Aspen Hills Healthcare Center
Aspen Hills Healthcare Center in PEMBERTON, NJ — inspection on October 31, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor verified the implementation of the Removal Plan on-site during the continuation of the survey and determined the IJ for F 600 was removed as of 10/31/25 at 1:35 PM. NJAC 8:39-4.1(a)(5)
jeopardy to resident health or safety
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/31/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Aspen Hills Healthcare Center
600 Pemberton Brown Mills Rd Pemberton, NJ 08068
SUMMARY STATEMENT OF DEFICIENCIES
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/31/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Aspen Hills Healthcare Center
600 Pemberton Brown Mills Rd Pemberton, NJ 08068
SUMMARY STATEMENT OF DEFICIENCIES
had been suspended.
The ADON confirmed that the staff from 8/17/25, the day the discoloration was first identified, should have been suspended that day (8/17/25) pending investigation for the injury of unknown origin. On 10/30/25 at 3:55 PM, the surveyor interviewed the DON, the Licensed Nursing Home Administrator (LNHA) and the ADON, and the ADON stated that immediately on 8/17/25, on initial discovery of the bruise on the clavicle, an investigation should have been initiated to rule out abuse.
The DON confirmed that the staff should have notified the DON immediately and that all staff should have been removed from the schedule until the investigation has been completed and abuse ruled out.
The DON also stated that statements should have been taken from staff who had cared for the resident for the last 24 hours, both nurses and CNAs.
The DON confirmed both CNA #1, CNA #2, and HA #1 were suspended on 8/18/25. At that time, the LNHA stated, on 8/18/25, was when [HA #1] identified Resident #2 was unable to raise their arm.
That's when we decided uh oh! we need to investigate this.
Until then the bruise was related to combative behavior.
The DON and ADON confirmed they only became aware of the resident's complaint of pain and decreased ROM on Monday 8/18/25. On 10/30/25 at 5:35 PM, the DON stated that Resident #2 had a skin assessment completed by the ADON as part of the investigation, however it was not initiated until 8/18/25. On 10/30/25 at 5:36 PM, the surveyor reviewed the timecards for CNA #1 and CNA #2 that were provided as follows:CNA #1:Worked two shifts on 8/16/25 (3:00 PM to 11:00 PM and 11:00 PM and 7:00 AM), and clocked in on 8/16/25 at 2:52 PM, and clocked out at 8/17/25 at 7:51 AM.
Worked two shifts on 8/17/25 (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM), and clocked in on 8/17/25 at 2:52 PM, and clocked out at 8/18/25 at 7:30 AM.Worked one shift on 8/18/25 (11:00 PM to 7:00 AM), and clocked in on 8/18/25 at 10:53 PM, and 8/19/25 at 7:36 AM.CNA #1 worked three shifts after the skin discoloration was initially observed giving her access to Resident #2 as well as 28 other residents on the nursing unit. CNA #2:Worked one shift on 8/17/25 (7:00 AM to 3:00 PM), and clocked in on 8/17/25 at 6:58 AM, and clocked out at 3:23 PM.Worked one shift 8/18/25 (7:00 AM to 3:00 PM), and clocked in on 8/18/25 at 6:59 AM, and out at 3:23 PM.CNA #2 continued to work two shifts after the skin discoloration was initially observed giving her access to Resident #2 as well as 28 other residents on the nursing unit.An acceptable Removal Plan was received on 10/31/25 at 12:12 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring.
The facility implemented a corrective action plan to remediate the immediacy including on 8/17/25, an incident report was completed by LPN/S #1 when the discoloration was noted to the resident's left collar bone. On 8/18/25, the ADON and LNHA initiated an investigation to rule out abuse, the physician was notified, and an X-ray was obtained which revealed a left clavicle fracture. On 8/18/25, the NJDOH and Ombudsman were notified, and the CNAs and HA were suspended. On 10/30/25, the [NAME] President (VP) of Clinical Services and LNHA reviewed the abuse policy with no changes, and the VP of Clinical Services re-educated the DON and the LNHA on the abuse policy and investigation. On 10/30/25, the ADON/designee began a facility wide education for all staff on the abuse and neglect policy.
On 10/31/25, the Unit Managers and Nursing Supervisors were re-educated on the abuse policy and requirement to report and suspend staff pending the outcome of investigations.
The surveyor verified the implementation of the Removal Plan on-site during the continuation of the survey and determined the IJ for F 600 was removed as of 10/31/25 at 1:35 PM. NJAC 8:39-4.1(a)(5)
Facility ID: