Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspen Hills Healthcare Center during CMS and state inspections, most recent first.
A resident with severe dementia and a history of falls was found with a bruise and swelling to the left clavicle of unknown origin. The LPN did not immediately initiate an investigation or remove staff from duty as required by policy. The next day, the resident was found to have a fractured clavicle, and only then was an investigation started and staff suspended. Staff involved continued to work additional shifts after the injury was first observed, contrary to facility policy.
A resident with severe dementia and a history of falls was found with discoloration and swelling to the left clavicle, later diagnosed as a fracture. The LPN did not immediately initiate an abuse investigation or suspend staff as required by policy, and staff continued to work until the following day when the injury was confirmed and an investigation began. Facility leadership confirmed the abuse and neglect policy was not followed.
A resident was found with discoloration and swelling to the clavicle, later diagnosed as a fracture. The injury was not reported to the NJDOH within the required two-hour window, and no immediate investigation was initiated. The DON and ADON were not informed promptly, and the LPN who identified the injury did not follow facility policy for escalation and reporting, resulting in delayed investigation and notification.
The facility consistently failed to provide sufficient nursing staff, particularly CNAs, to meet the needs of residents, as evidenced by multiple weeks of inadequate staffing levels. Interviews with staff and residents highlighted the challenges faced due to these deficiencies, including delayed response to call bells and difficulty completing tasks. The DON acknowledged the facility's failure to meet staffing requirements set by the NJ Department of Health.
The facility failed to document the administration of controlled medications accurately for several residents, as identified during an inspection of two medication carts. Discrepancies were found between the physical inventory and the declining inventory sheets for medications like pregabalin and oxycodone. Interviews with LPNs revealed they had administered the medications but did not sign the inventory sheets at the time of administration, contrary to facility policy.
Surveyors identified deficiencies in food handling and sanitation practices at the facility. Issues included unlabeled and undated food items, such as egg noodles and liverwurst, and expired nutritional shakes. A stand-up mixer had food debris, and a waste can was missing from the hand washing area. In the resident pantry, a freezer lacked a thermometer, and food items were found without labels or dates. The facility's policies on food safety and equipment maintenance were not followed.
A resident with a urinary catheter and a history of UTIs did not receive a urinalysis as ordered by a physician. The order was visible in the EMR but was not addressed by facility staff. The DON confirmed the oversight and noted the PA admitted the order was an error. The facility lacked a policy for handling physician orders.
A facility failed to follow infection control procedures during wound treatment and medication administration. An RN did not wear a gown or perform adequate hand hygiene while treating a resident's sacral wound, despite Enhanced Barrier Precautions. An LPN also neglected hand hygiene before and after administering insulin and oral medications to residents. Interviews with the IP and DON confirmed the importance of these protocols, which were not adhered to, risking cross-contamination and infection spread.
Failure to Immediately Investigate and Protect After Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse and neglect policy when a cognitively impaired resident was found with a bruise and swelling to the left clavicle of unknown origin. The injury was first observed by staff at approximately 12:20 PM, but the LPN/Supervisor did not immediately initiate an investigation as required by facility policy. The resident, who had severe dementia, agitation, a history of falls, and required substantial assistance with activities of daily living, was unable to describe how the injury occurred. The resident was noted to be physically combative and had poor safety awareness, but no immediate action was taken to protect the resident or to remove staff from duty pending investigation. On the following day, the resident complained of pain and had limited range of motion in the left arm. The physician was notified, and an X-ray revealed a closed, displaced fracture of the left clavicle. The Assistant Director of Nursing confirmed that the investigation and staff suspensions were not initiated until the day after the injury was first observed. Staff who had access to the resident continued to work additional shifts after the injury was identified, providing them continued access to the resident and other residents on the unit. Documentation and interviews revealed inconsistencies in staff accounts regarding the provision of care and the discovery of the injury. The facility's policy required immediate reporting, investigation, and protection of residents in cases of suspected abuse or injury of unknown origin. However, the required steps were not followed when the injury was first discovered. The delay in initiating an investigation and in suspending staff placed the resident and others at risk, as staff under investigation continued to provide care. The deficiency was identified as Immediate Jeopardy due to the likelihood of serious harm.
Removal Plan
- An incident report was completed by LPN/S #1 when discoloration was noted to left collar bone.
- 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.
- The NJDOH and Ombudsman were notified, and the CNA and HA were suspended.
- The 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.
- The ADON/designee began a facility wide education for all staff on the abuse and neglect policy.
- 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.
