Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

LITTLE BROOK NURSING AND CONVALESCENT HOME

CALIFON, NJ · 36 certified beds · Last Life Safety survey October 30, 2024

CMS Certification Number 315467 · first certified February 2001

Ownership

Independently operated (no chain recorded by CMS) · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NJ

40 citations — more than 99% of the 348 certified nursing homes in NJ. Compared within NJ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 15 citations; the earlier surveys in the window averaged 12.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (February 2026 to July 2026). Most NJ facilities have been surveyed by December 2026. This facility’s last Life Safety survey was October 2024. Facilities in NJ are typically surveyed 16–20 months after the last one (median 17), measured over 431 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

7 of the 40 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 40 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in NJ, and nationally. Surveyors differ markedly between states, so the NJ figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	40
Median facility in NJ	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
May 21, 2021	11
June 15, 2023	14
October 30, 2024	15

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	3	2024-10-30
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2024-10-30
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2024-10-30
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	2	2024-10-30
K-0712	Have simulated fire drills held at unexpected times.	2	2023-06-15
K-0252	Provide at least two remote exits on each floor or fire section of the building.	2	2023-06-15
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2024-10-30
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	1	2023-06-15

What the citations cover

Citations by CMS category

Smoke Deficiencies 12
Egress Deficiencies 9
Emergency Preparedness Deficiencies 7
Gas, Vacuum, and Electrical Systems Deficiencies 6
Other 6

Citations by CMS category
Category	Citations
Smoke Deficiencies	12
Egress Deficiencies	9
Emergency Preparedness Deficiencies	7
Gas, Vacuum, and Electrical Systems Deficiencies	6
Miscellaneous Deficiencies	4
Services Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 30, 2024 — 15 citations

Citations issued on October 30, 2024
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (November 22, 2024)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (November 22, 2024)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (November 22, 2024)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (November 22, 2024)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (November 27, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (November 22, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (November 22, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 22, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (November 25, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (November 25, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (November 25, 2024)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (November 25, 2024)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (November 25, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (November 27, 2024)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (November 25, 2024)

June 15, 2023 — 14 citations

Citations issued on June 15, 2023
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (July 26, 2023)
E-0009	Include a process for Emergency Preparedness collaboration.	Deficient, Provider has date of correction (July 26, 2023)
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (July 26, 2023)
E-0031	Provide emergency officials' contact information.	Deficient, Provider has date of correction (July 26, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (July 26, 2023)
K-0252	Provide at least two remote exits on each floor or fire section of the building.	Waiver has been granted (August 21, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (July 25, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (July 25, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 25, 2023)
K-0347	Properly provide smoke detection systems in areas open to corridors.	Deficient, Provider has date of correction (August 21, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 17, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (July 25, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (August 16, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (July 27, 2023)

May 21, 2021 — 11 citations

Citations issued on May 21, 2021
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (June 9, 2021)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (June 1, 2021)
K-0252	Provide at least two remote exits on each floor or fire section of the building.	Waiver has been granted (September 28, 2021)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (May 31, 2021)
K-0311	Have an enclosure around a vertical opening shaft.	Waiver has been granted (November 15, 2021)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (June 10, 2021)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (June 12, 2021)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (June 1, 2021)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (June 7, 2021)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (June 6, 2021)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (May 24, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.