Aspen Hill Rehab: Medication Cart Left Unlocked - MA

The discovery at Aspen Hill Rehabilitation & Healthcare Center came during a federal inspection that found systematic medication safety failures across multiple units. Inspectors documented expired medications sitting undated in carts, a nurse falsely recording insulin administration, and three residents waiting months for cataract surgery appointments that were never scheduled.

On January 15, 2025, at 8:14 A.M., the surveyor observed the unlocked medication cart on the dementia unit and was able to open and access it. Three minutes later, Nurse #1 returned and acknowledged the cart was supposed to be locked when unattended.

The medication problems extended far beyond the unlocked cart. On two different units, inspectors found multiple medications that had been opened but never dated, making it impossible to determine if they had expired.

On B-Unit, inspectors found a bottle of saline nasal spray that should be discarded after 30 days of opening. It was opened and undated. A bottle of Risperidone oral solution sat undated despite manufacturer instructions to discard after 90 days. Two inhalers for breathing conditions were opened and undated, when they should be discarded 30 days after opening their foil pouches.

On A-Unit, the problems continued. A bottle of liquid protein supplement was opened and undated, though it expires 90 days after opening. Four packages of breathing medications were opened and undated, when individual vials should be used within one week of opening. Most concerning, inspectors found a tuberculin test solution that had been opened and dated December 19, 2024, but was sitting unrefrigerated when it required refrigeration after opening.

Nurse #5 admitted the medications should have been dated when opened and that the tuberculin solution needed refrigeration. Unit Manager #3 said undated and expired medications must be removed from carts.

The Director of Nursing told inspectors she expected medications to be dated and labeled appropriately when opened according to manufacturer instructions, with expired medications removed.

But the medication failures went beyond storage and labeling. On January 15, inspectors observed Nurse #3 prepare oral medications for a diabetic resident who told her, "You didn't give me my insulin yet." The nurse said she was working on it and would return to give the morning insulin.

The surveyor watched as Nurse #3 completed her medication pass and left the room without administering insulin. A breakfast tray was delivered, and the resident began eating at 8:09 A.M. The nurse continued with other residents and never returned.

At 8:13 A.M., the resident confirmed to the surveyor he had not received his morning insulin: "I am supposed to have it before breakfast, but she didn't give it to me."

At 8:18 A.M., Nurse #3 admitted she had not given the insulin and said she was "working on getting it together now." But she continued with other residents instead of returning.

The resident finally received his insulin around 9:30 A.M., well after breakfast, when it should have been given before the meal. The nurse had already documented in the medication record that she gave the insulin at 7:52 A.M. When confronted, Nurse #3 admitted she should not have documented the insulin as given when she had not administered it.

"Nurse #3 said she should not have documented the insulin as given when she did not administer it and said she is new and thought she gave it, but did not," the inspection report stated.

The Director of Nursing said insulin must be given when ordered and before breakfast, and that the nurse should have notified the doctor about the delayed administration.

Beyond medications, the facility failed residents in other critical areas. Three residents had been waiting months for cataract surgery evaluations that doctors had specifically recommended, but staff never scheduled the appointments.

Resident #32 was recommended for cataract surgery in April 2024. By January 2025, no appointment had been scheduled. The resident told inspectors he could no longer read or see television clearly due to worsening vision, calling it "very frustrating." His health care proxy was unaware of the surgery recommendation.

Resident #28 received a similar recommendation in December 2024, with the eye doctor noting "ASAP" for the evaluation. Over a month later, no appointment had been made. The resident said he loves watching television but uses closed captioning because he's hard of hearing, and now cannot see the captions. "Resident #28 also said that he/she loves to read and has not been able to read because he/she cannot read the pages anymore."

The third resident, #93, also waited months without follow-up after his December recommendation for cataract surgery evaluation.

When inspectors called the recommended eye doctor's office, staff confirmed they had received no referrals or inquiries for any of the three residents.

The Director of Nursing said her expectation was that consultant recommendations be followed up within a week. None of these were.

Dental care presented similar problems. Resident #71, who had obvious tooth decay with dark discoloration on all remaining teeth, had never been asked if he wanted to see a dentist during his eight months at the facility. His care plan included arranging dental care, but no appointment was ever made.

Another resident, #93, had been told by a dentist in May 2024 that he needed tooth extractions before getting dentures. The dentist specifically referred him to an oral surgeon for the extractions. Eight months later, no extraction appointment had been scheduled, and the resident still had no dentures.

"Resident #93 said he/she has no choice but to not have them and chew the best he/she can," inspectors wrote.

The facility also failed to provide adequate trauma-informed care for residents with PTSD. Two residents diagnosed with post-traumatic stress disorder had care plans with generic interventions but no specific triggers or personalized approaches identified.

For one resident, the care plan focus for PTSD was left blank. Both plans contained identical, template language about being "consistent, positive, honest and nonjudgmental" but lacked the individualized triggers and interventions that staff acknowledged were necessary.

The Social Worker told inspectors that care plans should either reflect resident-specific triggers and interventions or document that the resident was unable to respond to assessment questions.

Staffing problems compounded the care failures. Federal data showed the facility triggered concerns for "excessively low weekend staffing" during the fourth quarter of 2024. The facility's own assessment indicated it needed 3.20 hours per patient day of direct care staffing, but records showed only one week out of twelve met this standard during the problematic quarter.

The Administrator acknowledged the facility had difficulty recruiting staff but said they now use on-call nursing management when needed.

Infection control failures put residents at additional risk. Staff repeatedly entered rooms of residents with C. difficile and MRSA infections without wearing required protective equipment or washing hands properly.

Inspectors observed staff entering a C. difficile patient's room without gloves or gowns, then immediately entering other residents' rooms. One staff member used contaminated gloves to handle equipment that other staff later touched with bare hands.

A resident with MRSA had no contact precaution signs posted and no protective equipment cart outside his room, despite facility policies requiring both.

The Director of Nursing and Administrator both told inspectors they expected staff to follow infection control protocols, but the violations continued throughout the inspection period.

The facility also failed to offer COVID-19 vaccinations to two employees during their new hire orientations, only providing the opportunity months later when inspectors discovered the oversight.

After two residents alleged abuse by the same nursing assistant, who was subsequently terminated, the facility failed to develop a meaningful quality improvement plan to prevent similar incidents. The Administrator initially provided inspectors with a blank, incomplete plan, then produced a different plan dated three weeks before the first abuse allegation.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Aspen Hill Rehabiliation & Healthcare Center from 2025-01-16 including all violations, facility responses, and corrective action plans.

Additional Resources

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