The October inspection at Orchard Hill Rehabilitation and Healthcare Center found the cart sitting outside a patient room at 8:14 AM. The nurse was inside the room and could not see the hallway from her position.
When Staff #5 emerged from the room, she asked the surveyor what she was doing. The surveyor explained that the medication cart was left unlocked and unattended, with the nurse not visible from the hallway.
Inside the cart's top drawer, inspectors found an opened 20-milliliter vial of sterile water with no date marking when it was opened. According to the National Institute of Health, sterile water must be discarded no later than four hours after the container is first punctured.
The drawer also contained multiple insulin pens with serious dating problems. One insulin pen for Resident #14 had been opened but carried no opening date. A second insulin for the same resident, Lispro brand, also lacked an opening date despite having a broken seal. A third insulin pen for Resident #14, Aspart brand, similarly had no opening date and a broken seal.
Inspectors found an opened Lispro insulin for Resident #3 and another opened Aspart insulin with no resident name and a broken seal.
Manufacturer instructions require insulin to be dated when opened and discarded 28 days later. The undated insulin pens made it impossible to determine whether they remained safe for patient use.
The medication cart violations occurred on one of three nursing units that inspectors observed during random checks throughout the facility.
When the Director of Nursing was informed of the findings at 12:22 PM that day, she stated that staff had received education about locking medication carts.
Federal regulations require all drugs and biologicals to be stored in locked compartments when unattended, with controlled substances kept in separately locked areas. The rules also mandate that medications be properly labeled according to professional standards.
The unlocked cart created potential access to prescription medications for unauthorized individuals. Insulin pens, while not controlled substances, require proper storage and dating to ensure patient safety.
Expired medications pose risks to residents who depend on nursing staff to administer safe, effective drugs. Sterile water that exceeds the four-hour limit after opening can become contaminated, while insulin that sits undated beyond 28 days may lose potency.
The inspection occurred in response to a complaint about the facility. Federal surveyors found the medication storage violations affected few residents but created minimal harm or potential for actual harm.
Orchard Hill Rehabilitation and Healthcare Center operates at 111 West Road in Towson. The facility must submit a plan of correction to address the medication storage and labeling deficiencies identified during the federal inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Orchard Hill Rehabilitation and Healthcare Center from 2025-10-17 including all violations, facility responses, and corrective action plans.
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