Aventura at Terrace View: Medication Mix-ups, Water - PA
Federal inspectors documented the medication error on November 13, 2024, when staff administered Doxycycline, a 100-milligram antibiotic, instead of Dicyclomine, a 20-milligram antispasmodic medication used to treat bowel cramping. The resident, identified as B3 in inspection records, experienced nausea and vomiting after taking the wrong drug.
The mix-up occurred despite facility policy requiring nurses to check medication labels three times before administration. The administering nurse noted the medication "appeared larger than usual" and verified with the resident that a prior dose had caused adverse effects. Only then did staff discover the pharmacy had mislabeled the package.
Resident B3 told investigators she vomited twice after the afternoon dose and refused her 6:00 PM medication. The facility's investigation concluded the pharmacy had packaged the wrong medication in a container labeled as Dicyclomine.
The Nursing Home Administrator confirmed during a January 8, 2025 interview that "the pharmacy mislabeled the medication and that the facility failed to ensure the accuracy of medication labeling prior to administration to Resident B3."
On the facility's dementia unit, inspectors found multiple residents without access to drinking water. During a noon observation on January 7, 2025, rooms 115, 123D, 126W and 127 had no water cups or accessible drinking water. Additional rooms contained Styrofoam cups marked with outdated dates from January 5 and 6, some empty and others containing warm water.
Employee A1, a Licensed Practical Nurse, told inspectors that night shift nursing staff are responsible for replacing cups and filling them with fresh water but "could not explain why the dates on the cups were not current or why some residents did not have water."
The daughter of Resident A11 expressed concern during the inspection. "Her mother does not consistently receive fresh water in her room," inspectors documented. "She expressed concern that her mother requires encouragement to drink and would not have access to water if it was not readily available."
Agency Nurse Aide A2 confirmed that "water had not been passed that morning and was unaware that cups had not been timely changed."
Residents also went without evening snacks despite facility policy requiring them when more than 14 hours elapse between dinner and breakfast. The facility's meal schedule creates a 14.83-hour gap between dinner at 5:25 PM and breakfast at 8:15 AM the next day.
Nine residents interviewed by inspectors reported they were not receiving bedtime snacks. Resident B15 stated staff "used to bring a tray (of snacks) and put it on the nurses station, but not anymore, not for months."
Resident B6 said staff do not provide nighttime snacks and "her family brings her food, so she has something to snack on." Resident B7 described snack service as "hit or miss, but mostly miss."
"Staff do not provide or offer snacks at bedtime," Resident B8 told inspectors, adding "I would like one if they gave it to me."
Multiple residents described seeing snack trays left at the nurses' station without being distributed. Resident B9 said "the dietary staff bring a snack tray and leave it at the nurses station, but the snacks are not passed out to the residents."
Resident B150 confirmed the same pattern: "The snack tray is left on top of the counter at the nurses station, but the snacks are not passed out to the residents. She added that when she asked for a snack, a staff member provided one but only when she asked. Snacks are not provided or offered otherwise."
Resident B12 expressed frustration about the discontinued service: "Snacks used to be provided, but not anymore. I enjoy a nighttime snack. I wish they would start that again; I'd like a snack at night."
The Nursing Home Administrator was "unable to explain why the residents were not routinely offered and provided with an evening/bedtime snack" during his January 8 interview.
Inspectors also found inadequate supplies of specialized dining equipment. Resident A11, who has dementia and difficulty swallowing, was observed at lunch with a regular plastic cup and straw despite physician orders for a spouted sippy cup and no straws.
The resident's daughter told inspectors her mother "had been having trouble drinking at mealtimes and required a handled sippy cup as per the physician's order." She reported that "nursing staff had been providing a straw to the resident, despite the resident's inability to use a straw" and that she had informed facility administration but "no corrective actions had been taken."
A kitchen inventory revealed the facility had only one Kennedy cup, one sippy cup, and three nosey cups available, while documentation showed four residents required two-handled cups, six residents needed Kennedy cups at all meals, and three residents required nosey cups. The current supply was insufficient to meet documented needs.
The corporate dietary manager confirmed during a January 8 interview that "the facility did not maintain an adequate supply of adaptive dining equipment."
Medication tracking problems extended beyond the mislabeling incident. Inspectors found that nursing staff failed to properly account for narcotic medications, with doses of Oxycodone signed out for Resident C2 on January 2 and January 4, 2025, but no corresponding administration records.
Additionally, shift-to-shift narcotic count sheets showed multiple instances where nurses failed to sign off on controlled substance counts between January 2 and January 7, 2025.
The facility also failed to provide adequate documentation for psychoactive medications prescribed to Resident A16, who has vascular dementia. The resident was prescribed Ativan, Seroquel, and Trazodone for mood disturbances, but physician documentation "failed to meet the criteria for use of the noted psychoactive medications," according to the inspection report.
The Director of Nursing confirmed during a January 8 interview that "the current physician documentation failed to include accurate resident specific details in support of the use of the psychoactive medications."
These violations occurred despite the facility implementing a corrective action plan following a previous inspection in October 2024 that identified similar deficiencies. The facility had committed to quality assurance monitoring to prevent recurrence, but inspectors found the same problems persisted.
The facility's quality assurance committee failed to identify root causes or implement sustained corrective actions, according to the inspection report. Despite staff re-education, policy updates, and promised audits following the October inspection, the facility continued to struggle with medication management, basic care provisions, and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Terrace View from 2025-01-23 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 22, 2026 · Our methodology
AVENTURA AT TERRACE VIEW in PECKVILLE, PA was cited for violations during a health inspection on January 23, 2025.
The resident, identified as B3 in inspection records, experienced nausea and vomiting after taking the wrong drug.
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.