Venetian Care: Medications Left Unattended at Bedside - NJ
The incident occurred on August 18 at Venetian Care & Rehabilitation Center during the third day of work for RN4, a newly hired nurse who had completed medication administration training just five days earlier.
Federal inspectors found two medication cups sitting on an overbed table next to a lunch tray in the room of Resident 16, who has epilepsy. One cup contained white powder, the other red liquid. The resident was lying in bed while a nursing assistant fed him lunch.
"The nurse left them there and has not returned to give them to him yet," the resident told inspectors at 1:16 PM.
Six minutes later, RN4 confirmed to inspectors that she had left phenobarbital elixir and polyethylene glycol powder on the table because she didn't have juice to administer the medications as ordered by the physician. The seizure medication was prescribed at 11.3 milliliters every 12 hours. The laxative required mixing with 6-8 ounces of water or juice.
"She should have locked the medications in the medication cart to keep other residents from self-administering them," RN4 told inspectors.
The Director of Nursing observed the medication cups still sitting on the bedside table when she arrived at the room. She confirmed that RN4 was a newly hired employee who had successfully administered medications with a preceptor during orientation.
"She should not have left the medications on the bedside table," the director said. "She should have administered the medications to R16 and for the safety of the other residents so they would not wander into the room and ingest the medications."
RN5, the nurse manager, said RN4 violated basic medication administration protocols when she abandoned the prepared drugs.
"She should have located the juice before preparing the medications or locked the medications in the cart while she found the juice," RN5 told inspectors. "Another resident could have walked in the room and ingested the medications."
The facility's own medication storage policy, revised in February 2023, explicitly prohibits the practice. The policy states that medication compartments must remain locked when not in use and that transport carts cannot be left unattended if open or potentially available to others.
RN4 had completed her medication administration competency test on August 13 with another nurse. The competency form documented that she understood not to leave medications at bedside or on top of medication carts after preparing them.
The Assistant Director of Nursing confirmed that RN4 passed the competency test and should have watched the resident take the medications. She emphasized that prepared medications cannot be placed back in carts and cannot be left unattended at bedside.
The violation occurred despite RN4 receiving two days of training with a preceptor nurse before working independently. Federal inspectors classified the incident as having minimal harm or potential for actual harm, affecting few residents.
Resident 16 was admitted to the facility in August 2024 with a diagnosis of epilepsy. The phenobarbital elixir he was prescribed is a controlled substance used to prevent seizures, while the polyethylene glycol powder treats constipation.
The inspection report does not indicate how long the medications remained unattended before nursing management discovered them or whether any other residents accessed the room during that time.
Federal regulations require nursing homes to store all medications in locked compartments when not being administered directly to residents. Controlled substances like phenobarbital must be kept in separately locked compartments. The rules aim to prevent medication errors, theft, and accidental ingestion by confused or wandering residents.
The citation represents RN4's failure to follow established safety protocols during her first week of independent practice at the facility, despite recent training that specifically covered proper medication handling procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Venetian Care & Rehabilitation Center, The from 2025-08-21 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 20, 2026 · Our methodology
VENETIAN CARE & REHABILITATION CENTER, THE in SOUTH AMBOY, NJ was cited for violations during a health inspection on August 21, 2025.
Federal inspectors found two medication cups sitting on an overbed table next to a lunch tray in the room of Resident 16, who has epilepsy.
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.