Bethesda Care Center: Unlabeled Insulin, Ozempic Pens - OH

Inspectors arrived at the 100-hall medication storage cart on the morning of September 25, 2025, at 9:49 a.m. alongside Licensed Practical Nurse #175. What they found was straightforward and uncontested.

A Lantus SoloStar Pen, a long-acting insulin, was stored with roughly 60 of its original 300 units remaining. No label. No open date. No expiration date. The nurse confirmed it. Lantus insulin pens expire 28 days after first use or removal from the refrigerator, whichever comes first, according to the facility's own medication supplier guidelines. There was no way to tell, from the pen in that cart, whether those 28 days had passed.

Two Ozempic pens, used to manage Type 2 diabetes, were in the same cart. Neither had a resident's name on it. Neither had an open date. Neither had an expiration date. One contained approximately one and a half milliliters of medication, or roughly two doses. The other was nearly empty. Both pens were labeled by the manufacturer for single patient use only. The facility's supplier guidelines put the expiration window for Ozempic at 56 days once opened at room temperature.

LPN #175 verified none of the three pens were labeled for a specific resident or marked with a date opened or an expiration date.

Two residents on the 100-hall, identified in the inspection report as Residents #23 and #42, had been prescribed injectable medication. The facility's census at the time was 75 residents.

The facility's own written policy on medication storage, reviewed by inspectors, was direct on what should have happened. When a manufacturer specifies a usable duration after opening, the nurse is to place a date-opened sticker on the medication and record both the date it was opened and the new expiration date. No expired medication will be administered to a resident.

None of that had been done.

The Ozempic pens carried an additional problem beyond the missing labels. Manufacturers mark those pens for single patient use. Storing unlabeled pens in a shared medication cart, with no name identifying which resident the pen belonged to, creates the possibility that a pen used for one resident could be administered to another. The inspection report rated the violation as minimal harm or potential for actual harm, affecting a few residents.

What the report does not answer, because there is no way to answer it from the labels that were not there, is how long those pens had been open. The Lantus pen had 60 units left out of 300. Someone had used 240 units from it. The Ozempic pen with two doses remaining had been used down from a full three-milliliter supply. The nearly empty pen was close to gone. Each of those pens had a clock running from the moment it was first used or pulled from the refrigerator. None of those clocks were marked anywhere.

For a diabetic resident receiving long-acting insulin from a pen that had quietly passed its 28-day window, the medication may have degraded in potency. Blood sugar that should have been controlled might not have been. The same math applies to the Ozempic doses still sitting in that cart.

The nurse standing at the cart when inspectors arrived did not dispute any of it.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Bethesda Care Center from 2025-09-25 including all violations, facility responses, and corrective action plans.

Additional Resources

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