Aventura at Pembrooke: Fall Caused Brain Bleed - PA
A nursing assistant who worked the unit consistently said it. A licensed nurse said it. Another aide said it, adding that the resident needed help even to eat. Three different employees, interviewed separately on the same afternoon, gave inspectors the same answer without hesitation. The resident required two people to move her in bed. That was not a judgment call. It was her care plan.
On the day she fell, she had one person. That person was an agency worker.
The fall sent her to the hospital. From there, she went to the ICU, where she was diagnosed with acute subarachnoid hemorrhage, a bleed between the brain and the tissue that surrounds it.
Inspectors from the Pennsylvania Department of Health arrived at Aventura at Pembrooke on November 3, 2025, following a complaint. What they found was not a mystery or a documentation gap. The supervision requirement was known. The staffing that day did not meet it. The resident was harmed.
The nursing home administrator, interviewed at 3:00 p.m. that afternoon, confirmed that the employee who had been providing care to the resident was agency staff. That was the extent of the explanation.
The aide identified as Employee E5, who described caring for the resident for several years, told inspectors: "She cannot do anything." Employee E6, a licensed nurse who worked on the unit when assigned there, said the resident was "dependent" and required two-person assistance for bed mobility. Employee E7, a nursing assistant with consistent unit presence, went further: "Cannot do anything, even with eating, they need help."
None of them expressed surprise that the two-person requirement existed. All of them knew it. The question inspectors did not need to ask out loud was how an agency worker came to be providing care to this resident alone.
Inspectors cited the facility under F0689, the federal tag for failure to protect residents from accident hazards, at a level of actual harm. The violation was not theoretical. The resident did not narrowly avoid injury. She was hospitalized. She bled into her brain.
What makes the citation harder to read past is a single line near the bottom of the inspection report: "Previously cited 8/25/25."
This was not the first time inspectors had flagged supervision and nursing services failures at this facility. The same Pennsylvania nursing codes, covering clinical records and nursing services, had been cited just over two months earlier. The facility had been here before, or close enough to it that the citation tags matched exactly.
The findings were presented to the nursing home administrator and the Director of Nursing together at 4:30 p.m. on November 3. The report does not describe their response.
Subarachnoid hemorrhage, the diagnosis the resident received, is a bleed in the space between the brain and the surrounding membrane. Falls are among its leading causes in older adults. The condition carries serious risks of permanent neurological damage and death. ICU monitoring, which the resident required, reflects how seriously the injury was treated.
She had been a resident at the facility for years. Staff knew her. They knew what she needed. On the day it mattered most, the person providing her care was someone who may not have known her care plan, or was working without a second set of hands, or both. The inspection report does not say which. It says she fell. It says she bled. It says the facility failed to ensure she had adequate supervision while someone was providing her care.
That is the sentence the facility's administrator heard at 4:30 on a Monday afternoon in November. It is also the sentence that follows a resident into an ICU.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Pembrooke from 2025-11-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
AVENTURA AT PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on November 3, 2025.
A nursing assistant who worked the unit consistently said it.
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.