State surveyors found medication cart A sitting unlocked outside the nursing station on unit 1 at 11:35 AM on December 22, with no authorized staff in sight. When the unit manager approached inspectors two minutes later, she admitted she didn't know where the nurse assigned to the cart was located.
The nurse, identified as LPN #1, entered the building through an outside door at 11:38 AM and told inspectors she had been outside making a phone call. She left the medication cart accessible to residents for at least three minutes, though the actual duration remains unclear.
During interviews later that day, both the unit manager and the nurse acknowledged the violation. The unit manager stated that LPN #1 "should not have been outside of the building while medication cart A was unlocked and not under direct observation of authorized staff."
The nurse admitted her mistake. "She knows it was wrong being outside of the building while medication cart A was not locked or under observation of authorized staff," according to the inspection report.
Federal regulations require medication carts to remain locked when not under direct supervision of authorized personnel. The facility's own policy, effective since September 2018, explicitly states that "medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access."
The violation potentially gave residents unsupervised access to controlled substances and other medications stored in the cart.
Facility administrators, including the director of nursing and regional clinical director, offered no additional comments during a final interview that evening and "voiced no concerns regarding the above allegation."
The incident represents a basic breach of medication security protocols designed to prevent resident access to potentially dangerous drugs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Virginia Beach Healthcare and Rehab Center from 2025-12-22 including all violations, facility responses, and corrective action plans.