Aspen Hills Healthcare Center

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain clean laundry that was stored in the service corridor in a safe and sanitary manner and b.) follow the recommendations for the use Personal Protective Equipment (PPE) during incontinence care for residents who required Enhanced Barrier Precautions (EBP) (an infection control strategy focused on reducing the spread of multidrug-resistant organisms [MDRO] in nursing homes), to prevent the potential spread of infection in accordance with the Center for Disease Control (CDC), Infection Prevention guidelines and standards of clinical practice. This deficient practice was identified for 7 residents (Resident # 183, #21, #78, #90, #162, #145, and #42) observed for incontinence care and was evidenced by the following:Reference: [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to follow hold parameters for the administration of a blood pressure medication in accordance with professional standards of practice. This deficient practice was identified for 2 of 38 residents (Resident #90 and Resident #10) reviewed for standards of practice and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to implement the recommendations from a resident's Pre-admission Screening and Resident Review (PASARR) level 2 determination into the resident's plan of care. This deficient practice was identified for 1 (one) of 7 resident (Resident #12) reviewed for mood and behavior and was evidenced by the following:On 12/16/2025 at 11:03AM, the surveyor observed Resident #12 sleeping in bed. On 12/18/2025 at 9:21AM, the surveyor reviewed the medical record for Resident #12. A review of the admission Record, an admission summary, revealed that resident #12 had diagnoses which included, but were not limited to: schizoaffective disorder (a chronic mental illness), and cerebral infarction (Brain tissue death due to a blocked blood vessel). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that treatment to prevent or reduce range of motion limitations were provided for 1 of 2 residents (Resident #121) reviewed for positioning and mobility. This deficient practice was evidenced by the following:On 12/16/2025 at 11:34 AM, the surveyor observed Resident #121 sitting in a wheelchair near the nurses' station, with the right hand clenched and closed. On 12/18/2025 at 10:30 AM, the surveyor reviewed the medical record for Resident #121 which revealed the following:A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide the necessary respiratory care and services by not ensuring: a) respiratory equipment was changed in accordance with the physician's order for1 (one) of 5 (five) residents reviewed for respiratory care (Resident #94), b) oxygen administration was documented on the treatment administration record (TAR) for 1 (one) of 5 (five) residents reviewed for respiratory care (Resident #94), and c.) oxygen equipment was applied and maintained in a safe and sanitary manner for 2 (two) of 5 (five) residents (Resident #94 and Resident #7) reviewed for respiratory care. This deficient practice was evidenced by the following: 1.) On 12/16/2025 at 11:56 AM, the surveyor observed Resident #94 in their bedroom, seated on their bed watching television. [...]

Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to ensure that the resident's meal preferences were implemented, and the resident was notified in advance of the menu changes for 1 (one) of 2 (two) residents (Resident #121) observed during the lunch meal on one of five nursing units (Laurel). This deficient practice was evidenced by the following:On 12/16/2025 at 9:57 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the registered dietician developed the menu for a four-week cycle, Week 1 (one), Week 2 (two), Week 3 (three), and Week 4 (four). She further stated that the facility was operating on Week 1(one) menu. On 12/19/2025 at 10:00 AM, the surveyor reviewed the lunch menu for Week 1(one), Friday, which revealed: [...]

Inspectors wroteComplaint #: 2594123 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to immediately implement its abuse and neglect policy by immediately investigating an injury of unknown origin that was discovered on 8/17/25, to protect the resident to rule out abuse. On 8/17/25, a cognitively impaired resident (Resident #2) was noted to have discoloration and minor swelling to the left clavicle (collar bone), and it was determined to be a clavicle fracture on 8/18/25. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #2). On 8/17/25, staff observed a faint discoloration and minor swelling to Resident #2's left clavicle at approximately 12:20 PM. At the time, the Licensed Practical Nurse/Supervisor (LPN/S #1) did not immediately initiate an investigation. [...]

Inspectors wroteComplaint #: 2594123Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an injury of unknown origin within two hours of initial identification. The injury was discovered on 8/17/25, when Resident #2 was noted to have discoloration and minor swelling to the left clavicle (collarbone). The injury was later diagnosed as a fracture on 8/19/25, and the facility failed to rule out possible abuse as required by policy. This deficient practice was identified for 1 of 5 residents (Resident #2) reviewed for abuse. The evidence was as follows:On 8/17/25, staff at the facility identified an injury of unknown origin for Resident #2 at approximately 12:20 PM. At the time, no immediate investigation was initiated and the NJDOH was not notified. [...]

Inspectors wroteBased on interviews, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: 1. For the week of Complaint staffing from 03/05/2024 to 03/11/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -03/05/23 had 11 CNAs for 170 residents on the day shift, required at least 21 CNAs. -03/06/23 had 14 CNAs for 168 residents on the day shift, required at least 21 CNAs. -03/07/23 had 14 CNAs for 166 residents on the day shift, required at least 21 CNAs. -03/08/23 had 17 CNAs for 166 residents on the day shift, required at least 21 CNAs. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of controlled medication for 7 sampled residents, (Resident #11, Resident #30, Resident #49, Resident #60, Resident #69, Resident #120 and Resident #128) identified upon inspection of 2 of 4 medication carts (Birch Unit A cart, and Birch Unit B cart). This deficient practice was evidenced by the following: On 6/18/2024 at 1:10 PM, the surveyor in the presence of the Licensed Practical Nurse #3 (LPN #3) inspected Birch unit, A cart. The surveyor and LPN #3 reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic inventory sheet, the surveyor identified the following concerns: [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 6/13/2024 from 9:30 to 10:23 AM, the surveyors, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On an upper shelf, a previously opened bag of egg noodles had no opened or use by dates. The FSD removed the noodles from storage. 2. In the paper storage area on a middle shelf a previously opened plastic bag of coffee filters was stored opened and exposed. The FSD removed the filters from storage. 3. A clean and sanitized stand-up mixer in the food production area was covered with plastic and not in use per the FSD. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility records, it was determined that the facility failed to follow a physician's order for a urinalysis to rule out a urinary tract infection (UTI). This deficient practice was identified for 1 of 2 resident's (Resident #43) reviewed for catheter/UTI. This deficient practice was observed by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to follow appropriate infection control procedures: 1) during the provision of a wound treatment and 2) during medication administration. This deficient practice was identified for 1 of 1 nurses Registered Nurse (RN #1) who administered a wound treatment to 1 of 2 residents (Resident #177) reviewed for pressure ulcers and for 1 of 3 nurses Licensed Practical Nurse (LPN #2) observed during the medication administration observation. This deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to maintain an indwelling urinary catheter drainage bag off the floor to prevent the spread of infection and according to the facility protocol. This was identified for 1 of 2 residents (Resident #18) reviewed for indwelling urinary catheters. This deficient practice was evidenced by the following: On 10/04/2022 at 10:34 AM, the surveyor observed Resident #18 in a wheelchair in the hallway near the nurse's station. The surveyor observed a urinary catheter drainage bag was attached to his/her wheelchair and the urinary drainage bag had direct contact with the floor. On 10/06/2022 at 12:00 PM the surveyor observed Resident #18 in bed. The surveyor observed the urinary catheter drainage bag had direct contact with the floor on the window side of the bed. [...]