Little Brook Nursing And Convalescent Home

F-F610 J was removed as of 3/18/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 11 315467 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315467 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Little Brook Nursing and Convalescent Home 78 Sliker Road Califon, NJ 07830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 After the IJ removal, the non-compliance continued from 3/18/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. Level of Harm - Immediate jeopardy to resident health or This deficient practice was identified for 2 of 4 residents (Resident #1 and Resident #2) reviewed and was safety evidenced by the following:

Residents Affected - Few According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 2/4/25 revealed that Resident #1 screamed and started to kick CNA #1 as CNA #1 tried to transfer the resident into the chair to keep the resident from falling. The Ombudsman was visiting the facility and witnessed the encounter. The LNHA was notified of the incident by the Ombudsman. The LNHA immediately suspended CNA #1 and did an investigation. CNA #1 was suspended upon further investigation and was allowed to return to work with disciplinary actions and sensitivity training. On 2/18/25, the Ombudsman came to the facility and interviewed several residents who stated CNA #1 was rough, would not help them, and threatened to throw the residents

in bed if they did not want to go to bed. The Ombudsman also reported that some residents felt unsafe. The LNHA terminated CNA #1 on 2/18/25.

A review of the updated facility policy titled Abuse Investigations revealed under Policy Statement, All reports of resident abuse, neglect and injuries of the unknown source shall be thoroughly and promptly investigated by facility management. Under Policy Interpretation and Implementation, 3. The individual conducting the investigation will, as a minimum: i. Interview other residents to whom the accused employee provides care or services.

1. According to the Admission Record (AR), Resident #1 was admitted to the facility in September 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression.

According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/24, Resident #1 had a blank space for the Brief Interview for Mental Status (BIMs) score. Under the Assessment section of the electronic medical record (EMR), Resident #1 had a BIMS score of 8 out of 15 on 3/11/2025, which indicated

the resident's cognition was moderately impaired. The MDS further revealed that Resident #1 needed partial to moderate assistance with most Activities of Daily Living (ADLs).

A review of Resident #1's February 2025 Progress Notes (PNS) dated 2/4/25 at 12:30 PM written by RN #1 revealed that the RN assessed Resident #1 for an incident involving CNA #1. Resident #1 told RN #1 that CNA #1 pulled and hurt his/her left arm. RN #1 observed bruising to the resident's left thumb. The resident complained of difficulty bending his/her left elbow and complained of 10 out of 10 pain to his/her arm.

The surveyor was unable to reach RN #1 for an interview.

The surveyor was unable to reach CNA #1 for an interview.

2. According to the AR, Resident #2 was admitted to the facility in 12/2024 with diagnoses which included but were not limited to: Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression, unspecified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 11 315467 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315467 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Little Brook Nursing and Convalescent Home 78 Sliker Road Califon, NJ 07830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 According to the Quarterly MDS, an assessment tool dated 2/9/2025, Resident #2 had a blank space for the BIMS score. Under the Assessment section of the EMR, Resident #2 had a BIMS score of 15 out of 15 on Level of Harm - Immediate 3/11/2025, which indicated the resident's cognition was intact. The MDS further revealed that Resident #2 jeopardy to resident health or was independent with most ADLs. safety

On 3/12/2025 at 1:26 PM, the surveyor interviewed Resident #2, who stated CNA #1 had taken care of Residents Affected - Few him/her in the past. According to Resident #2, CNA #1 was the only one who was not nice to her. CNA#1 caused her to feel frustrated and humiliated. Resident #2 indicated he/she did not report this to the facility staff because he/she did not want to make a big issue out of it, but he/she had reported this to the Ombudsman when they were at the facility.

