Inspection Reports for
Aspen Hills Healthcare Center
600 Pemberton Brown Mills Rd, Pemberton, NJ, 08068
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
188 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by the New Jersey Department of Health and Senior Services and related components.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health information, legal duties of the department, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 188
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ00181107.
Complaint Details
Complaint #NJ00181107 was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 191
Deficiencies: 7
Date: Jun 20, 2024
Visit Reason
Complaint investigations related to staffing levels, medication administration, infection control, food safety, and life safety code compliance.
Complaint Details
Complaint investigations NJ169221 and NJ166868 focused on staffing shortages and related resident care concerns.
Findings
The facility was found deficient in maintaining required minimum direct care staff-to-resident ratios, accurate medication administration and documentation, infection control practices, food safety and sanitation, and life safety code compliance including stairwell door latching and fire extinguisher maintenance.
Deficiencies (7)
Failed to follow a physician's order for a resident.
Failed to ensure sufficient nursing staff on a 24-hour basis to provide nursing care to residents, with multiple weeks of deficient CNA staffing documented.
Failed to accurately document administration of controlled substances for 7 sampled residents.
Failed to handle potentially hazardous foods safely and maintain sanitation to prevent foodborne illness.
Failed to follow appropriate infection control procedures during wound treatment and medication administration.
Failed to ensure 8 of 16 stairwell exit access doors positively latched to maintain 1-1/2 hour fire rated construction.
Failed to maintain 1 of 45 portable fire extinguishers in proper working condition.
Report Facts
CNA staffing deficiency days: 7
Resident census during inspection: 191
Fire extinguishers inspected: 45
Stairwell exit access doors inspected: 16
Stairwell exit access doors deficient: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in infection control and medication administration findings. |
| LPN #2 | Licensed Practical Nurse | Named in infection control and medication administration findings. |
| LPN/UM #4 | Licensed Practical Nurse/Unit Manager | Named in staffing interview and assignment sheet review. |
| CNA #2 | Certified Nursing Assistant | Named in staffing interview. |
| CNA #3 | Certified Nursing Assistant | Named in staffing interview. |
| Director of Nursing | Director of Nursing | Named in staffing interview and reporting. |
Inspection Report
Annual Inspection
Census: 175
Deficiencies: 4
Date: Oct 17, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to bowel/bladder incontinence, catheter use, urinary tract infections, staffing shortages, and life safety code violations including hazardous area door closures and sprinkler system installation.
Deficiencies (4)
Failure to maintain required minimum direct care staff-to-resident ratios for the day shift for 13 of 14-day shifts reviewed.
Failure to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions.
Failure to provide proper fire sprinkler coverage to all areas of the facility as required by NFPA 13.
Failure to ensure residents with bowel/bladder incontinence received appropriate treatment and services to restore continence.
Report Facts
Census: 175
Staffing deficiency days: 13
Storage room size: 240
Boxes in storage room: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged staffing shortages during interview on 10/18/2022 |
| Licensed Practical Nurse Unit Manager | Licensed Practical Nurse Unit Manager | Interviewed regarding resident care and floor contact on 10/17/22 |
| Maintenance Director | Maintenance Director | Confirmed fire door and sprinkler deficiencies and involved in corrective actions |
| Corporate Maintenance | Corporate Maintenance | Present during fire safety inspections |
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
The inspection was conducted in response to complaint NJ 154548 to investigate staffing ratio compliance at Aspen Hills Healthcare Center.
Complaint Details
Complaint NJ 154548 was investigated and the facility was found not in substantial compliance with staffing requirements. The deficient practice had the potential to affect all residents. No specific residents were identified as affected.
Findings
The facility was found not in substantial compliance with New Jersey Administrative Code 8:39 due to failure to meet required staffing ratios for Certified Nurse Aides (CNAs) on day shifts, potentially affecting all residents.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on day shifts.
Report Facts
Census: 180
Sample Size: 4
CNA staffing counts: 13
CNA staffing counts: 16
CNA staffing counts: 19
CNA staffing counts: 19.5
CNA staffing counts: 20
CNA staffing counts: 20
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 2
Date: May 3, 2022
Visit Reason
The inspection was conducted based on complaints NJ152051, NJ152957, and NJ154266 to investigate compliance with long term care facility regulations.
Complaint Details
Complaint investigation based on complaints NJ152051, NJ152957, and NJ154266. The facility was found not in substantial compliance with regulatory requirements.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, and New Jersey Administrative Code 8:39, with deficiencies related to failure to provide reasonable accommodations and inadequate staffing ratios. Specific issues included failure to provide staff assistance to a resident for appointments and deficient CNA staffing for multiple shifts.
Deficiencies (2)
Failure to provide a resident with staff assistance needed to meet the resident's needs at an appointment.
Failure to ensure staffing ratios were met for 20 shifts of 21 shifts reviewed, with deficient CNA staffing.
Report Facts
Census: 169
Shifts with deficient CNA staffing: 20
Residents on day shifts: 175
CNA staffing required: 22
CNA staffing actual: 13
CNA staffing deficient shifts: 7
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 0
Date: Jul 15, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint# NJ145495.
Complaint Details
Complaint# NJ145495 was investigated and the facility was found compliant.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 163
Deficiencies: 1
Date: Jun 2, 2021
Visit Reason
The inspection was conducted based on complaint intakes NJ139832 and NJ139275 to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint intakes NJ139832 and NJ139275 triggered the investigation. The facility was found non-compliant with minimum staffing requirements, affecting all residents. The census was 163 at the time of the survey.
Findings
The facility failed to meet required staffing ratios for 20 of 26 shifts reviewed, with ratios exceeding state-mandated limits on day, evening, and night shifts. The deficient practice had the potential to affect all residents.
Deficiencies (1)
Failure to ensure staffing ratios were met for 20 of 26 shifts reviewed.
Report Facts
Shifts reviewed: 26
Shifts with staffing ratio met: 6
Resident census: 163
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed on 06/01/2021 regarding staffing challenges and recruitment efforts | |
| Staffing Coordinator | Interviewed on 06/01/2021 acknowledging state required staffing numbers |
Inspection Report
Routine
Census: 161
Deficiencies: 0
Date: May 7, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Routine
Census: 157
Deficiencies: 0
Date: Jan 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 8
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