Little Brook Nursing And Convalescent Home

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.

315467

Form Approved OMB

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