On 3/12/2025 at 2:14 PM, the surveyor interviewed the LNHA, who stated that the Ombudsman had notified her that CNA #1 was trying to get Resident #1 out of bed and that the resident was screaming. The LNHA indicated that Resident #1 told her that CNA#1 had pulled her arm and hurt it. Resident #1 stated that he/she did not want Resident #1 touching him/her. The LNHA stated she immediately suspended the CNA on 2/4/25 while she conducted an investigation. The LNHA further stated she concluded that CNA #1 was rough with Resident #1 and should have reapproached the resident. The LNHA indicated she allowed CNA #1 to return to work on 2/7/25 after conducting an investigation and provided the CNA with sensitivity training and disciplinary action with the hope there would be no further issues. The LNHA indicated that on 2/18/25, the Ombudsman informed her that several residents complained about how CNA #1 treated them. Some residents felt afraid when CNA #1 provided care to them, which resulted in the LNHA terminating the CNA on that day. The LNHA confirmed she did not interview or obtain statements from other residents in the facility.

The LNHA could not speak to why she did not interview or obtain statements from other residents. The LNHA stated she did not call the police about the abuse allegation because she thought the police were only notified for serious injuries and elopements. The LNHA confirmed she did not notify the police about CNA #1

after the Ombudsman told her about the other resident complaints involving the CNA. The LNHA stated she did not follow up on the resident complaints she received from the Ombudsman because she ended up terminating CNA #1 on 2/18/25.

On 3/12/2025 at 2:48 PM, the surveyor conducted a follow-up interview with the LNHA, who confirmed that part of the facility's abuse investigation policy included interviewing other facility residents about if they had experienced or witnessed any mistreatment from the staff member involved in an abuse allegation. The LNHA indicated she had never asked the Ombudsman who were the residents that had complaints involving CNA #1. The LNHA stated she should have interviewed the residents that CNA #1 had provided care to as part of her investigation. The LNHA stated it was important to conduct a thorough investigation into an abuse allegation to ensure the safety of all the residents.

NJAC 8:39-4.1 (a) 5

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 315467 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315467 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Little Brook Nursing and Convalescent Home 78 Sliker Road Califon, NJ 07830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50919 potential for actual harm Complaint: NJ183318, NJ183964 Residents Affected - Some Based on interviews, medical record reviews, and review of other pertinent facility documents on 3/12/25 and 3/13/25, it was determined that the facility failed to complete Section C of the Quarterly Minimum Data Set (MDS) and failed to follow its policy titled MDS for 6 of 6 sampled residents. This deficient practice was evidenced by the following:

1. According to the Admission Record (AR), Resident #1 was admitted to the facility in September of 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression.

A review of Resident #1's Quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/24 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces.

2. According to the AR, Resident #2 was admitted to the facility in December of 2024 with diagnoses which included but were not limited to: Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression, unspecified.

A review of Resident #2's Quarterly MDS, an assessment tool dated 2/9/25 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should

the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces.

3. According to the AR, Resident #3 was admitted to the facility in March of 2024 with diagnoses which included but were not limited to: Diabetes, Depression, and Anxiety.

A review of Resident #3's Quarterly MDS, an assessment tool dated 11/24/24 under Section C0100 (Should

a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should

the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 315467 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315467 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Little Brook Nursing and Convalescent Home 78 Sliker Road Califon, NJ 07830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 4. According to the AR, Resident #4 was admitted to the facility in June of 2024 with diagnoses which included but were not limited to: Personality Disorder (a mental health condition that involves disruptive Level of Harm - Minimal harm or patterns of thinking and behaviors), Hypertension, and Mood Disorder. potential for actual harm

A review of Resident #4's Quarterly MDS, an assessment tool dated 12/1/24 under Section C0100 (Should a Residents Affected - Some Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should

the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces.

5. According to the AR, Resident #5 was admitted to the facility in March of 2024 with diagnoses which included but were not limited to: Spinal Stenosis (narrowing of the spine), Diabetes, and Morbid Obesity.

A review of Resident #5's Quarterly MDS, an assessment tool dated 12/29/24 under Section C0100 (Should

a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should

the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces.

6. According to the AR, Resident #6 was admitted to the facility in September of 2024 with diagnoses which included but were not limited to: Congestive Heart Failure (a condition that affects the heart's ability to pump blood well), Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways), and Falls.

