Fair Oaks Health & Rehabilitation: Medication Cart Key Left Unattended - VA
The incident unfolded on the morning of October 7, 2025, at Fair Oaks Health & Rehabilitation on Lee Jackson Memorial Highway. An inspector observed the nurse, identified in the report as RN #1, standing at a medication cart just after 8:30 a.m. He told the inspector he works only a few shifts a month at the facility and was not familiar with the residents or where medications were kept on the cart.
After several minutes of searching, he couldn't locate what he needed. He locked the cart, placed the keys under a towel on top of it, and walked downstairs to retrieve the medication from an emergency supply machine on another floor. He was gone until 8:35 a.m.
He returned, took the keys from under the towel, unlocked the cart, and kept searching. Three minutes later, he still couldn't find a second medication. He locked the cart again, put the keys back under the towel, and left for the first floor a second time.
At 8:40 a.m., two residents walked past the cart as they carried their breakfast trays back to the meal cart. The keys were sitting under a towel on top of a locked cart full of medications, including narcotics. RN #1 didn't return until 8:46 a.m.
He acknowledged the problem himself. At 8:51 a.m., after telling the inspector he had secured the cart, he added that the cart was "not totally secure" because he had left the keys on top of it.
The unit manager, LPN #2, was interviewed the following morning. She said the answer was straightforward: if a nurse needs to leave the cart for any reason, the keys go in the nurse's pocket. She noted the cart holds narcotics and that keeping medications locked is a matter of safety.
What the inspection report captures is a gap between what the facility's own policy requires and what happened in practice. The policy states that carts used to transport medications shall not be left unattended if open or otherwise potentially available to others. Hiding the keys under a towel on top of the cart and walking to another floor is not the same as locking them away.
The administrator, the director of nursing, and the regional director of clinical operations were all notified of the findings on October 8.
The deficiency was cited at a level of minimal harm or potential for actual harm. That classification reflects the fact that no resident was documented as having accessed the cart or its contents. But the cart was left in a hallway on a floor where residents move freely, and the keys were not hidden in any meaningful sense of the word. Two residents walked past during the window when RN #1 was downstairs the second time.
The nurse's own explanation of his situation is worth sitting with. He works a few shifts a month. He didn't know the residents. He didn't know where things were on the cart. He spent the better part of a morning unable to locate medications in a cart he was responsible for, making two separate trips to another floor to find them, and each time he left, he put the keys under a towel and walked away.
The unit manager knew exactly what should have happened. The policy said exactly what should have happened. On the morning of October 7, neither of those things was enough.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fair Oaks Health & Rehabilitation from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
FAIR OAKS HEALTH & REHABILITATION in FAIRFAX, VA was cited for violations during a health inspection on October 8, 2025.
The incident unfolded on the morning of October 7, 2025, at Fair Oaks Health & Rehabilitation on Lee Jackson Memorial Highway.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.