Little Brook Nursing and Convalescent Home

In the surveyor’s words

From the most serious findings on record at Little Brook Nursing and Convalescent Home, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jun 15, 2023

  Complaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F760K; F835L; F836L Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure 29 residents were adequately supervised when Licensed Practical Nurse (LPN) #1 worked 24 hours straight, six times in May 2023 with one Certified Nursing Assistant (CNA) #1 on the assignment during designated shifts. The failure to have adequate staff led to a lack of supervision for residents, which increased the risk of improper care, resident neglect, accidents such as falls, entrapments or elopements, and/or medication administration errors or omissions. […]

• Immediate jeopardy, widespreadF835Jun 15, 2023

  Complaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F689, F756, F760, F836 Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure a.) staffing levels outlined in the Facility Assessment Tool were consistently met to address the population census and needs of their residents; b.) minimum State staffing requirements were met for 17 weeks of 17 weeks reviewed during which time the facility continued to admit residents; c.) safe medication administration to residents resulting in significant medication errors; d.) Consultant Pharmacist (CP) monthly medication review reports were acted upon by the Director of Nursing (DON) and the Physician in… […]

• Immediate jeopardy, widespreadF836Jun 15, 2023

  Complaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F689, F756, F760, F835 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 118 of 119 day shifts, 54 of 119 evening shifts, and 10 of 119 overnight shifts. The failure of the facility to operate safely by following State minimum staffing requirements while continuing to admit new residents placed all residents at risk for serious harm, impairment or death. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. […]

• Immediate jeopardy, patternF756Jun 15, 2023

  Refer to 760K Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) recommendations dated 3/7/23 were acted upon in a timely manner regarding the documentation and administration of critical medications, including anticoagulants and insulin medications to prevent serious adverse outcomes for Resident #13, #19 and #20 who required blood sugar monitoring and were dependent on insulin, and Resident #17 and #230 who had physician orders for an anticoagulant to prevent blood clotting. […]

• Immediate jeopardy, patternF760Jun 15, 2023

  Refer to F756K, F689L, F835L and F836L Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents are free of significant medication errors regarding the documentation and administration of critical medications, including anticoagulants and insulin medications to prevent serious adverse outcomes for Resident #13, #19 and #20 who required blood sugar monitoring and were dependent on insulin, Resident #17, #25 and #230 who had physician orders for an anticoagulant to prevent blood clotting, and Resident #19 who had a physicians order for an oral hypoglycemic agent (medications to lower blood sugar). […]