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Complaint Investigation

Aspen Hills Healthcare Center

Inspection Date: October 31, 2025
Total Violations 3
Facility ID 315260
Location PEMBERTON, NJ
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Inspection Findings

F-Tag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Immediate Jeopardy

F 0600

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)

Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aspen Hills Healthcare Center

600 Pemberton Brown Mills Rd Pemberton, NJ 08068

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)

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F-Tag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0609 Level of Harm - Minimal harm or potential for actual harm

known.The Department of Health and Senior Services, and the office of the ombudsman if the resident is 60 or over, will be notified immediately (as soon as possible but not to exceed two hours) of the incident, followed by a written report within 5 days of the incident and if the alleged violation is verified, the facility shall take all appropriate corrective action. NJAC 8:39-9.4(f)

Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aspen Hills Healthcare Center

600 Pemberton Brown Mills Rd Pemberton, NJ 08068

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)

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F-Tag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Immediate Jeopardy

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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)

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

Aspen Hills Healthcare Center in PEMBERTON, NJ inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PEMBERTON, NJ, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Aspen Hills Healthcare Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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