Failure to Immediately Investigate Injury of Unknown Origin and Implement Abuse Policy
Penalty
Summary
The facility failed to immediately implement its abuse and neglect policy when a cognitively impaired resident was discovered with discoloration and minor swelling to the left clavicle, which was later determined to be a fracture. On the day the injury was first observed, the LPN/Supervisor did not initiate an immediate investigation as required by facility policy. Instead, the incident was documented, but no immediate action was taken to suspend staff or begin a thorough investigation to rule out abuse, despite the injury being of unknown origin and the resident being unable to describe how it occurred. The resident involved had severe dementia with agitation, a history of falls, and exhibited frequent physical and verbal behaviors toward others. The care plan indicated the resident required substantial assistance with activities of daily living due to impaired mobility and safety awareness. On the day of the incident, the resident was noted to be physically combative and unable to provide an account of the injury. The LPN/Supervisor documented the findings and notified the nurse practitioner and family, but did not initiate the required abuse investigation or remove staff from duty pending the outcome. It was not until the following day, when the resident complained of pain and had limited range of motion in the left arm, that the physician was notified, an X-ray was ordered, and an investigation was initiated. Staff who had cared for the resident continued to work and had access to the resident and other residents during this period. Interviews with facility leadership confirmed that the abuse and neglect policy was not followed, as the investigation and staff suspensions were delayed until after the injury was confirmed as a fracture.
Removal Plan
- An incident report was completed by LPN/S #1 when the discoloration was noted to the resident's left collar bone.
- 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.
- The NJDOH and Ombudsman were notified.
- The CNAs and HA were suspended.
- The VP of Clinical Services and LNHA reviewed the abuse policy with no changes.
- The VP of Clinical Services re-educated the DON and the LNHA on the abuse policy and investigation.
- The ADON/designee began a facility wide education for all staff on the abuse and neglect policy.
- 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.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) within the required two-hour timeframe after it was first identified. On 8/17/25, staff observed a resident with discoloration and minor swelling to the left clavicle during care, but no immediate investigation was initiated, and the NJDOH was not notified. The injury was later diagnosed as a closed, displaced fracture on 8/19/25. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were not informed of the injury at the time it was discovered, and the LPN/S who identified the injury did not escalate the issue as required by facility policy. The delay in reporting and investigation resulted in the facility not ruling out possible abuse in a timely manner. The ADON acknowledged that staff providing direct care should have been placed off duty pending investigation and that notifications to the NJDOH and Ombudsman should have occurred immediately or within the required timeframe. Facility policy mandates immediate reporting of any injury of unknown origin, but this protocol was not followed, leading to a late submission of the Facility Reported Event (FRE) and delayed initiation of the investigation.
Inadequate Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff on a 24-hour basis to meet the needs of its residents, as evidenced by multiple instances of inadequate staffing levels. Over several weeks, the facility consistently fell short of the required number of Certified Nursing Assistants (CNAs) needed to care for the residents during day shifts. For example, during the week of March 5, 2024, to March 11, 2024, the facility was deficient in CNA staffing on all seven day shifts, with the number of CNAs ranging from 11 to 20, while at least 20 to 21 were required. Similar deficiencies were noted in subsequent weeks, with the facility failing to meet the required staffing levels for both day and evening shifts. Interviews with staff and residents further highlighted the impact of these staffing deficiencies. A Unit Manager and several CNAs reported that staffing levels were inadequate, making it difficult to complete all necessary tasks during their shifts. One CNA mentioned having to care for 14 residents, which was challenging, especially when assistance was needed for tasks requiring two CNAs. Residents also expressed dissatisfaction, with one resident stating that call bells were not answered timely, leading to long waits for assistance. The Director of Nursing (DON) acknowledged that the facility was not meeting the staffing requirements set by the New Jersey Department of Health. The DON explained that the staffing plan was based on a full census of 204 residents, but the facility struggled to maintain the required ratios due to unreliable agency staffing. The facility's policy, as reviewed, indicated that staffing should be determined based on census, acuity, shift, and resident needs, but the facility consistently failed to adhere to these guidelines, resulting in the reported deficiencies.