Aventura at Pembrooke: Missed Wound Treatments - PA
The November 3, 2025 inspection, triggered by a complaint, found the facility had failed two residents on basic wound care in ways that caused both of them measurable, documented harm.
The first resident, identified in the inspection report as Resident R1, was readmitted to the facility with a diagnosis of wound infection. A physician ordered two intravenous antibiotics, Ertapenem and Daptomycin, to treat infected sacral wounds, meaning wounds on the lower middle back. Both were ordered once daily for eight days.
On October 5, 2025, nurses noted in their progress notes that R1 had no IV access and was a "hard stick," meaning finding a peripheral vein was difficult. They placed an order for IV access through an outside company. The antibiotics were not given. The next morning, October 6, nursing notes recorded simply: "IV not in the arm." By midday on October 6, a physician was notified that the resident still had no IV access and ordered placement of a new midline IV.
The physician was told the IV was gone. The physician was not told the antibiotics had been missed.
There is no documentation in R1's clinical record that staff ever informed the doctor that two consecutive doses of both Ertapenem and Daptomycin had gone unadministered. The Director of Nursing confirmed to inspectors that R1 received only six of the eight ordered doses of each medication.
The second resident, Resident R2, had two open wounds on both legs, a venous ulcer on the right leg and a moisture-associated skin damage wound, known as MASD, on the left. Both had physician-ordered wound treatments. From October 30 through November 2, 2025, four consecutive days, neither wound received its ordered treatment.
When the Director of Nursing measured both wounds on the day of inspection, November 3, the right leg venous ulcer measured 9.5 by 7.5 centimeters. The left leg MASD wound measured 8.5 by 2.5 centimeters. The surrounding skin on both legs was reddened. The Director of Nursing confirmed to inspectors that the wound treatments had not been administered during those four days, and the inspection report cited the missed care as the direct cause of both wounds deteriorating and increasing in size.
CMS classified the deficiency as causing actual harm to a small number of residents.
The violations were not new. Pennsylvania state code citations for clinical records and nursing services, the same categories cited in this inspection, had been issued to the same facility just over two months earlier, on August 25, 2025.
What the inspection lays out is a pattern of execution failure rather than a single oversight. A resident with an active infection lost IV access. That is a clinical problem with a straightforward solution: restore the access, notify the physician, document what happened. Staff did one of those three things. A second resident had wound treatments ordered, and for four days, those treatments simply did not happen. When inspectors arrived and measured the wounds, the evidence of those four days was visible in centimeters.
The Director of Nursing, in both cases, confirmed the failures when interviewed. There was no dispute about what had happened. The question the inspection report leaves open is how a resident fighting a wound infection with time-limited antibiotic therapy can miss two consecutive doses, and the physician who ordered that therapy can be contacted about the missing IV line without anyone mentioning the missed medications.
R1's wounds were in the lower back. The antibiotics ordered to treat them had an eight-day window. That window closed with two doses undelivered and, as far as the clinical record shows, unacknowledged.
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: 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 PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on November 3, 2025.
The first resident, identified in the inspection report as Resident R1, was readmitted to the facility with a diagnosis of wound infection.
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.