A review of Resident #6's Quarterly MDS, an assessment tool dated 12/25/24 under Section C0100 (Should

a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. The surveyor reviewed Sections C0200 (Repetition of Three Words), C0300 (Temporal Orientation), C0400 (Recall), and C0500 (BIMS Summary Score) which revealed blank spaces. Under Section C0600 (Should

the Staff Assessment for Mental Status be Conducted?) revealed a code of 1 which indicated Yes. Under Sections C0700 (Short Term Memory OK), C0800 (Long Term Memory OK), C0900 (Memory/Recall Ability), C1000 (Cognitive Skills for Daily Decision Making), and C1310 (Signs and Symptoms of Delirium) revealed blank spaces.

On 3/13/25 at 12:33 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the Social Worker (SW) was responsible for completing Section C of the MDS. The LNHA indicated

the reason Section C was not completed was because the facility has not had a SW since November. The LNHA stated that the MDS Coordinator resigned at the end of February, but she was not responsible for Section C of the MDS, it was the SW's responsibility. The LNHA further stated it was important that all sections of the MDS were accurate to reflect the residents' care needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 315467 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315467 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Little Brook Nursing and Convalescent Home 78 Sliker Road Califon, NJ 07830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 A review of the facility's policy titled MDS with a revision date of 5/2024 revealed under Policy, Little [NAME] Nursing and Convalescent Home will adhere to the following procedures related to the proper documentation Level of Harm - Minimal harm or and utilization of a resident's Minimum Data Set (MDS) to ensure that a comprehensive and accurate potential for actual harm assessment of residents will be completed . Under Procedure, 2.The following disciplines will be responsible to complete these sections: c. Section B, C, E, and Q completed by the Social Services Department. g. Residents Affected - Some Sections C, D, GG, G (partial) . are entered into the computer software by the MDS Coordinator.

NJAC 8:39-11.1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 315467 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315467 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Little Brook Nursing and Convalescent Home 78 Sliker Road Califon, NJ 07830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 50919

Residents Affected - Some Complaint #: NJ183318, NJ183964

Based on interviews, medical record reviews, and review of other pertinent facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to a.) update the care plan (CP) with interventions for a resident (Resident #1) involved in a staff to resident abuse allegation and b.) for residents (Resident #3 and #4) involved in a resident-to-resident incident.

This deficient practice was identified in 3 of 3 residents reviewed for care plans and was evidenced by the following:

1. According to the Admission Record (AR), Resident #1 was admitted to the facility in September of 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression.

According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/2024, Resident #1 had a blank space for the Brief Interview for Mental Status (BIMs) score. Under the Assessment section of

the electronic medical record (EMR), Resident #1 had a BIMS score of 8 out of 15 on 3/11/2025, which indicated the resident's cognition was moderately impaired. The MDS further revealed that Resident #1 needed partial to moderate assistance with most Activities of Daily Living (ADLs).

According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 2/4/25 revealed that Resident #1 screamed and started to kick CNA #1 as CNA #1 tried to transfer the resident into the chair to keep the resident from falling. The Ombudsman was visiting the facility and witnessed the encounter. The LNHA was notified of the incident by the Ombudsman. The LNHA immediately suspended CNA #1 and did an investigation. CNA #1 was suspended upon further investigation and was allowed to return to work with disciplinary actions and sensitivity training. On 2/18/25, the Ombudsman came to the facility and interviewed several residents that stated CNA #1 was rough, would not help them, and threatened to throw the residents

in bed if they did not want to go to bed. The Ombudsman also reported that some residents felt unsafe. The LNHA terminated CNA #1 on 2/18/25.

A review of Resident #1's CP revealed no new updates or interventions related to the abuse allegation that occurred on 2/4/25.

2. According to the AR, Resident #3 was admitted to the facility in March of 2024 with diagnoses which included but were not limited to: Diabetes, Depression, and Anxiety.

According to the Quarterly MDS, an assessment tool dated 11/24/24, Resident #3 had a blank space for the BIMS score. Under the Assessment section of the EMR, Resident #3 had a BIMS score of 15 out of 15 on 3/11/25, which indicated the resident's cognition was intact.

