Inspection Reports for
Little Brook Nursing And Convalescent Home

Complaint #NJ00185571 substantiated. The immediate jeopardy began on 2025-04-14 and was identified on 2025-07-02. The facility submitted an acceptable removal plan on 2025-07-08 and implemented corrective actions.

The facility failed to provide adequate one-to-one monitoring of Resident #7, which resulted in Resident #7 striking Resident #5 with a metal grabber causing a laceration requiring hospital transfer. The failure to supervise placed residents at immediate jeopardy, which was identified and later removed after corrective actions including staff education and monitoring audits were implemented.

Complaint numbers NJ183318 and NJ183964 involved allegations of abuse by CNA #1 towards Resident #1 and failure of the facility to properly investigate and report the abuse. The investigation found the facility did not notify police, did not interview other residents, and allowed the CNA to return to work prematurely, placing residents in immediate jeopardy until the CNA was terminated.

The facility failed to report an abuse allegation involving CNA #1 to the police, did not conduct a thorough investigation including resident interviews, allowed the CNA to return to work before completing a full investigation, and failed to update care plans for affected residents. Additionally, the facility did not complete required sections of the Minimum Data Set (MDS) assessments and failed to conduct annual performance evaluations for some CNAs.

Complaint NJ#173220 involved a late report of an incident on 4/20/24 involving Residents #29 and #81. The incident was reported to NJ DOH on 4/24/24, exceeding the required 24-hour reporting timeframe. The Director of Nursing acknowledged the delay and could not provide a reason for the late report. The facility's abuse policy did not specify a reporting timeframe.

The facility failed to report an allegation of abuse/neglect within the required timeframe for two residents involved in an incident where one resident touched another's face and attempted to remove their glasses. The Director of Nursing acknowledged the late reporting and the facility's policy did not specify a reporting timeframe.

The visit was complaint-related based on an anonymous complaint about inadequate supply of incontinence briefs and improper feeding practices. Complaint number NJ174200 was investigated and substantiated with findings of minimal harm.

The facility was found deficient in multiple areas including failure to provide correct size IBs, improper feeding posture by staff, failure to issue required Medicare notices, failure to notify representatives of hospital transfers, late transmission and inaccurate completion of MDS assessments, failure to provide accurate diet consistency leading to immediate jeopardy, incomplete fall investigations, failure to address significant weight changes timely, lack of CNA performance reviews, improper medication administration, expired medications stored on medication carts, failure to provide liquids per physician orders, poor kitchen sanitation, incomplete medical records, and inadequate infection prevention practices.

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.

Complaint NJ00171484 was investigated and substantiated based on the incomplete smoking assessment for Resident #1.

The facility failed to maintain a complete and accurate medical record by having an incomplete smoking assessment for Resident #1. The assessment lacked completion in sections including frequency, safety, resident need for adaptive equipment, and interdisciplinary team conference decision.

Complaint #: NJ00171484. The complaint was substantiated as the facility was found not in substantial compliance with federal requirements based on the complaint visit.

The facility failed to maintain a complete and accurate medical record for one of two residents reviewed, specifically an incomplete assessment. Additionally, the facility failed to meet required staffing ratios for Certified Nurse Aides (CNAs) on multiple days during the review period.

The complaint investigation revealed that the facility failed to report four allegations of resident-to-resident abuse involving Residents #1, #2, #4, and #6 to the NJDOH. The incidents included inappropriate touching and physical altercations. The facility also failed to thoroughly investigate these incidents and update care plans accordingly. The Administrator admitted lack of awareness of reporting requirements and incomplete investigations.

The facility failed to report four allegations of resident-to-resident abuse to the New Jersey Department of Health and did not thoroughly investigate these incidents according to facility policy. Additionally, the facility failed to revise care plans for the affected residents to reflect these incidents and implement interventions to prevent recurrence.

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.

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.

The investigation was triggered by complaints NJ00155172, NJ00161276, NJ00160806, and NJ00159306 alleging staffing shortages, medication errors, and inadequate supervision.

The facility failed to ensure adequate staffing levels, resulting in inadequate supervision of 29 residents, multiple medication administration errors, and failure to act on Consultant Pharmacist recommendations. The Licensed Practical Nurse worked excessive consecutive shifts, often sleeping on duty, leaving residents unsupervised. The facility was cited for immediate jeopardy due to these deficiencies. A removal plan was eventually accepted and verified onsite.

Complaint investigations NJ00155172, NJ00161276, NJ00160806, NJ00159306 were the basis for the inspection and findings.

The facility was found to have significant deficiencies including failure to provide adequate staffing, failure to administer medications properly and document them accurately, failure to follow consultant pharmacist recommendations timely, failure to ensure adequate supervision of residents, and failure to maintain required competencies and performance appraisals for nursing staff. Immediate jeopardy was identified due to these issues.

Complaint investigations were conducted during the survey. Multiple complaint numbers were referenced including NJ00159306, NJ00155172, NJ00161276, NJ00160806, NJ00155489.

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.

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.

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.

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.

The facility was found deficient in multiple areas including failure to properly assess and consent for physical restraints, failure to timely report and investigate suspected abuse and injuries of unknown origin, failure to update care plans after significant events, medication administration errors, improper storage and maintenance of emergency and medical equipment, inadequate infection control practices, failure to maintain current staffing postings, and failure to implement an effective antibiotic stewardship program.

The facility was found not in compliance with mandatory infection control and sanitation requirements, specifically failing to ensure that newly hired employees completed required health histories, physical examinations, and two-step Mantoux tuberculin skin tests within the mandated timeframes.

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.

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.