=F |
| Failed to act timely on consultant pharmacist recommendations regarding medication irregularities and omissions for multiple residents. | SS=K |
| Failed to maintain staffing levels as required by state minimum staffing ratios for 118 of 119 day shifts, 54 of 119 evening shifts, and 10 of 119 overnight shifts reviewed. | SS=L |
| Failed to provide two approved exits remote from each other for the basement level; only one exit stairway to first floor was available. | SS=F |
| Failed to provide battery backup emergency lighting above two transfer switches independent of building electrical system and emergency generator. | SS=F |
| Failed to provide fire barrier with one-hour fire resistance rating in hazardous area (laundry room) where combustible materials were stored. | SS=E |
| Failed to ensure smoke detection sensitivity testing was completed and maintenance program for battery-operated smoke detectors in resident rooms was maintained. | SS=F |
| Failed to maintain fire pump pond clean and free of debris, failed to perform monthly fire pump testing and document properly, and failed to maintain fire sprinkler heads in optimal condition. | SS=F |
| Failed to perform and document monthly visual inspection of all fire extinguishers including kitchen K-type extinguisher. | SS=F |
| Failed to conduct fire drills at expected and unexpected times under varying conditions at least quarterly on each shift with simulation of emergency fire conditions. | SS=F |
| Failed to certify generator transfer time within 10 seconds, perform weekly non-load test, and maintain proper generator testing logs. | SS=F |
| Failed to ensure timely physical examinations within two weeks of hire for 5 of 5 employees reviewed. | SS=D |
| Failed to ensure timely tuberculosis screening for 4 of 5 employees reviewed. | SS=D |
Report Facts
Deficiencies cited: 20
Residents present: 29
Total licensed beds: 36
Medication administration error rate: 13.5
Staffing deficiency counts: 118
Staffing deficiency counts: 54
Staffing deficiency counts: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration errors, excessive consecutive shifts, and sleeping on duty. |
| LNHA | Licensed Nursing Home Administrator | Named in multiple findings including staffing, medication management, and emergency preparedness. |
| DON | Director of Nursing | Named in medication management, staffing, and failure to act on consultant pharmacist recommendations. |
| CNA #1 | Certified Nursing Assistant | Named in staffing and resident supervision findings. |
| CP | Consultant Pharmacist | Named in medication review and recommendations. |
| MD | Medical Director | Named in failure to act on medication irregularities and lack of engagement. |
Inspection Report
Routine
Census: 30
Deficiencies: 3
Sep 13, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CMS/CDC recommended practices.
Findings
The facility was found not in compliance with infection control regulations, including failure to transcribe physician orders correctly onto the Medication Administration Record (MAR), improper infection control practices such as not wearing appropriate PPE, and failure to ensure all staff were fully vaccinated for COVID-19. Multiple deficiencies related to pharmacy services, infection prevention and control, and COVID-19 vaccination of staff were cited.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to transcribe a Physician's Order correctly onto the Medication Administration Record (MAR) for Resident #7, leading to medication errors. | SS=D |
| Failure to follow proper infection control practices by not wearing appropriate Personal Protective Equipment (PPE) in resident rooms and not performing hand hygiene. | SS=D |
| Failure to ensure all staff were fully vaccinated for COVID-19 or had appropriate exemptions. | SS=D |
Report Facts
Census: 30
Sample Size: 9
COVID+ In-House: 16
Deficiencies cited: 3
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Mar 23, 2022
Visit Reason
The inspection was conducted based on a complaint visit regarding failure to obtain pre-employment criminal background checks for certain employees.
Findings
The facility was found not in compliance with 42 CFR Part 483, Subpart B, due to failure to obtain criminal background checks for multiple employees, including those involved in an allegation of staff-to-resident abuse. Several employees lacked documented background checks, and some were terminated as a result.
Complaint Details
The complaint involved an allegation of staff-to-resident abuse by employee E#1. The facility failed to provide evidence of criminal background checks for E#1 and other employees. The allegation led to immediate suspension and termination of E#1.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain pre-employment criminal background checks for employees as required by facility policy and regulations. | SS=D |
Report Facts
Census: 29
Sample Size: 5
Completion Date: Apr 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E #1 | Certified Nursing Assistant (CNA) | Employee involved in abuse allegation and lacked criminal background check; terminated |
| E #4 | Certified Nursing Assistant (CNA) | Employee lacked criminal background check; terminated |
| E #6 | Licensed Practical Nurse (LPN) | Employee lacked criminal background check; worked one day and no longer employed |
| E #8 | Certified Nursing Assistant (CNA) | Employee lacked criminal background check; removed from payroll after failing to report to work |
| A #1 | Previous Administrator | Interviewed regarding missing background checks |
| A #2 | Current Administrator | Interviewed regarding scheduling employees pending background checks |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Jan 5, 2021
Visit Reason
The inspection was conducted as a complaint survey based on allegations of verbal abuse involving Resident #3.
Findings
The facility failed to report an allegation of verbal abuse to the New Jersey Department of Health within the required timeframe and did not submit the results of the investigation to the NJDOH. The allegation was not substantiated by the facility's investigation, but reporting requirements were not met.
Complaint Details
Complaint #: NJ 130039, NJ 130243, NJ 140363. The complaint involved failure to timely report and investigate an allegation of verbal abuse of Resident #3. The allegation was not substantiated by the facility investigation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an allegation of verbal abuse to the NJDOH within two hours and failure to report the results of the investigation within five days. | SS=D |
Report Facts
Census: 28
Sample size: 8
Suspension duration: 5
Monitoring duration: 3
Plan of correction completion date: Jan 25, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Named in the verbal abuse allegation and subsequent investigation. |
| Administrator | Provided statements regarding the investigation and reporting to NJDOH. |
Inspection Report
Routine
Census: 28
Deficiencies: 0
Jan 5, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 423 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report
Mar 4, 2024
File
20240304-COMPLAINT-CQ6J11.pdf
Report
May 21, 2021
File
20210521-ROUTINE-NCZ011.pdf
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