Aventura at Pembrooke: Wound Care Falsification - PA
The resident at the center of the November 3, 2025, complaint inspection, identified in records as Resident R2, had a Stage 4 pressure ulcer to the sacrum, a wound category representing full-thickness loss of skin and tissue, reaching down to muscle, bone, or deeper structures. The resident also had moisture-associated skin damage to the left medial thigh and wounds on both legs requiring dressings.
When inspectors arrived that morning and went to check on R2 at 11:35 a.m., they found the resident lying in bed with loose wound dressings on both legs. The left leg dressing carried a handwritten date of October 29. The right leg dressing had no date at all. The sacral wound, the Stage 4 ulcer, had no dressing on it. It was open to air.
The nurse responsible for R2's care that day, identified as Employee E9, had already charted the treatments as done. According to E9, the documentation was completed around 9:30 to 10:00 a.m., while finishing the resident's behavior paperwork.
At 11:40 a.m., inspectors interviewed E9 directly. E9 confirmed the wound treatments to the sacrum and legs had not been performed, despite the record showing otherwise. E9 also confirmed documenting that the left leg wound was treated on October 30, October 31, and November 1. When inspectors pointed to the dressing still on the leg, dated October 29, and asked whether those treatments had actually happened, E9 had no answer.
The physician had ordered specific wound care. An order from August 23, 2025, called for cleansing the left lower leg with normal saline, applying Medihoney, and covering the wound with an abdominal dressing and Kling wrap. A separate order from October 30, 2025, directed daily cleansing of the sacral wound with normal saline, application of nickel-thick Santyl, a collagenase-based ointment used to break down dead tissue in chronic wounds, and covering with a dry dressing. Neither treatment was carried out on November 3. And based on the undisturbed dressing dated five days earlier, there are serious questions about the days before.
A Stage 4 sacral pressure ulcer left without a dressing is not a paperwork problem. The sacrum bears the full weight of a person lying on their back. Wounds at that stage are already deep, already compromised, and already at risk of infection. Leaving such a wound open and undocumented, while charting it as treated, removes the only mechanism by which a physician or wound care specialist would know the wound's true condition.
This was not the first time inspectors flagged record-keeping failures at this facility. The same Pennsylvania code sections covering clinical records and nursing services, 28 Pa. Code 211.5(f) and 211.12(d)(1)(5), were cited in a previous inspection on August 25, 2025, just ten weeks earlier.
The deficiency was classified as causing minimal harm or potential for actual harm, a designation that reflects the regulatory finding but not necessarily the clinical reality for a resident with a Stage 4 wound going untreated while the chart said otherwise.
Resident R2's sacral wound sat open on the morning of November 3, dressing-free, while the treatment record showed the work had been done two hours before inspectors walked in.
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 23, 2026 · Our methodology
AVENTURA AT PEMBROOKE in WEST CHESTER, PA was cited for violations during a health inspection on November 3, 2025.
The resident also had moisture-associated skin damage to the left medial thigh and wounds on both legs requiring dressings.
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.