A review of Resident #3's CP initiated on 7/17/24 and revised on 9/21/24 revealed a Focus of Resident #3 has potential to be physically aggressive by biting other residents .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 315467 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315467 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Little Brook Nursing and Convalescent Home 78 Sliker Road Califon, NJ 07830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 3. According to the AR, Resident #4 was admitted to the facility in June of 2024 with diagnoses which included but were not limited to: Personality Disorder (a mental health condition that involves disruptive Level of Harm - Minimal harm or patterns of thinking and behaviors), Hypertension, and Mood Disorder. potential for actual harm According to the Quarterly MDS, an assessment tool dated 12/1/24, Resident #4 had a blank space for the Residents Affected - Some BIMS score. Under the Assessment section of the EMR, Resident #4 had a BIMS score of 10 out of 15 on 3/10/25, which indicated the resident's cognition was moderately impaired.

A review of Resident #4's CP initiated 11/23/24 and revised on 11/25/24 with a Focus of Resident #4 has a potential to be physically aggressive .

According to the FRE, a NJDOH document used by healthcare facilities to report incidents with an event date of 12/17/24 revealed that Resident #3 and Resident #4 had a verbal argument while sitting at the dining room table. Resident #3 proceeded to self-propel himself/herself around the table in an attempt to bite Resident #4. The Activity Director attempted to intervene and witnessed Resident #4 push Resident #3 in the chest. Both residents were separated.

A review of Resident #3 and #4's CP revealed no new updates or interventions related to resident-to-resident incident that occurred on 12/17/24.

On 3/12/25 at 3:08 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the resident's CP should be updated when an incident occurs. The DON acknowledged the CP for Resident #1 was not updated and revised with new interventions after the 2/4/25 abuse allegation. The DON also acknowledged the CPs for Residents #3 and #4 were not updated and revised with new interventions after

the 12/17/24 resident to resident incident. The DON stated she was responsible for updating the CPs but was not working in the facility when the abuse allegation and resident to resident incident occurred. The DON further indicated it was important to update the CPs to monitor the progression of the residents and help the staff know how to provide care to the residents.

Review of the facility's undated policy titled Care Plan-Comprehensive revealed under Policy Statement, An individualized comprehensive care that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Under Policy Interpretation and Implementation, 8. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change.

NJAC 8:39-11.2 (e) (1) (2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 315467 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315467 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Little Brook Nursing and Convalescent Home 78 Sliker Road Califon, NJ 07830

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 50919 potential for actual harm Complaint #: NJ1833183, NJ183964 Residents Affected - Few Based on interview and review of facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to evaluate the performance of a Certified Nursing Assistant (CNA) on an annual basis. This deficient practice was identified for 1 of 3 CNAs whose personnel files were reviewed (CNA #2).

The deficient practice was evidenced by the following:

On 3/12/25 at 11:13 AM, the surveyor reviewed the employee files for 3 CNAs which were provided by the facility. The surveyor identified the following:

CNA #2 had a hire date of 10/23/23. According to CNA #2's personnel file, there was no documentation that

an annual performance evaluation was completed.

On 3/12/24 at 3:19 PM, the surveyor interviewed the Business Office Manager /Human Resources (BO/HR) who confirmed there was no annual performance evaluation completed for CNA #2. The BO/HR stated the Director of Nursing (DON) was responsible for completing the annual performance evaluation. She further stated the previous DON would have been responsible for completing CNA #2's performance evaluation, but

she no longer works at the facility. The BO/HR stated the CNA performance evaluations should be completed yearly because it was a regulation. She further indicated the performance evaluations were important because it tells how the staff were performing in their job duties.

On 3/13/24 at 12:33 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA)who stated that the CNA performance evaluations were supposed to be done yearly by the DON.

A review of the facility policy titled Performance Evaluation Ratings with a revised date of 8/2010 revealed under Policy Statement, Our facility evaluates the employee on the performance of his/her assigned tasks. Under Policy Interpretation and Implementation 2. Failure to receive a satisfactory rating indicates that in-service training is needed .

A review of the facility job description titled Director of Nursing Services revealed under Duties and Responsibilities, Personnel Function: Assist the HR Director in developing performance evaluation schedules, criteria, and annual reviews for the nursing service department (e.g., RNs, LPNs, CNAs, medication aides, etc.)

NJAC 8:39-43.17(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 315467