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of controlled medications for seven residents during an inspection of two medication carts. The surveyor, in the presence of LPNs, identified discrepancies between the physical inventory of narcotic medications and the declining inventory sheets. For instance, Resident #60's pregabalin 75 mg capsule inventory did not match, with the blister pack containing 20 capsules while the inventory sheet indicated 21 capsules should remain. Similar discrepancies were found for other residents, including mismatches in the inventory of oxycodone, lorazepam, and Xtampza ER capsules. Interviews with the LPNs revealed that they had administered the medications but failed to sign the declining inventory sheets at the time of administration. The facility's policy requires nurses to document the administration of controlled substances on the declining inventory sheet, including the date, quantity administered, remaining amount, and their initials. The Director of Nursing confirmed that the nurses should sign the inventory sheets immediately after removing the medication from the packaging.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed by surveyors. During an inspection of the kitchen, several issues were noted: a previously opened bag of egg noodles and a roll of liverwurst were found without opened or use-by dates, and a plastic bag of coffee filters was left open and exposed. Additionally, a stand-up mixer, although covered with plastic, had unidentified food debris on its support arm. The surveyor also noted the absence of a waste can at the designated hand washing sink, which was explained by the Food Service Director (FSD) as being temporarily removed for emptying. Furthermore, two Ready Care Vanilla shakes were found in the Beverage Box with expired dates, and the FSD acknowledged they were past their 14-day shelf life once removed from the freezer. In the Laurel Unit designated resident pantry, the surveyors found that the freezer lacked an internal thermometer, and no temperatures were recorded on the temperature sheet. A single slice of pizza and portion control cups containing sauces were found in the refrigerator without any labeling or dates. The facility's policy requires all food and beverage items to be labeled with the resident's name and the date brought in, and to be discarded upon expiration, spoilage, or after 72 hours. The surveyor's review of the facility's policies on food safety, receiving, equipment, and dry goods storage revealed that the facility did not adhere to its own procedures, which include proper labeling, dating, and maintaining cleanliness and sanitation of food service equipment.
Failure to Follow Physician's Order for Urinalysis
Penalty
Summary
The facility failed to follow a physician's order for a urinalysis to rule out a urinary tract infection (UTI) for a resident with a urinary catheter. The resident, who had a history of UTIs and other medical conditions, was observed with cloudy urine in the catheter tubing. Despite an order for a urinalysis dated 06/03/2024, there was no documentation of the test being conducted. The Director of Nursing (DON) confirmed that the order was visible in the electronic medical record (EMR) but was not addressed by the facility staff. The DON explained that the physician assistant (PA) who ordered the urinalysis admitted it was written in error, but this was only realized after the surveyor's inquiry. The facility staff did not address the order prior to the surveyor's notification, and the unit manager was unaware of the order. The facility was unable to provide a policy or procedure for handling physician orders when requested by the surveyor, indicating a lapse in the facility's protocol for managing medical orders.
Infection Control Deficiencies in Wound Treatment and Medication Administration
Penalty
Summary
The facility failed to adhere to appropriate infection control procedures during wound treatment and medication administration, as observed by surveyors. In the first instance, a registered nurse (RN) did not follow Enhanced Barrier Precautions (EBP) while treating a resident with a sacral wound. Despite signage indicating the need for both gown and gloves, the RN only donned gloves and failed to wear a gown. Additionally, the RN did not perform hand hygiene for the required 20 seconds at various stages of the wound treatment process, including after removing gloves and before accessing the treatment cart and computer. This lapse in protocol was acknowledged by the RN during an interview, where she admitted to not adhering to the hand hygiene and PPE requirements. In another observation, a licensed practical nurse (LPN) did not perform hand hygiene before and after administering insulin and oral medications to residents. The LPN was observed preparing and administering medications without washing hands or using alcohol-based hand rub (ABHR) between residents, which is a breach of the facility's infection control policy. The LPN acknowledged the oversight during an interview, confirming that hand hygiene should have been performed before donning gloves, after doffing gloves, and between caring for different residents. Interviews with the facility's Infection Preventionist (IP) and Director of Nursing (DON) confirmed the importance of adhering to hand hygiene protocols and the use of PPE to prevent infection. The facility's policies on hand hygiene and Enhanced Barrier Precautions were reviewed, highlighting the requirement for handwashing for at least 20 seconds and the use of gowns and gloves during high-contact resident care activities. The failure to comply with these protocols poses a risk of cross-contamination and infection spread within the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pemberton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Holly Rehabilitation & Healthcare Center | 6.5 mi | ★★★★★ | 0 | 0 |
| Medford Leas | 9.9 mi | ★★★★★ | 0 | 0 |
| Masonic Village At Burlington | 10.3 mi | ★★★★★ | 2 | 0 |
| The Pines At Medford | 10.4 mi | ★★★★★ | 2 | 0 |
| Complete Care At Marcella | 10.5 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.