Inspection Reports for
Aspen Hills Healthcare Center

Complaint #2594123 involved allegations that the facility failed to protect Resident #2 from physical abuse and failed to timely report an injury of unknown origin. The injury was discovered on 8/17/25 but was not investigated or reported immediately. The investigation was delayed until 8/18/25, and staff who cared for the resident were not suspended until then. The facility was notified of Immediate Jeopardy on 10/30/25 and submitted a Removal Plan on 10/31/25.

The facility failed to immediately implement its abuse and neglect policy by not promptly investigating an injury of unknown origin found on Resident #2 on 8/17/25, which was later diagnosed as a left clavicle fracture. The facility also failed to report the injury to the New Jersey Department of Health within the required timeframe. Staff continued to work after the injury was identified, delaying investigation and protective actions, resulting in an Immediate Jeopardy situation that was removed on 10/31/25 after corrective actions were implemented.

Complaint investigations NJ169221 and NJ166868 focused on staffing shortages and related resident care concerns.

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.

The complaint investigation revealed persistent CNA staffing deficiencies on multiple day shifts over several weeks, with specific dates and staffing numbers documented. Substantiation status is not explicitly stated.

The facility was found deficient in providing adequate CNA staffing on multiple day shifts across several weeks, failing to meet required staffing ratios. Interviews with staff and residents confirmed delays in assistance and challenges in meeting care needs due to staffing shortages.

The complaint investigation revealed multiple issues including failure to follow physician orders, staffing shortages, medication documentation errors, food safety violations, and infection control breaches. The facility acknowledged errors such as failure to address a urinalysis order, insufficient staffing, and improper hand hygiene practices.

The facility failed to follow a physician's order for urinalysis, had persistent CNA staffing shortages across multiple weeks, inaccurate documentation of controlled medication administration, unsafe food handling and storage practices, and lapses in infection prevention and control including improper use of PPE and hand hygiene during wound care and medication administration.

The facility failed to maintain an indwelling urinary catheter drainage bag off the floor for one resident, which posed a risk for infection. Observations and interviews confirmed the catheter bag was in contact with the floor contrary to facility protocol.

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.

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.

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.

Complaint investigation based on complaints NJ152051, NJ152957, and NJ154266. The facility was found not in substantial compliance with regulatory requirements.

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.

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.

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.

The facility failed to follow physician-ordered treatment for one resident by not applying TED compression stockings as ordered, failed to adhere to infection control practices for a resident on contact isolation for MRSA, and improperly stored respiratory equipment for another resident. Nursing documentation errors and lack of specific policies were also noted.